The efficacy of intranasal desmopressin as an adjuvant in the acute renal colic pain management

Potential clinical applications of current and future oral forms of desmopressin (Review)

Desmopressin is a synthetic analogue of vasopressin and a selective vasopressin receptor 2 agonist. It was first synthesised in 1967 and utilised for its antidiuretic properties. It is also used in bleeding disorders to enhance clotting. Other potential uses of the drug have been reported. The present review aims to provide a broad overview of the literature on potential further uses of oral forms of desmopressin. Key therapeutic areas of interest were identified based on known physiological activities/targets of desmopressin or reports of an effect of desmopressin in the literature. The feasibility of adequate dosing with oral forms of the drug was also considered. Systematic literature searches were carried out using the silvi.ai software for the identified areas, and summaries of available papers were included in tables and discussed. The results of the searches showed that desmopressin has been investigated for its efficacy in a number of areas, including bleeding control, renal colic, the central nervous system and oncology. Evidence suggests that oral desmopressin may have the potential to be of clinical benefit for renal colic and bleeding control in particular. However, further research is needed to clarify its effect in these areas, including randomised controlled studies and studies specifically of oral formulations (and doses). Further research may also yield findings for cancer, cognition and overactive bladder.

Methodology and findings of randomized clinical trials on pharmacologic and non-pharmacologic interventions to treat renal colic pain - a review

Introduction

Renal colic pain is considered one of the most excruciating pains ever experienced and ranks as one of the most common urological emergencies. Despite existing established recommendations, new therapies and their combinations are continuously being tested. The aim of this systematic review is to analyze and compare studies involving pharmacologic and non-pharmacologic interventions used in the treatment of renal colic pain.

Material and methods

This systematic review was conducted following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Medline, Scopus, Cochrane Library, and Google Scholar were searched for relevant randomized controlled trials (RCTs) involving adult patients. The quality and results of the included studies were assessed and discussed.

Results

This review provides an extensive analysis of 71 identified RCTs. Opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and dipyrone/metamizole have demonstrated effectiveness as single medications. Some evidence points to opioids having a potential disadvantage compared to others when used as a first-line single medication. Among the 63 studies exploring pharmacological therapy, 51 reported opioids utilization for rescue therapy in significant proportion of patients. Promising combination therapies involve the administration of an NSAID alongside opioids, ketamine, desmopressin, steroids, or nitric oxide. Conversely, spasmolytics, magnesium, and lidocaine exhibited limited or no additional effect. Noteworthy methodological shortcomings encompass a low pain threshold during participant recruitment and the reliance on pain reduction rather than complete pain elimination as an endpoint.

Conclusions

Frequent use of opioids as rescue medications in RCTs undermine their conclusions on effectiness of other therapeutics. Combination therapies should be considered as first choice in renal colic pain management. RCTs should define success of therapy as achieving complete or near-complete pain relief rather than pain reduction.

Desmopressin effectiveness in renal colic pain management: Systematic review and meta-analysis

OBJECTIVE

This meta-analysis of trials was conducted to evaluate the impact of desmopressin on renal colic pain relief in comparison to more typically used medications (opioids and nonsteroidal anti-inflammatory drugs [NSAIDs]).

METHODS

PubMed, EMbase, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trials. Pain reduction and need for rescue treatment were the outcomes of interest.

RESULTS

Ten studies met our inclusion criteria and were analyzed. Pooling of data showed that, on a scale of 1-10, pain reduction after 30 minutes was significantly higher in NSAID in comparison to desmopressin (3.39 with a 95% confidence interval [CI] of 4.62-2.16; P<.01), but this reduction was not significantly different between NSAID and desmopressin-NSAID combination (-0.28 with 95% CI of -0.62 to 0.05; P=.01). Summary of relative risk (RR) for the need for rescue treatment in desmopressin in comparison to NSAID was 0.31 with a 95% CI of 0.13-0.74 and a significant RR (P<.04), but no difference was shown in desmopressin-NSAID combination in comparison to NSAID (0.70 with a 95% CI of 0.49-1.00; P<.19). On this outcome, desmopressin in comparison to opioid showed insignificant RR (1.82 with a 95% CI of 0.36-4.34; P=.72), but this need in desmopressin in comparison to desmopressin-opioid combination was 0.75 with a 95% CI of 0.56-0.99 and a significant RR (P=.042).

CONCLUSION

In conclusion, the results of this systematic review suggest that, according to the present low-quality studies, desmopressin can be used as an adjuvant therapy in renal colic management in combination with opioids.

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.

Analgesic Effects and Safety of Desmopressin, Tramadol and Indomethacin in Patients with Acute Renal Colic; A Randomized Clinical Trial

OBJECTIVE

To compare the efficacy of desmopressin (DDAVP), tramadol and indomethacin on pain intensity of patients with acute renal colic caused by urolithiasis.

METHODS

This prospective, randomized clinical trial was conducted between July 2005 and July 2006 including 120 patients (70 men and 50 women, mean age 38.2±5.8 years) referring to emergency room of Shahid Faghihi hospital with renal colic caused by urolithiasis without any previous treatment. The patients were randomly assigned to three groups: group A received tramadol 50mg intramuscularly (n=40), group B received desmopressin 40 µg intranasally (n=40) and group C received indomethacin 100mg rectally (n=40). The pain was assessed both on admission and 30 minutes after the intervention. The pain intensity and the side effects were compared between two study groups.

RESULTS

There was no significant difference between two study groups regarding the baseline characteristics. The intensity of pain of presentation was almost similar in all groups. In group A, 30 patients (75%), in group B, 15 patients (37.5%) and in group C, 19 patients (47.5%) had complete pain relief. The pain intensity decreased significantly after the intervention within all three groups (p<0.001).

CONCLUSION

According to the results of the current study, rectal indomethacin, intramuscular tramadol and intranasal desmopressin are effective and safe routs of controlling pain in acute renal colic secondary to urolithiasis. Tramadol was the most effective agent in controlling the pain.