Review – Stone DiseaseA Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic☆
Introduction
Renal colic is a common abdominal complaint with millions of emergency department visits worldwide due to excruciating pain. The reported prevalence of kidney stone varies widely from 0.1% to 18.5% [1], with a recurrence of stone in about 50% of cases over 5–10 yr.
Acute pain management is the main expectation of patients in severe pain from renal colic. The most important factors deciding the choice of initial analgesia include the safety, efficacy, cost, and availability of a drug, in addition to patient and clinician preferences [2]. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been recommended as the first-line analgesic [3], [4], [5], [6] based on the mechanism of action of prostaglandin synthesis inhibition and supported by the evidence of effectiveness [7]. However, NSAID use as the first-line analgesic in clinical practice has repeatedly been challenged, and many clinicians continue to prefer opioid treatment [8], [9]. The practice of using opioids as the preferred analgesic in renal colic is advocated based on the advantage of titrating the dose according to pain severity and lack of adverse events such as renal failure and gastrointestinal (GI) bleeding reported with NSAID treatment [8]. Following the last Cochrane review [7] concluding that NSAID treatment achieved higher pain reductions with a superior adverse effect profile compared with opioids, some randomized controlled trials (RCTs) with contrary evidence have been published [10], [11], [12]. In addition, alternative analgesics including paracetamol have been studied. Paracetamol (acetaminophen) has been reported to provide equal [13], [14] or better [15], [16] analgesia than opioids for the treatment of renal colic.
The uncertainty evident in current clinical practice requires an assessment review of the efficacy and safety of analgesics commonly used in renal colic. Therefore, we aimed to compare the efficacy and safety of NSAIDs against opioids or paracetamol for the management of acute renal colic.
Section snippets
Evidence acquisition
The protocol for this systematic review was registered on PROSPERO (CRD42016047559), and the detailed methodology was published [17] following the Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations for reporting of protocols (PRISMA-P).
Quantity of evidence identified
A total of 36 RCTs [10], [11], [12], [16], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55] (including 4887 patients), published from 16 countries between 1982 and 2016, were included in this systematic review (Fig. 1). Five articles were published in non-English literature (three in Spanish [30], [43], [46], one in Norwegian [29], and one in Danish [40]
Conclusions
NSAIDs were at least equivalent to opioids and paracetamol for the relief of acute renal colic pain at 30 min after delivery. There was less vomiting and fewer requirements for rescue analgesia compared with opioids. NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of
References (64)
- et al.
EAU guidelines on diagnosis and conservative management of urolithiasis
Eur Urol
(2016) - et al.
Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial
Ann Emerg Med
(2009) - et al.
Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial
Lancet
(2016) Measurement of pain
Lancet
(1974)- et al.
The measurement of clinical pain intensity: a comparison of six methods
Pain
(1986) - et al.
Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic
Ann Emerg Med
(1994) - et al.
Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic
Ann Emerg Med
(1996) - et al.
Paracetamol vs piroxicam to relieve pain in renal colic. Results of a randomized controlled trial
Am J Emerg Med
(2011) - et al.
Comparison of the efficacy of diclofenac, acupuncture, and acetaminophen in the treatment of renal colic
Am J Emerg Med
(2015) - et al.
Treatment of pain owing to acute ureteral obstruction with prostaglandin-synthetase inhibitor: a prospective randomized study
J Urol
(1986)
Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic
Am J Emerg Med
Prostaglandin-synthetase inhibition with diclofenac sodium in treatment of renal colic: comparison with use of a narcotic analgesic
Lancet
Papaverine hydrochloride for the treatment of renal colic: an old drug revisited. A prospective, randomized study
J Urol
Titrated doses are optimal for opioids in pain trials—authors’ reply
Lancet
Kidney stones: a global picture of prevalence, incidence, and associated risk factors
Rev Urol
Pseudo-objectivity in the conduct and reporting of systematic reviews: an example
BMJ
Managing patients with renal colic in primary care: Know when to hold them
BPJ
Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic
Br Med J
Nephrolithiasis treatment & management. Medscape, Drug & Disease, Urology section, stone articles; Chief Editor: Schwartz BF. Updated 03
American Urological Association, Medical Student Curriculum: Kidney Stones
Intravenous tenoxicam for the treatment of renal colic
N Z Med J
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
Analgesic effects and safety of desmopressin, tramadol and indomethacin in patients with acute renal colic; a randomized clinical trial
Bull Emerg Trauma
Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial
Emerg Med J
Comparison of clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic: a randomized, double-blind, controlled trial
Emerg Med Int
What is the best analgesic option for patients presenting with renal colic to the emergency department? Protocol for a systematic review and meta-analysis
BMJ Open
Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic
Cochrane Database Syst Rev
Basics of meta-analysis: I2 is not an absolute measure of heterogeneity
Res Synth Methods
Interpretation of random effects meta-analyses
BMJ
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