This Too Shall Pass: A Review of Effective Analgesia for Nephrolithiasis
Case Presentation:
62yo M presents to the ED with 2 days of left sided flank pain and hematuria
Sharp colicky flank pain radiating to the groin
PMH notable for recurrent nephrolithiasis and morphine allergy
PE: + L costovertebral angle tenderness
Labs: UA + for RBCs w/o casts. Serum Cr 1.5 (baseline 1.1)
CT abd/pelvis: 6mm obstructing stone in proximal left ureter (shown below)
The classic teaching for management of kidney stones focuses on hydration and analgesia before surgical management. Analgesia has typically been a combination of opioids and NSAIDs. Pain management for this specific patient was complicated by two obstacles: NSAIDs were contraindicated because of acute kidney injury, and the patient was allergic to opioids.
Clinical Question: What analgesic options are effective in managing renal colic?
Summary of Evidence:
NSAIDs: The mainstay of pain management. Multiple studies have shown potent analgesia from NSAIDs.
A systematic review of 36 RCTs published between 1982 and 2016 including 4887 patients showed superior or equivalent efficacy of NSAIDs to opioids and fewer adverse effects -- less nausea/vomiting and no risk of dependency.(1)
Specifically, ketorolac has been shown to provide greater analgesia than an equivalent dose of meperidine in a single-study RCT.(2)
Opioids: 2nd-line treatment Have been shown to have similar efficacy to NSAIDs.
Higher rate of adverse effects such as nausea and vomiting when compared to NSAIDs making it 2nd line.(1)
Limited evidence for combination of NSAIDs and opioids: single center RCT at an urban ED showed greater analgesia at 40 min with meperdine and ketorolac vs either medication separately.(3)
Cardiac Lidocaine IV: Initially shown to be effective for perioperative pain with few adverse effects, thereby reducing opioid use.(4) Co-opted for management of renal colic.
Initial study in a single-center in Iran compared the efficacy of IV lidocaine vs IV morphine. Progressive double blind RCT of 240 adults with renal colic assessed pain before analgesia was administrated and after administration. Results demonstrated higher rates of pain relief with IV lidocaine and fewer adverse effects.(5)
Other clinical trials have subsequently verified effect of IV lidocaine in treating renal colic but there has been some discrepancy over its superiority to opioids.(5-7)
Alpha-1 agonists: proposed to act on alpha-1 receptors lining the ureter and decrease tone/contractions, thereby facilitating stone passage and relieving pain.
A systematic review of multiple RCTS performed in North America and Europe reviewed efficacy of tamsulosin and nifedipine vs placebo for stone expulsion and analgesia among patients with uncomplicated distal ureteral obstruction from stones <10mm. Found to improve rates of stone expulsion and pain relief, but only in patients with stones smaller than 5mm.(7)
Recent SUSPEND trial enrolled 1167 patients with kidney stones from 24 UK hospitals. Also compared tamsulosin to nifedipine and placebo. Unlike the prior study, it found no improvement in stone passage or analgesia regardless of location or size of stone.(8)
Calcium Channel Blockers: smooth muscle relaxant; decrease ureteral tone
RCTs in Europe and China studied efficacy of nifedipine in distal ureter obstruction compared to tamsulosin. Results demonstrated similar or poorer analgesia compared to tamsulosin with more adverse events (GI upset, hypotension, breakthrough pain).(7,9)
Recommendations:
Initial management with NSAIDs (ketorolac recommended) or NSAID/opioid combination
IV lidocaine should be reserved for refractory pain or if NSAIDs and opioids are contraindicated. Administration should be coupled with cardiac monitoring
For distal ureteral stones >5 mm, tamsulosin can be used. No clinical indication for use with more proximal stones or stones < 5mm
Nifedipine and other CCBs should be avoided due to lack of efficacy and potential adverse effects
References:
1. Pathan SA, Mitra B, Cameron PA. A Systematic Review and Meta-analysis Comparing the Efficacy of Nonsteroidal Anti-inflammatory Drugs, Opioids, and Paracetamol in the Treatment of Acute Renal Colic. Eur Urol. 2018;73:583-595.
2. Larkin GL, Peacock WF, Pearl SM, Blair GA, D'Amico F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. Am J Emerg Med. 1999;17:6-10.
3. Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D'Onofrio G. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med. 2006;48:173-181, 181.e171.
4. Vigneault L, Turgeon AF, Côté D, et al. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth. 2011;58:22-37.
5. Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;12:13.
6. Keller D, Seamon J, Jones JS. BET 2: Usefulness of IV lidocaine in the treatment of renal colic. Emerg Med J. 2016;33:825-826.
7. Gottlieb M, Long B, Koyfman A. The evaluation and management of urolithiasis in the ED: A review of the literature. Am J Emerg Med. 2018;36:699-706.
8. Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015;386:341-349.
9. Dellabella M, Milanese G, Muzzonigro G. Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. J Urol. 2005;174:167-172.