What is the best pain treatment for renal colic?

Best Pain Treatment for Renal Colic

Intramuscular diclofenac 75 mg is the recommended first-line treatment for renal colic pain when the diagnosis is clear and there are no signs of complications. This injectable non-steroidal anti-inflammatory drug (NSAID) provides rapid pain relief within 30 minutes and should be maintained for at least six hours. 1

Initial Pain Management Algorithm

First-Line Treatment:

• Administer intramuscular diclofenac 75 mg immediately after assessment 1
• Oral and rectal administration are considered unreliable, and intravenous administration is often impractical in primary care settings 1
• Complete or acceptable pain control should be maintained for six hours or longer 1

When NSAIDs are Contraindicated:

• Use an opiate combined with an antiemetic (e.g., morphine sulfate and cyclizine) 1
• For IV morphine, the usual starting dose is 0.1 mg to 0.2 mg per kg administered slowly 2
• Be aware that opioids cause vomiting in about 20% of patients (versus about 6% with NSAIDs) 3

Monitoring and Follow-up

• Check response to analgesia within one hour (can be done by telephone) 1
• If pain is not alleviated within 60 minutes, arrange immediate hospital admission 1
• Abrupt recurrence of severe pain also warrants immediate hospital admission 1

Special Considerations

NSAID Contraindications:

• Avoid NSAIDs in patients with heart failure, renal artery stenosis, dehydration, renal impairment, or ongoing treatment with nephrotoxic drugs 3
• Never use NSAIDs during pregnancy - morphine carries a lower risk in pregnant women 3
• For elderly patients, use NSAIDs with caution due to increased risk of renal impairment 3

Combination Therapy:

• According to one trial, combining morphine and NSAIDs provided greater analgesic effect than either agent alone in about 10% of patients 3
• This approach may be considered for severe, refractory pain 3

Hydration and Supportive Care

• Encourage patients to drink plenty of fluids 1
• Have patients void urine into a container or through a tea strainer to catch any calculus 1
• Contrary to traditional practice, forced IV hydration shows no advantage over maintenance IV fluids in terms of pain control or stone passage 4

Comparative Efficacy

• Diclofenac 75 mg IM provides faster effective pain relief compared to tramadol 50 mg IV 5
• Ketoprofen and diclofenac show similar efficacy and tolerance profiles in renal colic treatment 6
• Local active warming (42°C to the abdomen or lower back) may help reduce pain according to one trial 3

Common Pitfalls to Avoid

• Do not delay analgesia - pain relief should be provided within 30 minutes of assessment 1
• Do not routinely admit all patients to hospital - only those failing to respond to analgesia within one hour 1
• Avoid using antispasmodics like scopolamine, as adding them to morphine does not provide additional efficacy 3
• Do not rely on oral or rectal analgesics for initial management of severe renal colic pain 1