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Review
, 2004 (2), CD004137

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Versus Opioids for Acute Renal Colic

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Review

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Versus Opioids for Acute Renal Colic

A Holdgate et al. Cochrane Database Syst Rev.

Abstract

Background: Renal colic is a common cause of acute severe pain. Both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treatment, but the relative efficacy of these drugs is uncertain.

Objectives: To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic.

Search strategy: We searched the Cochrane Renal Group's specialised register (May 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 2, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles. Most recent search date: January 2005

Selection criteria: Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included.

Data collection and analysis: Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity.

Main results: Twenty trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were significantly less likely to require rescue medication (RR 0.75, 95% CI 0.61 to 0.93, P = 0.007), though most of these trials used pethidine. The majority of trials showed a higher incidence of adverse events in patients treated with opioids, but there was significant heterogeneity between studies so the results could not be pooled. There was significantly less vomiting in patients treated with NSAIDs (RR 0.35, 95% CI 0.23 to 0.53, P < 0.00001). In particular, patients receiving pethidine had a much higher rate of vomiting compared with patients receiving NSAIDs. Gastrointestinal bleeding and renal impairment were not reported.

Authors' conclusions: Both NSAIDs and opioids can provide effective analgesia in acute renal colic. Opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine.

Conflict of interest statement

None known

Figures

1.1
1.1. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 1 VAS at 30 minutes by variance measure.
1.2
1.2. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 2 VAS at 30 minutes by NSAID type.
1.3
1.3. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 3 VAS at 30 minutes pethidine or not.
1.4
1.4. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 4 Failure of complete pain relief at 30 minutes or next earliest.
1.5
1.5. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 5 Failure of complete relief by NSAID type.
1.6
1.6. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 6 Rescue analgesia required.
1.7
1.7. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 7 Rescue analgesia required by study quality.
1.8
1.8. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 8 Number of patients with adverse events.
1.9
1.9. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 9 Number of patients with adverse events by type of opioid.
1.10
1.10. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 10 Number of patients with adverse events by NSAID type.
1.11
1.11. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 11 Adverse events by study quality.
1.12
1.12. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 12 Adverse events by opioid route.
1.13
1.13. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 13 Vomiting as adverse event.
1.14
1.14. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 14 VAS at 30 minutes by route.
1.15
1.15. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 15 Failure of complete pain relief by route.
1.16
1.16. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 16 Rescue analgesia required by route.
1.17
1.17. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 17 Failure of complete pain relief by opioid type.
1.18
1.18. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 18 Vomiting as adverse event by opioid type.
1.19
1.19. Analysis
Comparison 1 NSAIDs versus opioids, Outcome 19 VAS at 30 minutes by NSAID type (excluding ketorolac).

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