Clinical Question: Are intravenous nonsteroidal anti-inflammatory drugs (NSAIDs) more effective than narcotics in the treatment of patients with acute renal colic?

Setting: Various (meta-analysis)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: The authors of this study scoured nephrology textbooks, review articles, study bibliographies, conference proceedings, and four databases to find the 20 trials that primarily compared intravenous NSAIDs with opioids in a total of 1,613 patients with acute renal colic. The authors did not describe how this search was performed or how articles were selected for inclusion. Of the nine trials that evaluated pain at a fixed time after therapy, pain reports were slightly but significantly lower in the NSAID group. The studies using ketorolac produced heterogeneous results, but other NSAIDs produced scores that were lower, on average, by 4.6 mm on a 100-mm visual analog scale (a difference of 13 to 15 mm is considered clinically relevant). The number of patients with complete pain relief at 30 or 60 minutes was similar in the two groups. However, the risk of patients requiring rescue (i.e., additional) analgesia was significantly less in the NSAID group (relative risk [RR] = 0.75; 95 percent confidence interval [CI], 0.61 to 0.93).

Approximately 16 patients who received an NSAID instead of a narcotic (nine of 10 trials used meperidine) would need to be treated for one additional patient to avoid the use of additional analgesia (number needed to treat = 16; 95 percent CI, 10 to 57). Vomiting occurred less often with NSAIDs than with narcotic treatment (RR = 0.35; 95 percent CI, 0.23 to 0.53), with one fewer patient experiencing vomiting for every eight patients treated with an NSAID instead of an opioid (95 percent CI, 7 to 11). The risk of vomiting was highest among those treated with meperidine. The effect of the type of analgesia on the duration of colic was not evaluated in these studies, although their pharmacology would suggest that NSAIDs would produce more rapid resolution.

Bottom Line: NSAIDs produce analgesia equal to or better than that of opioid narcotics, reduce the need for additional analgesia, and result in less vomiting among patients with renal colic. The investigators did not study a potential benefit of NSAIDs on the duration of colic—their ability to cause ureteral dilation may hasten stone passage. (Level of Evidence: 1a)