What is the current evidence and recommendation for using Buscopan (hyoscine butylbromide) in acute renal colic?

Buscopan (Hyoscine Butylbromide) in Acute Renal Colic: Current Evidence and Recommendations

Buscopan (hyoscine butylbromide) should NOT be used in the management of acute renal colic, as it provides inferior analgesia compared to NSAIDs, does not reduce opioid requirements, and offers no advantage over established first-line therapies. 1, 2

Evidence Against Buscopan Use

Inferior Analgesic Efficacy

• Hyoscine butylbromide as monotherapy is significantly less effective than NSAIDs or opioids for pain control in renal colic, providing shorter-lasting relief than NSAIDs. 1
• A randomized controlled trial of 178 patients demonstrated that adding Buscopan to morphine therapy did not reduce morphine requirements (median 0.12 mg/kg with Buscopan versus 0.11 mg/kg with placebo, p=0.4) and did not decrease the proportion of patients requiring additional morphine (33% versus 38%, p=0.5). 2

No Adjunctive Benefit

• Buscopan provides no benefit when added to opioid therapy and does not serve as an effective adjunct to standard analgesic regimens. 1, 2
• The addition of antispasmodics (including hyoscine) to NSAIDs does not result in better pain control compared to NSAIDs alone. 3

No Effect on Stone Passage

• Hyoscine butylbromide does not facilitate passage of ureteral stones and has no effect on stone expulsion rates. 1

Guideline-Recommended First-Line Treatment

NSAIDs as Gold Standard

• Intramuscular diclofenac 75 mg is the first-line analgesic for acute renal colic, providing superior pain relief to opioids with fewer side effects and reduced need for rescue medication. 4, 5
• The European Association of Urology recommends NSAIDs over all other analgesic classes due to their dual mechanism of reducing ureteral smooth muscle spasm and providing anti-inflammatory effects. 4, 5
• Effective analgesia should be achieved within 30 minutes of IM diclofenac administration, with pain control maintained for at least 6 hours. 4

When NSAIDs Are Contraindicated

• If NSAIDs cannot be used (renal impairment, cardiovascular disease, GI bleeding risk), opioids combined with antiemetics are second-line therapy—specifically morphine sulfate plus cyclizine. 4, 5
• In patients with renal failure, fentanyl is the preferred opioid because it does not generate active metabolites that accumulate; morphine, codeine, and tramadol must be avoided. 4, 5

Clinical Practice Reality

Current Non-Evidence-Based Use

• Despite lack of supporting evidence, hyoscine butylbromide continues to be used in some settings based on non-peer-reviewed protocols and empiric recommendations rather than rigorous clinical evidence. 1
• The theoretical rationale—that urinary tract smooth muscle spasm contributes to renal colic pain—has not translated into clinically meaningful benefit in controlled trials. 1

Combination Products

• One study of a combination suppository containing ketoprofen 100 mg plus hyoscine butylbromide 10 mg showed non-inferior results to IV ketorolac at 60 minutes, but the benefit was attributable to the NSAID component rather than the antispasmodic. 6
• The addition of hyoscine to NSAIDs provides no incremental benefit over NSAID monotherapy. 3

Critical Admission Criteria (Regardless of Analgesic Choice)

Red Flags Requiring Immediate Hospital Transfer

• Failure to achieve adequate pain control within 60 minutes of appropriate first-line analgesia mandates hospital admission. 4, 5
• Fever or any sign of systemic infection (suggesting obstructed infected kidney/pyonephrosis) requires urgent admission and decompression. 4
• Anuria or severe oliguria (≤1 void in 24 hours) necessitates immediate intervention. 4
• Hemodynamic shock or instability is an absolute indication for urgent admission. 4

Urgent Decompression Indications

• Sepsis and/or anuria in an obstructed kidney require immediate percutaneous nephrostomy or ureteral stenting before definitive stone treatment. 4, 5

Common Pitfalls to Avoid

• Do not delay effective analgesia by administering antispasmodics first—this wastes critical time and prolongs patient suffering. 4
• Do not combine Buscopan with NSAIDs expecting additive benefit—the evidence shows no advantage and only increases medication exposure. 3
• Do not use Buscopan as a substitute for proper assessment of contraindications to NSAIDs—screen for renal function, cardiovascular risk, and GI bleeding history before NSAID administration. 4
• In patients over 60 years, actively exclude leaking abdominal aortic aneurysm before attributing pain to renal colic. 4