Key messages
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce pain in adults with renal colic.
- Some NSAIDs may work better than others in adults with renal colic.
- The risks of NSAIDs in the treatment of renal colic are not clear.
What is renal colic?
Kidney (urinary) stones may cause sudden ('acute') and severe abdominal pain when they block urinary flow. This pain is known as 'renal colic'.
How is renal colic treated?
Different drugs are used to treat this severe abdominal pain, usually in an emergency setting. NSAIDs are given to decrease inflammation and pressure in the kidneys, which should relieve pain. There are many different types of NSAIDs used for this purpose. NSAIDs may cause unwanted reactions ('adverse events'). Unlike narcotics, which are also used for renal colic, NSAIDs are not addictive.
What did we want to find out?
We wanted to find out the benefits and harms of NSAIDs for the treatment of adult patients with renal colic.
What did we do?
We thoroughly searched the medical literature for studies that compared NSAIDs with placebo, or compared different types of NSAIDs. The treatment given to the participants was determined randomly, in order to reduce the risk of bias. The outcomes we were interested in were changes in the severity of pain, the need for more drugs to control the pain, and adverse events.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 29 studies that involved 3593 people (over the age of 16 years) with renal colic. The largest study involved 337 people. The average age of participants ranged from 27 to 47 years. The studies took place in 23 countries. Study duration varied between 30 minutes and 48 hours. Six studies received funding from the pharmaceutical industry, and 15 studies did not report their source of funding.
We found that NSAIDs may be more effective than placebo for reducing renal colic pain.
Intravenous ibuprofen (ibuprofen given into a vein) may be better than intravenous ketorolac at relieving pain within 30 minutes. Pirprofen may cause a large decrease in the need for additional medication compared to indomethacin.
Whether NSAIDs are administered via the intramuscular or intravenous route probably makes little to no difference in the reduction of renal colic pain. However, the intravenous route may be better than the rectal route.
For other comparisons and outcomes, there was either insufficient evidence to draw any conclusions or the evidence suggested there was no difference between the interventions.
We do not have enough information to draw any conclusions about the potential harms associated with using NSAIDs to treat renal colic.
What are the limitations of the evidence?
Our confidence in the evidence is generally low to very low, and the results of further research could differ from the results of this review. The studies either did not report information that we could use (especially about the risk of harm) or produced findings in which we have very little confidence. These studies were small or used methods likely to introduce errors into their results.
How up to date is this evidence?
The evidence is up to date to 25 August 2023.
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.
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.