NSAIDs to Manage Acute Renal Colic Pain

How do nonsteroidal anti-inflammatory drugs (NSAIDs) compare with placebo and each other for managing moderate to severe pain in adults with acute renal colic?

In adults with acute renal colic, NSAIDs provide clinically meaningful pain relief at 30 minutes. (Strength of Recommendation [SOR]: A, consistent, good-quality patient-oriented evidence.) NSAIDs also reduce the need for rescue analgesia within 1 hour.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Renal colic occurs when urinary stones obstruct the ureter, producing sudden, severe flank or abdominal pain.¹ This Cochrane review sought to determine how various NSAIDs compare with placebo and each other for control of renal colic pain.

This Cochrane review included 29 randomized controlled trials (N = 3,593) in 23 countries, none in the United States, mostly in emergency department settings.¹ All studies used a 10-cm visual analog scale to report participant pain. Primary end points included short-term pain reduction, need for rescue medication up to 6 hours after initial analgesic administration, and serious adverse events.

Compared with placebo, NSAIDs provided clinically meaningful pain reduction at 30 minutes (mean difference = −3.8 cm on a 10-cm visual analog scale; 95% CI, −6.41 to −1.27; I² = 95%; based on three studies; n = 250; low-certainty evidence).¹ NSAIDs also reduced the need for rescue analgesia within 1 hour (absolute risk reduction of approximately 58%; number needed to treat to prevent one patient from needing rescue analgesia = 2; four studies; n = 280; very low-certainty evidence). Across 15 head-to-head comparisons, there was little to no difference among NSAIDs in 30- to 60-minute pain relief scores on visual analog scales, with moderate- to very low-certainty evidence.

Adverse events were inconsistently reported across trials, limiting conclusions about NSAIDs’ comparative safety for renal colic.¹ No serious adverse events were reported in the placebo-controlled studies; data on minor events were sparse. Because most included trials were small and of short duration, evidence is insufficient to rule out uncommon but clinically important harms (eg, acute kidney injury, gastrointestinal bleeding).

A 2015 Cochrane review including 50 trials that compared NSAIDs with other nonopioid treatments concluded that NSAIDs were superior to placebo and antispasmodics for pain control in renal colic, and adding an antispasmodic to an NSAID conferred no additional benefit.² More recent network meta-analyses have reinforced that although opioids remain an option for refractory pain, NSAIDs consistently decrease perceived pain and are associated with fewer adverse effects.³ The European Association of Urology and the National Institute for Health and Care Excellence guidelines recommend NSAIDs as initial analgesics for acute renal colic.^4,5

Editor’s Note: The absolute risk reduction and numbers needed to treat in this review were calculated by the authors based on raw data provided in the original Cochrane review.

The practice recommendations in this activity are available at https://www.cochrane.org/CD006027.