How is pain managed during the emergent treatment of nephrolithiasis?

Updated: Jan 13, 2020
  • Author: Chirag N Dave, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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The cornerstone of ureteral colic management is analgesia, which can be achieved most expediently with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs). If oral intake is tolerated, the combination of oral narcotics (eg, codeine, oxycodone, hydrocodone, usually in a combination form with acetaminophen), NSAIDs, and antiemetics, as needed, is a potent outpatient management approach for renal (ureteral) colic.

According to the most recent 2018 Guidelines from the EAU, NSAIDs are now recommended as the first line therapy for pain management over opioids. [1] Recent studies have found them more effective, less likely to require additional pain medications when used, and in the setting of a growing opioid epidemic providers must do their part to minimize patient exposure to the addictive potential of narcotics. [50, 51]

A recent systematic review and meta analysis by Hollingsworth et al investigating the role of alpha-blockers in the treatment of ureteric stones addressed pain reduction and a secondary outcome and found medical expulsive therapy (MET) seemed helpful in reducing pain episodes of patients with acute ureteral colic. [52]

Parenteral narcotics are another mainstay of analgesia for patients with acute renal colic. They work primarily on the central nervous system (CNS) to reduce the perception of pain. They are inexpensive and quite effective. When considering a medication and dosage range, remember that acute renal colic is probably the most painful malady to affect humans. Adverse effects of narcotic analgesics include respiratory depression, sedation, constipation, a potential for addiction, nausea, and vomiting. Respiratory depression is the most concerning adverse effect which caused by a direct effect on the brain stem respiratory center. This effect is most severe in patients who are elderly, debilitated, or both.

Naloxone (0.4 mg or 1 mL) is a specific narcotic antagonist that can be administered to counteract inadvertent narcotic overdosage or unusual opioid sensitivity. Naloxone has no analgesic properties.

Of the NSAIDs, the only one approved by the US Food and Drug Administration (FDA) for parenteral use is ketorolac. Ketorolac works at the peripheral site of pain production rather than on the CNS. It has been proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects. [53, 54] The dosage is 30-60 mg IM or 30 mg IV initially followed by 30 mg IV or IM every 6-8 hours. A dose of 15 mg is recommended in patients older than 65 years.

In more severe cases, ketorolac is particularly effective when used together with narcotic analgesics. Oral ketorolac is available in 10-mg pills, but the efficacy of this form in persons with acute renal colic is less clear. Some practitioners use parenteral ketorolac in the hospital but recommend either ibuprofen for pain management in outpatients.

An intranasal ketorolac preparation is now available for moderate-to-severe pain and may be particularly useful for outpatient use in patients unable to take oral medication. A maximum of 5 days of ketorolac therapy is recommended.

Chemically, ketorolac is similar to aspirin and may increase the prothrombin time when administered with anticoagulants. Ketorolac can increase methotrexate toxicity and phenytoin levels. It is potentiated by probenecid and should be avoided in patients with peptic ulcer disease, renal failure, or recent gastrointestinal (GI) bleeding.

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