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
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.
Rescue Analgesia: NSAIDS decreased need for rescue analgesia vs Opiates.
Vomiting: NSAIDs decreased likelihood of vomiting. (meperidine (Demerol) studies had a large biasing effect on this result)
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)
|Pain Score at 40m||4.0||2.7||
|Needs Rescue Med||33%||42%||
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.