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Three Part Question

In [patients presenting with suspected renal colic to the ED] is the [administration of a combination of intravenous NSAID and opioids better than an intravenous non-steroidal anti-inflammatory drug alone or an opioid alone] at [providing adequate analgesia]?

Clinical Scenario

An adult with an acute onset of severe, colicky, left-sided loin pain presents at your emergency department. Your clinical examination and laboratory results suggest a diagnosis of ureteric stone disease.

As the majority of renal calculi will pass spontaneously, the focus of acute management should be rapid pain relief. While opiates can offer pain relief by subduing patients' awareness of these stimuli, NSAID's can actually treat the pathophysiological mechanisms that cause them in the first place.

Search Strategy

Pubmed (MEDLINE)1966–March 2008.

intravenous AND ("opioid analgesics"[Text Word] OR "analgesics, opioid"[MeSH Terms] OR "analgesics, opioid"[Pharmacological Action] OR opioid[Text Word]) AND ("colic"[MeSH Terms] OR colic[Text Word]) AND ("non-steroidal anti-inflammatory agents"[Text Word] OR "anti-inflammatory agents, non-steroidal"[MeSH Terms] OR "anti-inflammatory agents, non-steroidal"[Pharmacological Action] OR NSAID[Text Word]) AND ("humans"[MeSH Terms] AND English[lang])

Search Outcome

The Cochrane Database, Embase, DARE Database, TRIP database, SUMsearch and MD Consult were searched for NSAIDS AND opioid AND colic. There were no new relevant articles found.

23 Papers were found in Pubmed of which 21 were irrelevant because they did not include a combination therapy with NSAIDs and Morphine or they administered the medications by a different route.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cordell 1996 august USA	106 patients; 60 mg Ketorolac Vs50 mg Meperidine Vs a combination of both	prospective, double-blind, randomised controlled trial	Effectiveness (reduction of pain intensity scores 30 min after administration of 1st dose of drug).	Ket > Mep (P<0.001) Combination = Ket (P<0.052)	Use of doubled dose instead of normal dose of Ketorolac, which is 30 mg IV.31% Of patients excluded because diagnosis could not be confirmed.Use of anti-emeticum may have affected pain perception
			% Of patients requiring additional analgesia after 30 min.	Mep 89% Ket 64%Combination 66% Combination = Ket (P=.67)
			% Of patients with adverse effects	55% Mep 37% Ket67% Combination Combination > Ket (P<.002)
Safdar 2006 USA	130 patients; 5 + 5 mg Morphine Vs 15 + 15 mg Ketolorac Vs a combination of both (t=0 en t=15 minutes)	prospective, double-blind, randomized controlled trial	Effectiveness/Pain reduction after 30 minutes.	Ket = Morphine Combination > Morphine P<.003Combination > Ketorolac P<.003	Use of anti-emeticum Promethazine may have affected pain perception.Data are based on clinical diagnosis, not on confirmatory studies.
			% Of patients requiring additional analgesia after 30 min.	Morphine 42% Ket 33%Combination 16% Combination < Morphine [OR 0,3]Combination < Ket [OR 2,55], but not significant
			% Of patients with adverse effects	37% Morphine 4% Ketorolac 17% Combination

Comment(s)

These studies might have used low dosages of NSAIDs and inappropriate dosages of Morphine. Further evaluation should include maximal initial dosages for NSAIDs and dosages based on the patient’s individual weight for Morphine.

Clinical Bottom Line

A combination of NSAID and Morphine intravenously in a normal dose is most effective in reducing pain from acute renal colic in the ED.

References

1. Cordell Comparison of intravenous ketorolac, meperidine, and for renal colic Ann Emerg Medicine 1996 Aug;28(2):151-8
2. Safdar Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic Ann Emerg Med 2006 Aug;48(2):173-81