Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Nonsteroidal anti-inflammatory drugs relieve pain in renal colic

ACP J Club. 1995 Jan-Feb;122:5. doi:10.7326/ACPJC-1995-122-1-005


Source Citation

Labrecque M, Dostaler L-P, Rousselle R, Nguyen T, Poirier S. Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic: a meta-analysis. Arch Intern Med. 1994 Jun 27;154:1381-7.


Abstract

Objective

To determine the efficacy for pain relief of nonsteroidal anti-inflammatory drugs (NSAIDs) compared with analgesic agents and placebo in patients with acute renal colic.

Data sources

Studies were identified by searching MEDLINE (1966 to 1992) and EMBASE (1975 to 1992) using the terms anti-inflammatory agent, colic, kidney disease, and ureteral disease. The Family Medicine Library Index was consulted, as were the information services of 2 pharmaceutical companies and a hospital emergency department library. Relevant citations from the bibliographies of retrieved studies were also reviewed.

Study selection

English or French studies were selected if they were randomized controlled trials comparing an NSAID with an analgesic agent or placebo for the treatment of acute renal colic.

Data extraction

Quality assessment was done independently by 4 evaluators using a 20-item checklist adapted from published criteria. Final scoring was done by consensus. The main outcome measure was number of patients with complete and partial pain relief 20 to 30 minutes after drug administration.

Main results

Of the 169 studies identified, 20 trials of 946 patients met the inclusion criteria. Most studies (18 of 20) compared parenteral diclofenac or indomethacin with placebo (n = 4) or an analgesic agent (n = 16). 17 of the 20 studies reported data on pain relief. NSAIDs were more effective in achieving complete pain relief compared with placebo (pooled relative risk [RR] 2.34, 95% CI 1.79 to 3.07). Compared with analgesic agents, NSAIDs were marginally more effective at achieving partial pain relief (pooled RR 1.07, CI 1.02 to 1.12) and complete pain relief (pooled RR 1.19, CI 1.03 to 1.37). These last 2 comparisons did not show a clinically important effect, which was considered to be an RR ≥ 1.25 or ≤ 0.8.

Conclusion

Nonsteroidal anti-inflammatory drugs are more effective than placebo and are at least as effective as analgesic agents in alleviating pain in patients with acute renal colic.

Source of funding: Not stated.

For article reprint: Dr. M. Labrecque, Unite de medecine familiale, 165, rue des Governeurs, Rimouski, Québec G5L 7R2, Canada. FAX 418-723-7668.


Commentary

Few entities are as painful as the colic caused by an obstructing renal calculus. Historically, narcotic analgesics are the principal therapy for pain management in this setting. A safe and effective alternative to narcotics would be desirable in view of their many adverse effects (nausea, oversedation, and respiratory depression). Labrecque and colleagues culled data from 20 studies in which NSAIDs were used for renal colic. Each study was scrutinized for the quality of its methods, and data that appeared suspect were excluded. The overall results show that NSAIDs are superior to placebo and as effective as narcotic analgesics in treating renal colic.

Ketorolac is the only parenteral NSAID available in the United States used for pain control after surgery. Ketorolac at a dose of 30 to 90 mg has been shown to have the analgesic equivalence of 100 mg of meperidine or 12 mg of morphine (1). It is not used widely in the United States for pain associated with renal colic, although such use has been reported (2). Renal colic is often accompanied by volume depletion. NSAIDs may further reduce renal plasma flow and glomerular filtration rate, particularly in patients with preexisting renal insufficiency. Hyperkalemia, exacerbation of congestive heart failure, and aggravation of hypertension also have been reported with the use of NSAIDs.

This meta-analysis by Labrecque and colleagues shows that NSAIDs can be an effective alternative to narcotics for renal colic. In patients with concomitant congestive heart failure, hypertension, peptic ulcer disease, or renal insufficiency, however, NSAIDs must be used with extreme caution.

Lloyd H. Alterman, MD
Summit Medical GroupSummit, New Jersey, USA


References

1. Physicians Desk Reference. 48th ed. Montvale, New Jersey: Medical Economics Data Production Company; 1994.

2. Larsen LS, Miller A, Allegra JR. The use of intravenous ketorolac for the treatment of renal colic in the emergency department. Am J Emerg Med. 1993;11:197-9.