4. Best Pain Medications in Renal Colic?

Take Home: For patients with renal colic, I will use both an NSAID and opiate up front for pain control.  This study has some problems with dosing, but overall supports a practice that makes intuitive sense.

Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic

– BMJ 2004

Click to access 1401.full.pdf

Review of 20 studies and 1613 patients from 1982-1999 with high variability in quality of study, medications compared, protocols, placebos, etc…


PAIN control: 7/9 studies comparing NSAIDS to Opiates favored NSAIDs, 1 showed no difference, while only 1 favored opioids.

June 1

Rescue Analgesia: NSAIDS  decreased need for rescue analgesia vs Opiates.

june 2

Vomiting: NSAIDs decreased likelihood of vomiting. (meperidine (Demerol) studies had a large biasing effect on this result)

june 3

Interestingly, NONE of these studies compared our two most common treatments: Toradol and Morphine, Until:

Intravenous morphine plus ketorolac superior to either drug alone for treatment of acute renal colic.

– Annals of Emerg Med 2006

Study: Randomized Prospective trial comparing ketorolac vs morphine vs morphine and ketorolac together

Population: 18-55 yo with diagnosis of renal colic and pain >/= 5 on VAS

Interventions: Pts divided into three groups, got:

  • 5mg morphine IV (M)
  • 15mg Ketorolac IV(K), or
  • Both (B).

0 min – Randomized medications given

20 min – Reassessed at to see if patient needed redosing. (Re-dosed was done with the same medication to which they were randomized).

40 min – Final Outcome measured.

Primary Outcome: Pain level on 10 point VAS at 40 minutes.

Secondary Outcomes: need for rescue meds at 40 min, side effects

Results: 130 patients randomized

Pain at time 0 min = 8.7 (equal in all groups)

Ketorolac Morphine Both
Pain Score at 40m 4.0 2.7


Needs Rescue Med 33% 42%


Nausea/Vomiting 2% 24% 6%

Conclusions: Though the dosing of the medications in this study is suboptimal (low dose for ketorolac and not weight based for morphine), it seems that a combination of morphine and Toradol does improve symptoms, which makes intuitive sense. 

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