What medications are used to treat biliary colic?

Medications for Biliary Colic

NSAIDs are the first-line treatment for biliary colic pain, as they provide superior pain control compared to placebo and spasmolytic drugs, and reduce the risk of progression to acute cholecystitis. 1, 2, 3

First-Line Treatment: NSAIDs

Recommended Agents and Dosing

• Diclofenac is the most studied NSAID for biliary colic and should be considered the preferred agent 4, 1
• Ketorolac is an effective alternative with comparable efficacy 4
• Intravenous tenoxicam and injectable flurbiprofen have also demonstrated effectiveness 4

Evidence for NSAIDs

• NSAIDs achieve complete pain relief in significantly more patients compared to placebo (RR 3.77,95% CI 1.65-8.61) 1
• NSAIDs reduce complications by approximately 47% compared to placebo (RR 0.53,95% CI 0.31-0.89) 1
• NSAIDs are more effective than spasmolytic drugs for pain control (RR 1.47,95% CI 1.03-2.10) 1, 3
• NSAIDs reduce progression to acute cholecystitis by 81% compared to other analgesics (OR 0.19,95% CI 0.08-0.44) 2
• The quality of evidence is moderate for NSAIDs versus placebo regarding pain relief 3

Second-Line Treatment: Opioids

When to Use Opioids

• Opioids provide equivalent pain control to NSAIDs (RR 1.05,95% CI 0.82-1.33) and should be used when NSAIDs are contraindicated 1
• Consider opioids in patients with:
  • History of gastrointestinal bleeding 3
  • Renal impairment 3
  • Cardiovascular disease 3
  • Known NSAID hypersensitivity 3

Opioid Dosing Strategy

• Low-dose morphine (0.05 mg/kg) combined with paracetamol (1000 mg) provides effective pain control comparable to standard-dose morphine (0.1 mg/kg) alone 5
• This combination approach reduces opioid-related side effects while maintaining analgesic efficacy 5
• Pain scores decrease significantly by 15 minutes and continue to improve at 30 minutes with this regimen 5

Third-Line Treatment: Spasmolytic Drugs

• Spasmolytic drugs are less effective than NSAIDs for both pain control and complication prevention 1, 3
• Reserve spasmolytics for patients who cannot tolerate NSAIDs or opioids 1

Common Pitfalls to Avoid

• Do not use paracetamol (acetaminophen) as monotherapy for biliary colic, as it lacks the anti-inflammatory properties needed to prevent complications 5
• Do not delay NSAID administration in patients without contraindications, as early treatment reduces progression to acute cholecystitis 2
• Do not assume all analgesics are equivalent—NSAIDs have disease-modifying effects beyond pain control 4, 1
• Do not overlook NSAID contraindications including active peptic ulcer disease, severe renal impairment (GFR <30 mL/min), or recent cardiovascular events 3

Rescue Analgesia

• If initial treatment fails, consider intravenous fentanyl (0.75 µg/kg) as rescue medication 5
• Reassess for complications if pain persists despite adequate analgesia, as this may indicate progression to acute cholecystitis or other biliary complications 6

Important Caveats

• The evidence base consists primarily of trials in younger adults without significant comorbidities, limiting generalizability to elderly patients or those with multiple comorbidities 3
• Most trials excluded patients over 86 years of age 3
• No mortality was reported in any of the included trials, but this reflects the generally benign nature of uncomplicated biliary colic rather than treatment safety in high-risk populations 3
• Minor adverse events with NSAIDs (abdominal pain, drowsiness, headache, dizziness, cutaneous manifestations) were reported but were not severe 3