What is the next step in pain management for a patient with a renal colic (kidney stone) who has not responded to 15mg of Toradol (ketorolac), should Morphine be considered or an alternative?

From the Guidelines

For a patient with kidney stone pain in the ER where 15mg of toradol has been ineffective, the next appropriate step would be to administer an opioid analgesic, with morphine being a viable option, but considering the patient's kidney issue, fentanyl could be a safer choice. When considering opioid therapy, it's crucial to evaluate the underlying clinical situation, pain and adverse effect intensity, comorbidities, and concomitant drugs 1. Given the lack of strong evidence supporting one opioid over another in this context, the choice between morphine and fentanyl should be based on the patient's specific condition, including their kidney function. Fentanyl, being a safer option in patients with chronic kidney disease, as suggested by the ESMO clinical practice guidelines 1, could be considered, especially if the patient has impaired renal function.

Some key points to consider when administering opioids for kidney stone pain include:

• Starting with a low dose and titrating to effect
• Monitoring for respiratory depression, hypotension, and nausea
• Considering the use of an antiemetic such as ondansetron to manage nausea
• Evaluating the patient's kidney function and adjusting the opioid choice accordingly
• Keeping in mind that opioid switching may be necessary if the initial opioid is ineffective or causes unmanageable adverse effects, and that conversion ratios between opioids should be used with caution and as part of a comprehensive assessment of opioid therapy 1.

In terms of specific dosing, morphine can be given at 0.1 mg/kg IV (typically 4-10 mg for adults) every 4 hours as needed for pain, while fentanyl dosing will depend on the patient's opioid naive status and kidney function, but typically starts at 0.5-1 mcg/kg IV. It's essential to prioritize the patient's safety and adjust the treatment plan based on their response to the medication and any potential side effects.

From the FDA Drug Label

KETOROLAC TROMETHAMINE INJECTION ... For breakthrough pain, do not increase the dose or the frequency of ketorolac tromethamine Consideration should be given to supplementing these regimens with low doses of opioids “prn” unless otherwise contraindicated.

• The patient has already received a 15mg dose of toradol (ketorolac), which was ineffective.
• Breakthrough pain management is needed.
• According to the label, for breakthrough pain, consideration should be given to supplementing with low doses of opioids “prn” unless otherwise contraindicated.
• Morphine is an option, but the label warns against mixing ketorolac tromethamine injection with morphine sulfate in a small volume.
• The next step in pain management could be to administer morphine or another opioid, as long as it is not mixed with ketorolac in a small volume, and to monitor the patient closely 2.

From the Research

Next Steps in Pain Management

Given the ineffectiveness of the 15mg dose of toradol, the next steps in pain management for a patient with a kidney stone in the ER can be considered as follows:

• Nonopioid analgesics, such as acetaminophen or gabapentinoids, may be considered as alternative options for pain management, with careful dose considerations in kidney disease 3.
• NSAIDs may be used in CKD and ESKD for short durations with careful monitoring, and have been shown to be effective in relieving acute renal colic pain with fewer side effects compared to opioids 4.
• If opioid use is necessary, opioids that are safer to use in kidney disease, such as oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine, should be considered 3, 5.
• However, morphine is not recommended as a first-line option due to the risk of accumulation and adverse events in patients with kidney disease 5.

Considerations for Opioid Use

When considering opioid use in patients with kidney disease, the following factors should be taken into account:

• The risk of neuroexcitatory effects, such as tremor, myoclonus, agitation, and cognitive dysfunction, associated with hydromorphone use in patients with renal insufficiency 6.
• The potential for opioid accumulation and adverse events in patients with decreased kidney function 3, 5.
• The importance of careful monitoring and dose adjustment to minimize the risk of adverse events 3, 5.