Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic

Anna Holdgate, Tamara Pollock, Anna Holdgate, Tamara Pollock

Abstract

Objective: To examine the relative benefits and disadvantages of non-steroidal anti-inflammatory drugs (NSAIDs) and opioids for the management of acute renal colic.

Data sources: Cochrane Renal Group's specialised register, Cochrane central register of controlled trials, Medline, Embase, and reference lists of retrieved articles.

Review methods: Randomised controlled trials comparing any opioid with any NSAID in acute renal colic if they reported any of the following outcomes: patient rated pain, time to pain relief, need for rescue analgesia, rate of recurrence of pain, and adverse events.

Results: 20 trials totalling 1613 participants were identified. Both NSAIDs and opioids led to clinically important reductions in patient reported pain scores. Pooled analysis of six trials showed a greater reduction in pain scores for patients treated with NSAIDs than with opioids. Patients treated with NSAIDs were significantly less likely to require rescue analgesia (relative risk 0.75, 95% confidence interval 0.61 to 0.93). Most trials showed a higher incidence of adverse events in patients treated with opioids. Compared with patients treated with opioids, those treated with NSAIDs had significantly less vomiting (0.35, 0.23 to 0.53). Pethidine was associated with a higher rate of vomiting.

Conclusions: Patients receiving NSAIDs achieve greater reductions in pain scores and are less likely to require further analgesia in the short term than those receiving opioids. Opioids, particularly pethidine, are associated with a higher rate of vomiting.

Figures

Fig 1
Fig 1
Flow of studies through trial
Fig 2
Fig 2
Patient rated scores on visual analogue scale for pain due to renal colic according to type of non-steroidal anti-inflammatory drug, excluding trials using ketorolac
Fig 3
Fig 3
Number of patients failing to achieve complete pain relief from renal colic after receiving anti-inflammatory drugs (NSAIDs) or opioids
Fig 4
Fig 4
Number of patients requiring rescue analgesia after treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or opioids for acute renal colic
Fig 5
Fig 5
Incidence of vomiting as adverse event in patients receiving non-steroidal anti-inflammatory drugs (NSAIDs) or opioids for acute renal colic

References

    1. Stewart C. Nephrolithiasis. Emerg Med Clin North Am 1988;6: 617-30.
    1. Drach GW. Urinary lithiasis: etiology, diagnosis, and medical management. In: Walsh PC, Refik AB, Stamey TA, Vaughan ED, eds. Campbell's urology. 6th ed. Philadelphia, WB Saunders, 1992: 2085-156.
    1. Holdgate A, Hardcastle J. Renal colic: a diagnostic and therapeutic review. Emerg Med 1999;11: 9-16.
    1. Curry C, Kelly AM. Intravenous tenoxicam for the treatment of renal colic. NZ Med J 1995;108: 229-30.
    1. Smally AJ. Analgesia in renal colic. Ann Emerg Med 1997;29: 296.
    1. Reich JD, Hanno PM. Factitious renal colic. Urology 1997;50: 858-62.
    1. Tramer MR, Williams JE, Carroll D, Wiffen PG, Moore RA, McQuay HJ. Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain: a qualitative systematic review. Acta Anaesthesiol Scand 1998;42: 71-9.
    1. Labrecque M, Dostaler L-P, Rouselle R, Nguyen T, Poirier S. Efficacy of non-steroidal anti-inflammatory drugs in the treatment of acute renal colic. Arch Intern Med 1994;154: 1381-7.
    1. Nicholson F. Renal colic. In: Cameron P, Jelinek G, Kelly AM, Murray L, Heyworth L, eds, Textbook of adult emergency medicine. Edinburgh: Churchill Livingstone, 2000: 372-4.
    1. Moll J, Peacock WF. Urologic stone disease. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency medicine: a comprehensive study guide. 5th ed. New York: McGraw-Hill, 1999: 640-5.
    1. Cordell WH, Wright SW, Wolfson AB, Timerding BL, Maneatis TJ, Lewis RH, et al. Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic. Ann Emerg Med 1996;28: 151-8.
    1. al-Sahlawi KS, Tawfik OM. Comparative study of the efficacy of lysine acetylsalicylate, indomethacin and pethidine in acute renal colic. Eur J Emerg Med 1996;3: 183-6.
    1. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs versus opioids for acute renal colic. Cochrane Database Syst Rev 2004;(1): CD004137.
    1. Edwards JE, Meseguer F, Faura C, Moore RA, McQuay HJ. Single dose dipyrone for acute renal colic. Cochrane Database Syst Rev 2003;(4): CD003867.
    1. Willis NS, Mitchell R, Craig JC. Renal Group. In: Cochrane library, Issue 4. Chichester: Wiley, 2003.
    1. Egger M, Davey-Smith G, Scneider M, Minder C. Bias in meta-analysis detected by a simple graphical test. BMJ 1997;315: 629-34.
    1. Arnau JM, Cami J, Garcia-Alonso F, Laporte JR, Palop R. Comparative study of the efficacy of dipyrone, diclofenac sodium and pethidine in acute renal colic. Eur J Clin Pharmacol 1991;40: 543-6.
    1. Cordell WH, Larson TA, Lingeman JE, Nelson DR, Woods JR, Burns LB, et al. Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic. Ann Emerg Med 1994;23: 262-9.
    1. Hetherington JW, Philp NH. Diclofenac sodium versus pethidine in acute renal colic. BMJ 1986;292: 237-8.
    1. Indudhara R, Vaidyanathan S, Sankaranarayanan A. Oral diclofenac sodium in the treatment of acute renal colic. A prospective randomized study. Clin Trials J 1990;27: 295-300.
    1. Jonsson PE, Olsson AM, Petersson BA, Johansson K. Intravenous indomethacin and oxycone-papaverine in the treatment of acute renal colic. A double-blind study. BJU Int 1987;59: 396-400.
    1. Larkin GL, Peacock WF, Pearl SM, Blair GA, D'Amico F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Am J Emerg Med 1999;17: 6-10.
    1. Lehtonen T, Kellokumpu I, Permi J, Sarsila O. Intravenous indomethacin in the treatment of ureteric colic. A clinical multicentre study with pethidine and metamizol as the control preparations. Ann Clin Res 1983;15: 197-9.
    1. Lundstam SOA, Leissner K-H, Wahlander LA, Kral JG. Prostaglandin-synthetase inhibition with diclofenac sodium in treatment of renal colic: comparison with use of a narcotic analgesic. Lancet 1982;i: 1096-7.
    1. Marthak KV, Gokarn AM, Rao AV, Sane SP, Mahanata RK, Sheth RD, et al. A multi-centre comparative study of diclofenac sodium and a dipyrone/spasmolytic combination, and a single-centre comparative study of diclofenac sodium and pethidine in renal colic patients in India. Curr Med Res Opin 1991;12: 366-73.
    1. Oosterlinck W, Philp NH, Charig C, Gillies G, Hetherington JW, Lloyd J. A double-blind single dose comparison of intramuscular ketorolac tromethamine and pethidine in the treatment of renal colic. J Clin Pharm 1990;30: 336-41.
    1. Persson NH, Bergqvist D, Melander A, Zederfelt B. Comparison of a narcotic (oxicone) and a non-narcotic anti-inflammatory analgesic (indoprofen) in the treatment of renal colic. Acta Chir Scand 1985;151: 105-8.
    1. Quilez C, Perez-Mateo M, Hernandez P, Rubio I. Usefulness of a non-steroid anti-inflammatory, sodium diclofenac, in the treatment of renal colic. Comparative study with a spasmolytic and an opiate analgesic. Med Clin (Barc) 1984;82: 754-5. [In Spanish.]
    1. Sandhu DP, Lacovou JW, Fletcher MS, Kaisary AV, Philip NH, Arkell DG. A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic. BJU Int 1994;74: 690-3.
    1. Sommer P, Kromann-Andersen B, Lendorf A, Lyngdorf P, Moller P. Analgesic effect and tolerance of Voltaren and Ketogan in acute renal or ureteric colic. BJU Int 1989;63: 4-6.
    1. Thompson JF, Pike JM, Chumas PD, Rundle JS. Rectal diclofenac compared with pethidine injection in acute renal colic. BMJ 1989;299: 1140-1.
    1. Nicolas Torralba JA, Rigabert Montiel M, Banon Perez V, Valdelvira Nadal P, Perez Albacete M. Ketorolaco intramuscular frente a Tramadol subcutaneo en el tratemiento inicial de urgencia del colico renal. Arch Esp Urol 1999;52: 435-7.
    1. Uden P, Rentzhog L, Berger T. A comparative study of the analgesic effects of indomethacin and hydromorphine-chloride-atropine in acute, ureteral-stone pain. Acta Chir Scand 1983;149: 497-9.
    1. Todd KH, Funk KG, Funk JP. Clinical significance of reported changes in pain severity. Ann Emerg Med 1996;27: 485-9.
    1. Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 2001;38: 633-8.
    1. Smith LA, Carroll D, Edwards JE, Moore RA, McQuay HJ. Single-dose ketorolac and pethidine in acute postoperative pain: systematic review with meta-analysis. Br J Anaesth 2000;84: 48-58.
    1. McEvoy A, Livingstone JI, Cahill CJ. Comparison of diclofenac sodium and morphine sulphate for postoperative analgesia after day case inguinal hernia surgery. Ann R Coll Surg Engl 1996;78: 363-6.
    1. Zackova M, Taddei S, Calo P, Bellochchio A, Zanello M. Ketorolac vs tramadol in the treatment of postoperative pain during maxillofacial surgery. Minerva Anestesiol 2001;67: 641-6.
    1. DeAndrade JR, Maslanka M, Reines HD, Howe, D, Rasmussen GL, Cardea J, et al. Ketorolac versus meperidine for pain relief after orthopaedic surgery. Clin Orthop 1996;1: 302-12.
    1. Shende D, Das K. Comparative effects of intravenous ketorolac and pethidine on peri-operative analgesia and postoperative nausea and vomiting (PONV) for paediatric strabismus surgery. Acta Anaesthesiol Scand 1999;43: 265-9.
    1. Dula DJ, Anderson R, Wood GC. A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic. J Emerg Med 2001;20: 121-4.
    1. Henderson SO, Swadron S, Newton E. Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic. J Emerg Med 2002;23: 237-41.
    1. Rainer TH, Jacobs P, Ng YC, Cheung NK, Tam M, Lam PK, et al. Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury: double blind randomised controlled trial. BMJ 2000;321: 1247-51.
    1. Chia YY, Liu K. Prospective randomized trial of intravenous tenoxicam versus fentanyl and tramadol for analgesia in outpatient extracorporeal lithotripsy. Acta Anaesthesiol Sin 1998;36: 17-22.
    1. Streiner DL, Norman GR. Health measurement scales—a practical guide to their development and use, 2nd ed. Oxford: Oxford University Press, 1995.

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