Choosing an analgesic regimen for renal colic

Renal colic is acute, often severe pain caused by kidney or ureteral stone passage or obstruction in the urinary tract. Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids have similar analgesic efficacy for renal colic¹. Paracetamol is less well studied but limited evidence suggests that intravenous paracetamol may have similar analgesic efficacy to an opioid or NSAID. Paracetamol may be used if opioids and NSAIDs are not appropriate for the patient.

Note: NSAIDs and opioids have similar analgesic efficacy for renal colic.

Antispasmodics (eg hyoscine butylbromide) do not have a role in the treatment of renal colic because they offer little analgesic benefit if co-administered with NSAIDs or opioids. Alpha-blockers do not have a role in the management of acute pain associated with renal colic.

Renal colic is usually episodic pain and a single dose of analgesia is often sufficient for management. If repeat doses of analgesia are required, follow the approach in Using analgesics to manage acute pain.

The choice of drug and route of administration depends on the pain intensity, individual patient factors (eg contraindications, ability to take medications orally), and the clinical setting (eg general practice, an emergency department).

For patients with severe pain, parenteral opioids or NSAIDs are often required for rapid pain relief. For patients with moderate pain, oral opioids or NSAIDs are preferred, but parenteral treatment may be required for patients with significant nausea or vomiting. See Features of mild, moderate and severe acute pain for the features of moderate and severe pain.

In a hospital setting, intravenous opioids are often preferred to parenteral NSAIDs because they have a faster onset of action. Morphine may be preferred to oxycodone because of its longer duration of action. An intravenous opioid may be combined with a parenteral NSAID to reduce opioid requirements and prolong the duration of analgesia. Intravenous opioids should only be administered in hospitals with staffing and resources that allow immediate resuscitation of a patient with opioid-induced ventilatory impairment; see Using opioids in hospital. If these requirements are not met, use an alternative route of opioid administration (eg oral, subcutaneous) or an NSAID.

In a community setting (eg general practice) NSAIDs are preferred over opioids because they are associated with a lower risk of harm.

¹ Although opioids have been shown experimentally to induce smooth muscle spasm, it has not been shown to be a problem in clinical practice.Return