Can I give Toradol (ketorolac) to a patient with impaired renal function?

Ketorolac Use with Creatinine Clearance of 53 mL/min

You should avoid ketorolac in this patient with a creatinine clearance of 53 mL/min, as the FDA label explicitly states ketorolac should be used with caution in impaired renal function, and multiple case reports document acute renal failure even after single doses in patients with mild renal insufficiency. 1

FDA Contraindications and Warnings for Renal Impairment

• Ketorolac is contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion 1
• The FDA label warns that ketorolac should be used with caution in patients with impaired renal function because it is a potent inhibitor of prostaglandin synthesis 1
• Ketorolac and its metabolites are eliminated primarily by the kidneys, and reduced creatinine clearance results in diminished drug clearance 1
• Patients with underlying renal insufficiency are at increased risk of developing acute renal decompensation or failure, and the risks and benefits must be assessed prior to giving ketorolac 1

Dose Adjustment Requirements

• For adults ≥65 years, renally impaired, or weight <50 kg, the recommended dose is reduced to 15 mg every 6 hours via IV/IM route (compared to 15-30 mg every 6 hours for normal renal function) 2
• However, this dose reduction does not eliminate the risk—it merely attempts to mitigate it 2

Clinical Evidence of Renal Toxicity

Multiple case reports demonstrate the serious risk of ketorolac in patients with even mild renal impairment:

• Acute renal failure has occurred following single doses of ketorolac in patients with mild baseline renal dysfunction 3
• In one case series, six patients developed renal insufficiency with serum creatinine increasing from a mean of 106 µmol/L (1.2 mg/dL) to 256 µmol/L (2.9 mg/dL), though recovery occurred after discontinuation 4
• A 71-year-old woman with mild preexisting renal dysfunction developed acute renal failure after just three doses of ketorolac 5
• Postoperative ketorolac therapy should be avoided in patients with conditions that predispose to NSAID nephrotoxicity, and elderly patients or those with underlying renal insufficiency require dosing interval adjustment or complete avoidance 6

Risk Factors Present

Your patient has a creatinine clearance of 53 mL/min, which represents moderate renal impairment (Stage 3 chronic kidney disease). This places them in the high-risk category for NSAID-induced nephrotoxicity 1, 6

Safer Alternative Approaches

• Standard NSAIDs like ibuprofen 400-800 mg every 6-8 hours have better safety profiles for sustained use and are recommended as first-line treatment 2, 7
• For acute pain requiring parenteral therapy, consider opioid analgesics which do not carry the same renal toxicity risk 2
• If NSAIDs are absolutely necessary, use oral ibuprofen with close monitoring of renal function (blood pressure, BUN, creatinine) rather than ketorolac 7

Critical Monitoring if Ketorolac is Used Despite Risks

If you decide to proceed with ketorolac despite the contraindications:

• Discontinue immediately if BUN or creatinine doubles, hypertension develops or worsens, or any signs of decreased urine output occur 2, 1
• Monitor baseline and daily BUN, creatinine, blood pressure, and urine output 2
• Limit use to absolute maximum of 5 days 2, 1
• Use the reduced dose of 15 mg every 6 hours maximum 2

Common Pitfall to Avoid

Never combine ketorolac with other NSAIDs (including ibuprofen), as toxicities are additive without providing additional analgesic benefit, significantly increasing risks of renal failure 2