We searched the Cochrane Renal Group's Specialised Register (to 27 November 2014) through contact with the Trials' Search Co-ordinator using search terms relevant to this review.
SELECTION CRITERIA: Only randomised or quasi randomised studies were included. Other inclusion criteria included adult patients with a clinical diagnosis of
renal colic due to
urolithiasis, at least one treatment arm included a non-
narcotic analgesic compared to placebo or another non-
narcotic drug, and reporting of
pain outcome or medication adverse effect. Patient-rated
pain by a validated tool, time to relief, need for rescue medication and
pain recurrence constituted the outcomes of interest. Any adverse effects (minor or major) reported in the studies were included.
DATA COLLECTION AND ANALYSIS: Abstracts were reviewed by at least two authors independently. Papers meeting the inclusion criteria were fully reviewed and relevant data were recorded in a standardized Cochrane Renal Group data collection form. For dichotomous outcomes relative risks and 95% confidence intervals were calculated. For continuous outcomes the weighted mean difference was estimated. Both fixed and random models were used for meta-analysis. We assessed the
analgesic effects using four different outcome variables: patient-reported
pain relief using a visual analogue scale (VAS); proportion of patients with at least 50% reduction in
pain; need for rescue medication; and
pain recurrence. Heterogeneity was assessed using the I² test.
MAIN RESULTS: A total of 50 studies (5734 participants) were included in this review and 37 studies (4483 participants) contributed to our meta-analyses. Selection bias was low in 34% of the studies or unclear in 66%; performance bias was low in 74%, high in 14% and unclear in 12%; attrition bias was low in 82% and high in 18%; selective reporting bias low in 92% of the studies; and other biases (industry funding) was high in 4%, unclear in 18% and low in 78%.Patient-reported
pain (VAS) results varied widely with high heterogeneity observed. For those comparisons which could be pooled we observed the following:
NSAIDs significantly reduced
pain compared to
antispasmodics (5 studies, 303 participants: MD -12.97, 95% CI -21.80 to - 4.14; I² = 74%) and combination
therapy of
NSAIDs plus
antispasmodics was significantly more effective in
pain control than
NSAID alone (2 studies, 310 participants: MD -1.99, 95% CI -2.58 to -1.40; I² = 0%).
NSAIDs were significantly more effective than placebo in reducing
pain by 50% within the first hour (3 studies, 197 participants: RR 2.28, 95% CI 1.47 to 3.51; I² = 15%).
Indomethacin was found to be less effective than other
NSAIDs (4 studies, 412 participants: RR 1.27, 95% CI 1.01 to 1.60; I² = 55%).
NSAIDs were significantly more effective than
hyoscine in
pain reduction (5 comparisons, 196 participants: RR 2.44, 95% CI 1.61 to 3.70; I² = 28%). The combination of
NSAIDs and
antispasmodics was not superior to
NSAIDs only (9 comparisons, 906 participants: RR 1.00, 95% CI 0.89 to 1.13; I² = 59%). The results were mixed when
NSAIDs were compared to other non-
opioid medications.When the need for rescue medication was evaluated, Patients receiving
NSAIDs were significantly less likely to require rescue medicine than those receiving placebo (4 comparisons, 180 participants: RR 0.35, 95% CI 0.20 to 0.60; I² = 24%) and
NSAIDs were more effective than
antispasmodics (4 studies, 299 participants: RR 0.34, 95% CI 0.14 to 0.84; I² = 65%). Combination of
NSAIDs and
antispasmodics was not superior to
NSAIDs (7 comparisons, 589 participants: RR 0.99, 95% CI 0.62 to 1.57; I² = 10%).
Indomethacin was less effective than other
NSAIDs (4 studies, 517 participants: RR 1.36, 95% CI 0.96 to 1.94; I² = 14%) except for
lysine acetyl
salicylate (RR 0.15, 95% CI 0.04 to 0.65).
Pain recurrence was reported by only three studies which could not be pooled: a higher proportion of patients treated with 75 mg
diclofenac (IM) showed
pain recurrence in the first 24 hours of follow-up compared to those treated with 40 mg
piroxicam (IM) (60 participants: RR 0.05, 95% CI 0.00 to 0.81); no significant difference in
pain recurrence at 72 hours was observed between
piroxicam plus
phloroglucinol and
piroxicam plus placebo groups (253 participants: RR 2.52, 95% CI 0.15 to12.75); and there was no significant difference in
pain recurrence within 72 hours of discharge between IM
piroxicam and IV
paracetamol (82 participants: RR 1.00, 95% CI 0.65 to 1.54).Side effects were presented inconsistently, but no major events were reported.
AUTHORS' CONCLUSIONS: