Oral indomethacin for acute renal colic

Sublingual desmopressin is efficient and safe in the therapy of lithiasic renal colic

PURPOSE

To evaluate the effects of newer sublingual desmopressin administration in lithiasic renal colic, alone or combined with a nonsteroidal anti-inflammatory drug (NSAID).

METHODS

Prospective single-blind study including an initial number of 249 patients with lithiasic renal colic was randomized as follows: group NSAID (71 patients) received ketorolac tromethamine (ketorolac) 30 mg im and sublingual placebo (vitamin C), groups D1 and D2 (57 and 62 patients) received sublingual desmopressin (Minirin Melt), 60 and 120 μg, respectively, whereas group C (59 patients) received a combination of 30 mg im ketorolac and 60 μg sublingual desmopressin. Pain intensity was assessed using the visual analogue scale before and thirty minutes after drug administration. Patients experiencing pain aggravation were rescued and excluded from the study.

RESULTS

Dropout incidence was higher in the NSAID group than in the groups treated with desmopressin in monotherapy or combined with ketorolac (p < 0.05). Pain intensity was diminished at least as potently by the monotherapy with desmopressin and ketorolac. The higher dose of desmopressin and the combination therapy decreased pain intensity with 56 and 59%, respectively, significantly more than the 47% decrease obtained with ketorolac alone (p < 0.05 and p < 0.001). Mean pain decrease was higher in the combination group (C) than in the NSAID or D1 groups (p < 0.001 and p < 0.05, respectively), suggesting drug additivity. Patients did not experience severe side effects.

CONCLUSIONS

Sublingual desmopressin is at least as potent as NSAID in the treatment of lithiasic renal colic. The combination of sublingual desmopressin and NSAID has additive analgesic effects.

Clinical efficacy of Spasmofen® suppository in the emergency treatment of renal colic: a randomized, double-blind, double-dummy comparative trial

Background

Renal colic is typically characterized by the sudden onset of severe pain radiating from the flank to the groin and its acute management in emergency departments essentially aims at rapid pain relief. Spasmofen^® is a brand of Amriya Pharmaceutical Industries in the form of rectal suppositories containing ketoprofen 100 mg and hyoscine butylbromide 10 mg. This combination is intended for the rapid relief of severe colicky pain in the renal system, hepatobiliary system, or gastrointestinal tract. This trial aims to compare a single-dose of Spasmofen rectal suppository to a single intravenous (IV) ketorolac tromethamine 30 mg/2 mL dose in patients with acute renal colic.

Methods

A total of 80 eligible consecutive patients presenting to the emergency departments of two medical centers with acute renal colic were included in the study. Eligible patients who signed the informed consent were randomly assigned into two treatment groups: an experimental group (Spasmofen group) who received one Spasmofen rectal suppository plus an IV injection of 2 mL of normal saline solution; and a control group (ketorolac group) who received one ketorolac 30 mg/2 mL ampoule IV plus one placebo suppository. Treatment success, defined as a change in the verbal rating score from severe or moderate pain to none or mild at 60 minutes after the dose, was compared between groups using the chi-square/Fisher’s exact test. Percentage reductions in visual pain analog scale (VPAS) scores at 15 and 60 minutes after the dose were compared between groups using the Z-test for proportions.

Results

Successful treatment at 60 minutes occurred in 35 of 40 (87.5%) of Spasmofen-treated patients and in 33 of 40 (82.5%) of ketorolac-treated patients. The difference was not statistically significant by Fisher’s exact test (P=0.755). The mean percentage reduction of VPAS after 15 minutes was 61.82% in the Spasmofen-treated group and 64.76% in the ketorolac-treated group. The difference was also not statistically significant by the Z-test for proportions (P=0.795). Sixty minutes after being treated, Spasmofen was associated with a statistically significant greater reduction in VPAS (mean% reduction =92.36%) than ketorolac (75.06%; P=0.0466).

Conclusion

Single-dose Spasmofen rectal suppository might be a safe and effective first-aid treatment for the emergency department relief of acute renal colic.

Time-dependent changes of resistive index in acute renal obstruction during nonsteroidal drug administration

OBJECTIVE

To evaluate Doppler ultrasonography (DUS) and assess time-dependent changes of the renal resistive index (RI) in acute unilateral renal obstruction during treatment with nonsteroidal analgesic for the relief of renal colic.

PATIENTS AND METHODS

In 31 patients with symptoms of renal colic, treated with ketoprofen, unilateral obstruction was confirmed by intravenous urography. The patients were divided into four groups according to the duration of their symptoms, i.e. < 23 h, 24-47 h, 48-72 h and > 72 h. In each patient, the RI was measured over the arcuate, segmental and renal arteries of both kidneys using DUS. The values obtained in the obstructed kidney were compared with those for the contralateral kidney.

RESULTS

The mean (sd) RIs for all 31 patients were 0.71 (0.05) for the obstructed and 0.60 (0.05) for the contralateral kidney (P < 0.001), the mean difference (dRI) being 0.12 (0.07). In those with obstruction for < 23 h the mean RI of the obstructed kidney was 0.70 (0.05) and of the contralateral healthy one 0.62 (0.07). Values of RI were similar in the group with obstruction for 24-47 h and 48-71 h. In those with obstruction for > 72 h the mean RI of the obstructed kidney was 0.69 (0.07) and of the contralateral one 0.60 (0.04), with a dRI of 0.09 (P < 0.005). The RI was 87% sensitive and 90% specific for detecting renal obstruction.

CONCLUSION

Although the patients were given ketoprofen, their mean RI for the obstructed kidney remained above the discriminatory threshold (> 0.70) during the first 71 h of obstruction. Only in those obstructed for > 72 h was the mean RI on the obstructed side slightly below the threshold, but the difference between the kidneys was significant. The measurement of RI is a reliable diagnostic method for detecting acute renal obstruction. With a longer duration of symptoms, the difference in RI between the kidneys becomes clinically more relevant.

Acute pain and pain control: state of the art

Recognition and treatment of pain in the emergency department has undergone an evolution in the past decade. Emergency clinicians, educators, and researchers have begun to address the undertreatment of pain as well as challenge the long-standing dogmas concerning pain treatment. Well-described barriers, both psychological and educational, contribute to our providing inadequate pain relief. This state-of-the-art update describes the current perception of our practice with regard to pain relief and how it can be modified. Pain and pain control is such a broad and complex topic that only new advances and important principles relevant to the practice of emergency medicine are presented. Headache, pediatric pain, and procedural sedation and analgesia are not covered in this article as they will be addressed in future state-of-the-art articles.

Resistive index in renal colic: the effect of nonsteroidal anti-inflammatory drugs

OBJECTIVE

To investigate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on the findings of Doppler ultrasonography (DU) in patients with acute unilateral renal obstruction.

PATIENTS AND METHODS

The study included 60 patients (120 kidneys) with unilateral loin pain suspected to be of renal origin. All patients were evaluated using renal ultrasonography (US) and intravenous urography (IVU) during the attack of loin pain and before giving any medication. Then the patients were given 75 mg diclofenac sodium and DU studies were repeated at 6 and 12 h. In 10 patients with acute renal colic, DU was possible 12-24 h after the relief of ureteric obstruction. The mean resistive index (RI) and DeltaRI at baseline were compared with the mean values 6 and 12 h after giving diclofenac. The RI and DeltaRI were considered positive at values >/=0.70 and >/=0.06, respectively. The sensitivity, specificity and overall accuracy of RI and DeltaRI values before and after giving diclofenac were calculated using IVU as the reference standard.

RESULTS

IVU showed that both kidneys were normal in 20 patients that 40 had unilateral obstruction. At baseline, the mean (sd) RI was 0.72 (0.06) in the 40 obstructed kidneys, significantly higher than the RI of 0.60 (0.06) for the 60 normal kidneys (P<0. 001). Six hours after giving diclofenac, the mean RI of normal kidneys remained stable and that of the obstructed kidneys decreased significantly to 0.67 (0.06) (P<0.001) and was almost stable at 12 h. Nevertheless, the mean RI of the obstructed kidneys remained significantly higher than that of the normal kidneys at 6 and 12 h after diclofenac. The mean DeltaRI decreased significantly from 0.11 (0.04) at baseline to 0.06 (0.04) at 6 h after diclofenac (P<0.001) and remained almost stable at 12 h. In the 10 patients undergoing DU after the relief of obstruction, the mean RI returned to normal. At baseline, RI was sensitive in 70% and specific in 98%, while DeltaRI was sensitive in 88% and specific in all cases. Six hours after diclofenac, the specificity of RI and DeltaRI remained stable while the sensitivity decreased significantly to 50% and 68%, respectively.

CONCLUSION

NSAIDs significantly decrease the RI of acutely obstructed kidneys, causing a significant reduction in the sensitivity of DU values identifying acute renal obstruction. To evaluate acute loin pain, DU should be carried out while the patient is in pain and before giving NSAIDs.

Resistive index in renal colic: a prospective study

OBJECTIVE

To study the role of Doppler ultrasonography (DU) in the diagnosis of acute unilateral renal obstruction.

PATIENTS AND METHODS

In all, 117 patients with suspected renal colic were evaluated by intravenous urography (IVU) and DU, with determination of the resistive index (RI) and the difference between the RI of ipsilateral and contralateral kidneys (deltaRI). RI and deltaRI were considered positive with values of > or = 0.70 and > or = 0.06, respectively. IVU results were considered the 'gold standard' with which renal DU findings were compared.

RESULTS

IVU showed both kidneys to be normal in 49 patients and unilateral ureteric obstruction with a normal contralateral kidney in 68. The mean (SD) RI was 0.73 (0.05) in 68 obstructed kidneys, significantly higher than the mean RI of 0.64 (0.05) in 166 normal kidneys (P<0.001). The deltaRI in patients with unilateral obstruction was significantly higher than that in patients with both kidneys normal, at 0.09 (0.05) and -0.001 (0.02), respectively (P<0.001). For all the patients, RI was sensitive in 77% and specific in 83%, and deltaRI was sensitive in 88% and specific in 98%. Obstructed kidneys showing delayed pelvicalyceal filling with excretion of contrast medium (n=42) had significantly higher values of RI and deltaRI than obstructed kidneys without delayed filling (n=26). The RI and deltaRI were more sensitive in the former group. Among patients with obstruction, the RI did not relate to the time of delay of filling with contrast medium, the duration of renal colic or the level of ureteric obstruction.

CONCLUSIONS

Renal DU is a sensitive and highly specific test that can contribute significantly to the diagnosis of acute unilateral renal obstruction. It can replace the IVU, particularly in situations where IVU is undesirable.

Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic

To compare the efficacy of intramuscular ketorolac and meperidine in the emergency department (ED) treatment of renal colic, a prospective, controlled, randomized, double-blind trial was conducted in an academic ED with 76,000 annual visits. Participants were volunteer ED patients with a diagnosis of ureterolithiasis confirmed by intravenous pyelogram. Subjects were randomized 1:1 to receive a single intramuscular injection of either 60 mg ketorolac or 100 to 150 mg meperidine, based on weight. Of the 70 patients completing the trial, 33 received ketorolac and 37 received meperidine. Demographic characteristics and baseline pain scores of both groups were comparable (P = NS, Mann Whitney U). Ketorolac was significantly (P < .05) more effective than meperidine in reducing renal colic at 40, 60, and 90 minutes as measured on a 10-cm visual analogue scale. Similar proportions of patients in each group were given rescue analgesia and admitted. Of patients who were discharged home without rescue, those treated with ketorolac left the ED significantly earlier than those treated with meperidine (3.46 v 4.33 h, P < .05). These results show that intramuscular ketorolac as a single agent for renal colic is more effective than meperidine and promotes earlier discharge of renal colic patients from the ED.

Acute pain management

Analgesic regimens should be based on sound clinical data and tailored to the individual patient's needs. The combination of specific agents for selected syndromes and traditional analgesics allows safe pain relief to be achieved for most emergency patients.

Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic

STUDY OBJECTIVES

To develop a protocol for the blinded IV titration of morphine and to compare the analgesic efficacy and side effect profile of indomethacin suppositories versus IV morphine in the treatment of acute ureteral colic.

DESIGN

Randomized, double-blind, double-dummy, two-period crossover study.

SETTING

Emergency department of a central-city, teaching hospital.

PARTICIPANTS

Patients 18 to 75 years of age with pain suggestive of ureteral colic. Exclusions included pregnancy, adverse reactions to the study drugs, chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or any pain medicine taken within four hours of ED admission.

INTERVENTIONS

Patients were randomized to one of two groups: indomethacin 100-mg rectal suppository or morphine by IV titration (5-mg loading dose and up to two additional 2.5-mg doses if needed). At the end of 30 minutes, if adequate pain relief had not been obtained, treatment was crossed over.

MEASUREMENTS

Verbal analog scale (initial pain) and visual analog pain relief scale.

MAIN RESULTS

Seventy-five patients were entered into the study. Only data from those patients with stone presence confirmed by IV pyelogram or stone passage were analyzed. Twenty-four could not be evaluated (23 who did not meet criteria for stone presence and one whose pain resolved spontaneously before study medications could be administered). Of the remaining 51 patients, 31 received indomethacin first and 20 received morphine first. Morphine recipients reported more pain relief at ten minutes (P = .02), but at 20 and 30 minutes, no significant difference (P = .17 and .74, respectively) existed between the two groups.

CONCLUSION

IV morphine produced more rapid analgesia than rectally administered indomethacin. There were no significant differences in vital sign changes or number of side effects between the two treatment groups. This study is the first to compare an NSAID with morphine administered by IV titration, considered by many to be the "gold standard" for relief of acute, severe pain. Future studies could evaluate the simultaneous administration of an opioid combined with an NSAID or compare an IV titrated opioid with an IV NSAID.

[Pain therapy in acute renal colic.]

The severe pain of a renal colic is an emergency and requires a fast and sufficient analgesic therapy with few side-effects. The release of the ureteral obstruction is secondary to this initial treatment. Inhibition of prostaglandin synthesis directly interferes with the mechanism of renal colic pain. Dipyrone, indomethacin and diclofenac are the drugs of choice. They should be administered intravenously if possible. Narcotic agents and their derivatives are the second choice. Spasmolytic agents are unnecessary in the treatment of renal colic.