NSAIDs Are First-Line Analgesia for Ureteral Stones
NSAIDs (diclofenac, ibuprofen, or metamizole) are the first-line treatment for renal colic and should be administered at the lowest effective dose. 1
Recommended NSAID Regimens
Specific Agents and Dosing
- Diclofenac: Preferred first-line agent based on extensive evidence 1
- Ibuprofen: Equally effective alternative 1
- Metamizole: Third option where available 1
- Ketorolac: Commonly used in emergency departments, though may be slightly less effective than IV ibuprofen for significant pain relief 2
Route of Administration
- Intravenous administration is likely equivalent to intramuscular but may be superior to rectal administration for reducing need for rescue medication 2
- Use the lowest effective dose regardless of route to minimize cardiovascular and gastrointestinal risks 1
Evidence Supporting NSAIDs Over Alternatives
NSAIDs vs. Opioids
- NSAIDs reduce pain more effectively than opioids at 30 minutes (mean difference -5.58 cm on VAS scale) 3
- NSAIDs require fewer rescue treatments (NNT = 11) 3
- NSAIDs cause significantly less vomiting (NNT = 5) compared to opioids 3
- Opioids, particularly pethidine, are associated with higher rates of vomiting and greater likelihood of requiring additional analgesia 1
NSAIDs vs. Placebo
- NSAIDs reduce pain by approximately 3.84 cm on VAS at 30 minutes compared to placebo 2
- Patients receiving NSAIDs are 76% less likely to require rescue medication than those receiving placebo (RR 0.24) 2
NSAIDs vs. Antispasmodics
- NSAIDs provide superior pain control compared to antispasmodics like hyoscine (mean difference -12.97 cm on VAS) 4
- NSAIDs are 66% more effective than antispasmodics in reducing need for rescue medication 4
- Do not combine NSAIDs with antispasmodics as combination therapy shows no additional benefit over NSAIDs alone 4
Absolute Contraindications to NSAIDs
Pregnancy
- NSAIDs (including ketorolac) are absolutely contraindicated in pregnancy 1
- For pregnant patients with controlled symptoms, observation is first-line therapy 1
- If intervention needed in pregnancy, consider ureteroscopy or temporary drainage (stent/nephrostomy) rather than NSAIDs 1
Renal Impairment
- NSAIDs may significantly impact renal function in patients with low glomerular filtration rate 1
- Avoid NSAIDs in patients with pre-existing renal insufficiency or solitary kidney with compromised function 1
Other High-Risk Conditions
- Active gastrointestinal bleeding or peptic ulcer disease 1
- Significant cardiovascular disease where even short-term NSAID use poses unacceptable risk 1
- Bleeding disorders or concurrent anticoagulation requiring high bleeding-risk procedures 1
Second-Line Analgesic Options
When NSAIDs Are Contraindicated
- Opioids other than pethidine are recommended as second-choice analgesics 1
- Preferred opioid agents include:
- Avoid pethidine due to high vomiting rates and poor sustained analgesia 1
Paracetamol (Acetaminophen)
- Paracetamol shows no significant difference from NSAIDs at 30 minutes for pain reduction 3
- However, patients treated with NSAIDs require less rescue analgesia compared to paracetamol (RR 0.56) 3
- Consider paracetamol as adjunct or alternative when NSAIDs contraindicated 3
Critical Clinical Caveats
Mandatory Reassessment Triggers
Stop NSAID therapy immediately and escalate care if: 1
- Signs of infection or sepsis develop (requires urgent decompression via nephrostomy or stent)
- Declining renal function occurs
- Anuria develops in obstructed kidney
- Refractory pain despite adequate NSAID dosing
Duration Limits
- Continue NSAIDs for pain control during conservative management, but do not exceed 4-6 weeks of total observation without definitive intervention 5
- Complete ureteral obstruction beyond 6 weeks risks irreversible kidney injury 5
Common Pitfall to Avoid
Do not add antispasmodics to NSAIDs thinking it will enhance analgesia—nine studies with 906 participants show no additional benefit (RR 1.00) and only add unnecessary medication exposure and cost 4