Pain Management for Nephrolithiasis
First-Line Treatment: NSAIDs
NSAIDs (diclofenac, ibuprofen, or metamizole) are the first-line treatment for renal colic and should be used at the lowest effective dose. 1, 2
Why NSAIDs Are Superior
NSAIDs reduce the need for additional rescue analgesia compared to opioids and provide more sustained pain relief with fewer adverse effects. 1, 3
NSAIDs are at least as effective as opioids for kidney stone pain and have the added benefit of decreasing ureteral smooth muscle tone and ureteral spasm, directly addressing the pathophysiology of renal colic. 1
Meta-analysis demonstrates that NSAIDs result in significantly less vomiting (NNT 5) and fewer requirements for rescue treatments (NNT 11) compared to opioids. 3
Patients receiving NSAIDs are significantly less likely to require rescue medication than those receiving placebo (RR 0.35,95% CI 0.20 to 0.60). 4
Specific NSAID Considerations
Indomethacin is less effective than other NSAIDs and should be avoided in favor of diclofenac, ibuprofen, or ketorolac. 4
Ketorolac at appropriate dosing (15 mg) is effective and represents an evidence-based option for acute pain management. 5
Critical Safety Warnings
Use the lowest effective dose due to cardiovascular and gastrointestinal risks, particularly in patients with hypertension, renal insufficiency, heart failure, or those at risk for peptic ulcer disease or cardiovascular disease. 1
NSAIDs may increase cardiovascular and gastrointestinal risks, so clinicians must weigh risks and benefits, especially in older adults. 1
Second-Line Treatment: Opioids
Opioids (hydromorphone, pentazocine, or tramadol—but not pethidine/meperidine) serve as second-line agents when NSAIDs are contraindicated or insufficient. 2
When to Use Opioids
Reserve opioids for patients with contraindications to NSAIDs (active GI bleeding, severe renal insufficiency, documented cardiovascular disease). 1
Use opioids when NSAIDs provide inadequate pain relief after appropriate dosing and time for effect. 2
Adjunctive Analgesic Options
Intravenous lidocaine can be considered as an adjunctive nonopioid option (5.6% utilization in pathway-based care). 5
Antispasmodics alone are inferior to NSAIDs and should not be used as monotherapy (MD -12.97,95% CI -21.80 to -4.14). 4
Combination therapy of NSAIDs plus antispasmodics does not provide superior pain control compared to NSAIDs alone and should be avoided to minimize polypharmacy. 4
Emergency Situations Requiring Urgent Intervention
Urgent decompression via percutaneous nephrostomy or ureteral stenting is mandatory for sepsis and/or anuria in an obstructed kidney. 2
Red Flags Requiring Immediate Action
Administer antibiotics immediately and adjust based on culture results in patients with signs of infection (pyuria, bacteriuria, fever). 2, 6
Obtain urine culture before initiating treatment if urinalysis shows pyuria, bacteriuria, or positive nitrites. 6
Delay definitive stone treatment until sepsis is resolved. 6, 7
Medical Expulsive Therapy
Alpha-blockers are strongly recommended for ureteral stones >5 mm in the distal ureter in patients suitable for conservative management. 2
- Prescribe tamsulosin for 28 days at discharge to facilitate stone passage (22.7% vs 6.8% prescription rate with pathway implementation, OR 3.78, p<0.001). 5
Common Pitfalls to Avoid
Do not use pethidine (meperidine) as it is specifically excluded from recommended opioid options. 2
Do not combine NSAIDs with antispasmodics as this provides no additional benefit and increases medication burden. 4
Do not prescribe opioids as first-line therapy given the current opioid epidemic and superior efficacy of NSAIDs. 1, 8
Do not delay imaging or intervention in patients with signs of infection or obstructive uropathy. 1, 6