What are the step-wise analgesic doses for an adult patient with renal colic in an Indian healthcare setting, particularly if pain does not subside?

Stepwise Analgesic Protocol for Renal Colic in Indian Healthcare Settings

For acute renal colic, administer intramuscular diclofenac 75 mg as first-line therapy, with reassessment at 60 minutes; if pain persists, immediately admit the patient to hospital for opioid analgesia and further evaluation. 1, 2

Initial Assessment (Within 30 Minutes)

• Patients presenting with acute renal colic require medical assessment within 30 minutes of presentation 3, 1
• Confirm diagnosis based on abrupt onset of severe unilateral flank pain radiating to groin or genitals 3, 1
• Critical exclusions: Rule out leaking abdominal aortic aneurysm in patients over 60 years, and ruptured ectopic pregnancy in women of reproductive age 1
• Check vital signs (pulse, blood pressure, temperature) to exclude shock and systemic infection 3
• Immediate hospital admission required if: fever/signs of infection, shock/hemodynamic instability, or anuria in obstructed kidney 1

Step 1: First-Line Analgesia (0-60 Minutes)

Diclofenac 75 mg intramuscular injection is the preferred initial treatment 3, 1, 2

• NSAIDs are superior to opioids for renal colic, with reduced need for additional analgesia and fewer side effects 1, 4
• Intramuscular route is preferred because oral and rectal routes are unreliable in acute settings 3, 1
• A large randomized trial of 1,644 patients demonstrated that intramuscular diclofenac achieved at least 50% pain reduction in 68% of patients at 30 minutes, significantly more effective than morphine (61%, p=0.0187) 4
• Target is to provide pain relief within 30 minutes of administration 3, 1

Alternative NSAIDs if diclofenac unavailable:

• Ketoprofen 100 mg intramuscular (similar efficacy to diclofenac) 5
• Intravenous ketorolac or ibuprofen (IV route may be as effective as IM) 6

For patients with NSAID contraindications:

• Use opioid analgesics: hydromorphone, pentazocine, or tramadol (avoid pethidine due to high vomiting rates) 1, 2
• In renal impairment specifically: Use fentanyl only, as it does not accumulate active metabolites 1, 2
• Never use morphine, codeine, or tramadol in renal failure 1, 2

Step 2: Reassessment at 60 Minutes

• Telephone or in-person follow-up 1 hour after initial analgesic administration 3, 1, 2
• Assess pain control using visual analogue scale or clinical judgment 3

If adequate pain relief achieved:

• Arrange fast-track imaging (ultrasound or CT urography) within 7 days 3, 1
• Provide limited supply of oral or rectal NSAIDs for home use if pain recurs 3, 1
• Instruct patient to maintain high fluid intake and strain urine to capture stone 3, 1
• Schedule urology outpatient assessment within 7-14 days if stone identified 3

Step 3: Failure of First-Line Analgesia (After 60 Minutes)

If pain persists or inadequately controlled after 60 minutes, immediately admit patient to hospital 3, 1, 2

Hospital management includes:

• Intravenous opioid analgesia with antiemetics 1, 2
• Urgent imaging to identify stone location and size 1
• Consider repeat dose of intramuscular NSAID if not contraindicated 3
• Urgent decompression via percutaneous nephrostomy or ureteral stenting if sepsis and/or anuria present 1, 2

Adjunctive Therapy

• For stones >5 mm in distal ureter, consider medical expulsive therapy with alpha-blockers (tamsulosin) to facilitate spontaneous passage 1, 2
• Approximately 90% of stones causing renal colic pass spontaneously 1

Critical Safety Considerations

NSAID contraindications to screen for: 1

• Impaired renal function (low GFR)
• History of peptic ulcer disease or gastrointestinal bleeding
• Cardiovascular disease in elderly patients
• Known allergy to NSAIDs or salicylates

Opioid safety in renal impairment: 1, 2

• Never use standard opioid dosing in renal failure; start with lower doses and titrate carefully
• Avoid morphine, codeine, and tramadol as they accumulate toxic metabolites
• Monitor for respiratory depression and confusion

Red flags requiring immediate admission regardless of pain control: 1

• Fever or signs of systemic infection
• Hemodynamic instability
• Anuria in obstructed kidney
• Abrupt recurrence of severe pain after initial relief