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Three Part Question

In [patients with a clinical diagnosis of renal colic] is [PR NSAIDs better than IM NSAIDs] at [reducing pain (length and speed of analgesia)]?

Clinical Scenario

A 21 year old male presents to the emergency department with sudden onset of left lumbar pain radiating to the groin. A clinical diagnosis of renal colic is made. You wonder whether rectal NSAID's would be more effective than IV or IM NSAIDs?

Search Strategy

Medline 1966 – 03/2005 using the OVID interface
The Cochrane Library of systematic reviews Issue 1 2005
Medline
[Exp Urinary Calculi/ or exp Kidney Calculi OR renal colic.mp OR ureteric colic.mp OR renal calculi.mp OR kidney stone.mp] AND [exp Anti-Inflammatory Agents, Non Steroidal/ or NSAID.mp] limit to (humans and english language)
Cochrane
renal colic OR NSAID

Search Outcome

179 papers were found of which two were relevant to the question.
No additionally relevant citations were found in The Cochrane Library.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nelson CE et al, 1988, Sweden	84 patients from two emergency departments with a preliminary diagnosis of acute renal colic who later had diagnosis confirmed by IVU or urine sediment. Patients received one rectal and one iv injection. Randomised to receive 100mg indomethacin PR plus placebo iv injection (riboflavin coloured saline) in 37 patients OR placebo PR plus 50mg indomethacin intravenously in 47 patients.	Double blind RCT	Pain severity score (visual analogue scale 0-100) at 0, 10, 20 and 30 minutes after treatment	Faster analgesic effect with iv vs rectal at ten minutes. Effective reduction in mean pain score for both groups (74, 39, 22, 14 for IV Vs 82, 41, 34, 22 for PR).	Excluded patients if could not retain rectal drug therefore did not analyse as intention to treat.
			Side effects.	Significantly more side effects in intravenous group (49%) vs rectal group (17%).
			Need for supplementary analgesia.	No significant difference in need for supplementary analgesia 21% IV Vs 34% PR.
Nissen I, et al 1990 Denmark	116 patients from ten departments of surgery/urology with clinical symptoms of ureteric colic who were later proven to have a stone on IVU or on passage of stone. Randomised to receive 100mg indomethacin PR or 50mg indomethacin IV.	Double blind RCT	Intensity of pain (visual analogue score 0-100) at 0, 10, 20 and 30 minutes after treatment.	Analgesia achieved faster in the intravenous group. Significant improvement in mean relative pain intensity in both groups.	Does not describe how study was randomised. Included 42 patients in analysis of adverse reactions who had no proven diagnosis.
			Adverse events at time of treatment.	More adverse reactions in intravenous group (44/80, 55%) vs PR group (29/79, 37%) (P=0.03).
			Need for supplementary analgesia.	Need for supplementary analgesia in 27% of PR group Vs 9% of IV group (P=0.018)

Comment(s)

There are many studies in the literature which compare intravenous to intramuscular NSAID use in acute renal colic. Unfortunately no studies were found comparing intramuscular NSAID's with rectal NSAID which are commonly used in our emergency departments. Rectal NSAIDs have advantages in busy departments by providing urgent analgesia when there are delays in staff available to cannulate the patient and the patient is vomiting.

Clinical Bottom Line

Rectal NSAIDs are an effective form of analgesia for patients with acute renal colic and have fewer side effects compared to intravenous NSAIDs.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Nelson CE, Nylander C, Olsson AM, et al. Rectal v. intravenous administration of indomethacin in the treatment of renal colic. Acta Chirurgica Scandinavica 1988;154(4):253-255.
2. Nissen I, Birke H, Olsen JB, Wurtz E, Lorentzen K, Salomon H et al Treatment of ureteric colic. Intravenous versus rectal administration of indomethacin. Br J Urol 1990; 65:576-579.