Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute renal colic

Urolithiasis (urinary stones) is a common disease with an increasing incidence globally. It often presents with renal colic, which is characterised by acute and intense abdominal pain. The first step in the management of renal colic is pain control. Various medications, including narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), antispasmodics, and others, have been used for this condition. NSAIDs are amongst the most commonly used drugs for renal colic. They act by reducing inflammation and lowering the pressure inside the urinary collecting system. This review updates a previous Cochrane Systematic Review (Afshar 2015), focusing exclusively on NSAIDs.

To assess the benefits and harms of different nonsteroidal anti-inflammatory drugs (NSAIDs) for the management of pain in adults with acute renal colic.

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Google Scholar, trial registries, and conference proceedings up to 25 August 2023. We applied no restrictions on publication language or status.

We included randomised (or quasi-randomised) controlled trials (RCTs) assessing the effects of NSAIDs in the management of renal colic adult patients (i.e. study participants over 16 years of age). We included studies that compared NSAIDs versus placebo, one NSAID versus another, or different doses or routes of administration of the same NSAID.

Two review authors independently classified studies and abstracted data from the included studies. Primary outcomes included pain up to one hour after treatment as measured by a validated patient-reported tool, the need for rescue medication up to six hours after treatment, and serious adverse events up to one week after treatment. Secondary outcomes included pain recurrence, significant pain relief, and minor adverse events. We performed meta-analysis using the random-effects model. We rated the certainty of evidence according to the GRADE approach.

Our search identified 29 RCTs for inclusion in the review. The 29 studies involved a total of 3593 participants who were randomly allocated to treatment with an NSAID or placebo. The mean age of participants ranged from 27 to 47 years across the studies. Participants used a 10 cm visual analogue scale (VAS) to indicate the extent of their pain. NSAIDs versus placebo NSAIDs may reduce renal colic pain in 30 minutes compared to placebo (mean difference (MD) -3.84 cm, 95% confidence interval (CI) -6.41 to -1.27; I² = 95%; 3 studies, 250 participants; low-certainty evidence). The evidence is very uncertain about the effect of NSAIDs on the need for rescue medication (risk ratio (RR) 0.24, 95% CI 0.11 to 0.53; I² = 73%; 4 studies, 280 participants; very low-certainty evidence). NSAID versus NSAID Piroxicam may result in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD 0.01 cm, 95% CI -1.50 to 1.52; I² = 78%; 2 studies, 144 participants; low-certainty evidence). Parecoxib likely results in little to no difference in renal colic pain at 30 minutes compared to ketoprofen (MD 0.03 cm, 95% CI -0.59 to 0.65; 1 study, 337 participants; moderate-certainty evidence). Lornoxicam likely results in little to no difference in renal colic pain at 30 minutes compared to other NSAIDs (MD -0.22 cm, 95% CI -0.69 to 0.24; I² = 12%; 2 studies, 170 participants; moderate-certainty evidence). Ketorolac may result in little to no difference in renal colic pain at 60 minutes (MD 0.23 cm, 95% CI -1.16 to 1.62, 1 study, 57 participants; low-certainty evidence) and need for rescue medication within 120 minutes (RR 1.76, 95% CI 0.73 to 4.24; I² = 0%; 2 studies, 114 participants; low-certainty evidence) compared to diclofenac. Intravenous (IV) ketorolac may result in little to no difference in renal colic pain at 30 minutes compared to IV ibuprofen (MD 1.36 cm, 95% CI 0.85 to 1.87; I² = 84%; 2 studies, 361 participants; low-certainty evidence). IV ketorolac may result in less chance of significant pain relief within 30 minutes compared to IV ibuprofen (RR 0.17, 95 CI 0.04 to 0.73; 1 study, 240 participants; low-certainty evidence). Ketoprofen likely results in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD -0.43 cm, 95% CI -1.18 to 0.32; 1 study, 80 participants; moderate-certainty evidence). The evidence is very uncertain about the effect of ketoprofen on significant pain relief within 40 minutes compared to diclofenac (RR 1.38, 95% CI 1.08 to 1.78; 1 study, 80 participants; very low-certainty evidence). Indomethacin likely results in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD 0.20 cm, 95% CI -0.90 to 1.30; 1 study, 83 participants; moderate-certainty evidence). Pirprofen may result in a large reduction in the need for rescue medication within 30 minutes compared to indomethacin (RR 0.58, 95% CI 0.41 to 0.82; 1 study, 205 participants; low-certainty evidence). Intravenous NSAIDs likely result in little to no difference in renal colic pain at 30 minutes compared to intramuscular NSAIDs (MD -0.34 cm, 95% CI -1.19 to 0.51; I² = 42%; 2 studies, 134 participants; moderate-certainty evidence). Intravenous NSAIDs may reduce the need for rescue medication within 30 minutes compared to rectal NSAIDs (RR 0.35, 95% CI 0.14 to 0.88; 1 study, 116 participants; low-certainty evidence). The evidence is uncertain regarding the potential harms of NSAIDs. Risk of bias We judged the risk of bias in the studies to be moderate to high. This was due to a high proportion of unknown risk judgments for concealment bias and a high risk of selective reporting bias.

NSAIDs may reduce pain in adult patients with renal colic compared to placebo. Comparing one NSAID against another, IV ketorolac may be less effective than IV ibuprofen, and pirprofen may result in less need for rescue medication than indomethacin. The intravenous route of administration is probably similar to the intramuscular route but may be better than the rectal route. The evidence is uncertain regarding the potential harms of NSAIDs. We were not able to perform subgroup analysis based on our predefined criteria because there were no eligible studies.