Summary Table 4Studies on the management of acute pain in renal colic and biliary stone (KQ2)

Author, YearStudy Design, settingSample sizeClinical condition/ baseline painIntervention/ exposure of interestOutcomes measuredResults
Holdgate, 200715Cochrane systematic review, NSAIDs20 trials with 1613Most studies included only participants with renal calculi confirmed on subsequent testing, and excluded patients with negative results on followup tests.Trials compared one of 5 NSAIDS (diclofenac, indomethacin, indoprofen, ketorolac, tenoxicam), to 1 of 7 opioids (pethidine was used in 10 of the 20 trials). The intramuscular route was most commonly used for each drug type (10 trials), followed by the intravenous route (7 trials).Patient-rated pain and/or time, time to pain relief, need for rescue medication, rate of pain recurrence, adverse events. Major events were defined as GI hemorrhage, renal failure, hypotension, and respiratory depression. Minor adverse events were defined as GI disturbance without bleeding, dizziness, sleepiness.Patients receiving NSAIDs reported lower pain scores than patients receiving opioids in 10 of 13 studies, though the differences were small. No pooled results on efficacy due to heterogeneity. Use of rescue analgesia was significantly less likely with NSAIDs (RR 0.75, 95%CI 0.61–0.93).
More AEs with NSAIDs in the majority of trials, especially vomiting with pethidine.
The reviewers concluded that both NSAIDs and opioids provide effective analgesia in acute renal colic, but opioids, particularly pethidine, result in a higher incidence of vomiting and other adverse events.
Jasani, 199416Prospective DB RCT comparing hydrmorpho ne v. meperidine in a tertiary care center with 93,000 annual ED visits.36 hydrom orphone, 37 meperidine.Presumed ureteral colicComparable doses of the 2 medications were administered at t=0. The patients were randomized to receive either 50 mg meperidine (M) or 1 mg hydromorphone (H) IV in a double-blind manner.Remedication interval for patients requiring additional analgesia; proportions of men and nonrespondersBaseline VAS pain scores were similar between treatment groups at t=0. The H group had significantly lower pain intensity levels at each timepoint. The M group had significantly more nonresponders than the H group. Significantly fewer patients required IV pyelograms in the H group (28% v 54%, p=0.05) and there were fewer admissions in the H group than the M group (25% v 49%, p=0.08). AEs: there were more patients with nausea and vomiting in the M group compared with H: 40% v 28%, p=0.31. More patients on H had dizziness than did M (22% v 11%, p=0.25. The two groups experienced similar rates of drowsiness (41% H v 46% M).
Muriel-Villoria, 199517IM v. IV dipyroneVaried by intervention, 22–70Renal colicdipyrone 1g IM + placebo IV
dipyrone 1g IV + placebo IM
dipyrone 2g + placebo IM
dipyrone 2g + placebo IV
diclofenac 75mg IV + placebo IM
Proportion of patients with >50% improvementSignificant differences:
dipyrone 2g IV > 1g IV at 10’
dicloefenac 75 mg IV > IM at 20’
dipyrone 1g IV > 1g IM at 20’
Nelson, 198818Rectal v. IV indomethacinVaried by intervention, 53–63Renal colicindomethacin 100mg PR indomethacin 50mg IVVASPI at 10’IV significantly lower than PR; at 30’ no difference.
Supplementary analgesics: pr 16/47; IV 8/37
Nissen, 199019Rectal v. IV indomethacinVaried by intervention, 44–54Renal colicindomethacin 100mg PR indomethacin 50mg IVVASPI at 10’ and 20’:VASPI: IV significantly lower than PR; at 30’ no difference.
Use of supplementary analgesics: PR 17/63 v. IV 5/53 (p=0.03).
Uden, 198420Single-blind, randomized trial
Biliary stone: subcutaneous injection of dihydromporphinone v. IV indomethacin
42Acute attacks of biliary stone painGroup D received 1 mL of dihydromorphinone and patients in Group I received 50 mg of indomethacin intravenously. The surgeon on duty conducted patient exam and provided information about the ongoing study. (Subsequently?) the attendant nurse provided the drug injection, but the examiner was blinded to the treatment. Pain was evaluated at baseline and at 10 and 30 minutes after drug injection. In cases of insufficient pain relief, a second injection was given.Pain (VAS) at 10 and 30 minutes after administering treatmentN/total free of pain at 10 minutes and 30 minutes:
Group D: 2/21 at 10 min, 11/21 at 30 min
Group I: 2/21 at 10 min, 10/21 at 30 min
Mean scores at baseline, 10 minutes, and 30 minutes:
Group D: 71.8, 44.1, 14.2
Group I: 68.5, 32.4, 15.8
Pain reduction within each group was statistically significant (p<0.01) whereas the difference between the two groups was not.
AEs: 2 pts in each group felt nausea and vertigo. 1 in D developed a red, itching subcutaneous infiltration at injection site. 1 in Group I vomited during injection, another in Group I experienced nasal congestion.

From: APPENDIX E, Evidence Summary Tables

Cover of Assessment and Management of Acute Pain in Adult Medical Inpatients
Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review [Internet].
Helfand M, Freeman M.
Washington (DC): Department of Veterans Affairs (US); 2008 Apr.

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