Context

Renal colic is a common, acute presentation of urolithiasis that requires immediate pain relief. European Association of Urology guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia. However, the fear of NSAID adverse effects and the uncertainty about superior analgesic effect have maintained the practice of advocating intravenous opioids as the initial analgesia.

Objective

The objective of this systematic review and meta-analysis was to compare the safety and efficacy of NSAIDs with opioids and paracetamol (acetaminophen) for the management of acute renal colic.

Evidence acquisition

Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, World Health Organization International Clinical Trials Registry Platform, Google Scholar, and the reference list of retrieved articles were searched up to December 2016 without language restrictions. Two reviewers independently assessed eligible studies using the Cochrane Collaboration tool for assessing and reporting the risk of bias and abstracted data using predefined data fields.

Evidence synthesis

From 468 potentially relevant studies, 36 randomized controlled trials (RCTs) including 4887 patients, published between 1982 and 2016, were included in this systematic review. The treatment effect observed indicated marginal benefit of NSAIDs over opioids in initial pain reduction at 30 min (11 RCTs, n = 1985, mean difference [MD] –5.58, 95% confidence interval [CI] –10.22 to –0.95; heterogeneity I² = 81%). In the subgroup analyses by the route of administration, NSAIDs required fewer rescue treatments (seven RCTs, n = 541, number needed to treat [NNT] 11, 95% CI 6–75) and had lower vomiting rates compared with opioids (five RCTs, n = 531, NNT 5, 95% CI 4–8). Comparisons of NSAIDs with paracetamol showed no difference for both drugs at 30 min (four RCTs, n = 1325, MD –5.67, 95% CI –17.52 to 6.18, p = 0.35; I² = 89%). Patients treated with NSAIDs required fewer rescue treatments (two trials, n = 1145, risk ratio 0.56, 95% CI 0.42–0.74, p < 0.001; I² = 0%).

Conclusions

NSAIDs were equivalent to opioids or paracetamol in the relief of acute renal colic pain at 30 min. There was less vomiting and fewer requirements for rescue analgesia with NSAIDs compared with opioids. Patients treated with NSAIDs required less rescue analgesia compared with paracetamol. Despite observed heterogeneity among the included studies and the overall quality of evidence, the findings of a lower need for rescue analgesia and fewer adverse events, in conjunction with the practical advantages of ease of delivery, suggest that NSAIDs should be the preferred analgesic option for patients presenting to the emergency department with renal colic.

Patient summary

In kidney stone–related acute pain episodes in patients with adequate renal function, treatment with nonsteroidal anti-inflammatory drugs offers effective and most sustained pain relief, with fewer side effects, when compared with opioids or paracetamol.

中文翻译：

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非甾体抗炎药，阿片类药物和扑热息痛治疗急性肾绞痛疗效的系统评价和荟萃分析

语境

肾绞痛是尿路结石的常见急性表现，需要立即缓解疼痛。欧洲泌尿外科协会指南建议将非甾体类抗炎药（NSAIDs）作为首选的镇痛药。但是，由于担心使用非甾体抗炎药会产生不良反应以及对镇痛效果的不确定性，人们一直主张将静脉内阿片类药物作为最初的镇痛药。

客观的

该系统评价和荟萃分析的目的是比较非甾体抗炎药与阿片类药物和对乙酰氨基酚（对乙酰氨基酚）治疗急性肾绞痛的安全性和有效性。

取证

截至2016年12月，Cochrane对照试验中心注册资料库，MEDLINE，EMBASE，世界卫生组织国际临床试验注册平台，Google学术搜索以及检索到的文章参考清单均不受语言限制。两位审稿人使用Cochrane协作工具独立评估了合格的研究，以使用预定义的数据字段评估和报告偏差和抽象数据的风险。

证据综合

该系统评价包括1982年至2016年间发表的468项潜在相关研究中的36项随机对照试验（RCT），其中包括4887例患者。观察到的治疗效果表明，在30分钟的初始疼痛减轻中，非甾体抗炎药相对阿片类药物的获益较小（11个RCT，n  = 1985，平均差[MD] –5.58，95％置信区间[CI] –10.22至–0.95；异质性I ²  = 81％）。在按给药途径进行的亚组分析中， 与阿片类药物（5个RCT）相比，NSAIDs需要更少的抢救治疗（7个RCT，n = 541，需要治疗[NNT] 11的数量，95％CI 6–75）且呕吐率较低。 ，n = 531，NNT 5，95％CI 4-8）。NSAID与扑热息痛的比较显示两种药物在30分钟时没有差异（四个RCT，n  = 1325，MD –5.67，95％CI –17.52至6.18，p  = 0.35；I ²  = 89％）。用NSAID治疗的患者需要更少的抢救治疗（两项试验，n  = 1145，风险比0.56，95％CI 0.42-0.74，p  <0.001；I ²  = 0％）。

结论

在缓解30分钟的急性肾绞痛时，NSAIDs相当于阿片类药物或扑热息痛。与阿片类药物相比，使用NSAIDs进行呕吐的人较少，对抢救镇痛的需求也更少。与扑热息痛相比，接受NSAIDs治疗的患者需要较少的急救镇痛。尽管在纳入的研究中观察到异质性和整体证据质量，但对挽救性镇痛的需求较低和不良事件较少的发现，以及易于分娩的实际优势表明，非甾体抗炎药应该是患者首选的镇痛药向急诊科诊治肾绞痛。

病人总结

与阿片类药物或对乙酰氨基酚相比，在肾功能适当的患者中与肾结石相关的急性疼痛发作中，非甾体类抗炎药治疗可提供有效且最持久的疼痛缓解，且副作用较少。