Annals of Emergency Medicine
Volume 48, Issue 2 , Pages 173-181.e1 , August 2006

Intravenous Morphine Plus Ketorolac Is Superior to Either Drug Alone for Treatment of Acute Renal Colic

Presented as an oral paper at the Society of Academic Emergency Medicine annual meeting, May 2004, Orlando, FL; the Northeast Regional Society of Academic Emergency Medicine meeting, April 2004, Worchester, MA; and the Connecticut College of Emergency Medicine annual meeting, November 2004, CT.

  • Basmah Safdar, MD

      Affiliations

    • Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT
    • Corresponding Author InformationAddress for reprints: Basmah Safdar, MD, Section of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519; 203-785-4363, fax 203-785-4580
  • ,
  • Linda C. Degutis, DrPH

      Affiliations

    • Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT
  • ,
  • Keala Landry, MD

      Affiliations

    • Department of Emergency Medicine, The Mount Sinai School of Medicine, New York, NY
  • ,
  • Swarupa R. Vedere, MD

      Affiliations

    • Department of Medicine, Hospital of Saint Raphael, New Haven, CT
  • ,
  • Harry C. Moscovitz, MD

      Affiliations

    • Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT
  • ,
  • Gail D’Onofrio, MD

      Affiliations

    • Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT

Received 20 September 2005 ,Revised 24 January 2006 ,Accepted 28 February 2006.

References 

  1. Sierakowski R , Finlayson B , Landes RR , et al.   The frequency of urolithiasis in hospital discharge diagnoses in the United States . Invest Urol. . 1978;15:438–441
  2. Menon M , Parulkar BG , Drach GW . Urinary lithiasis (etiology, diagnosis and medical management) . In:  Walsh PC ,  Retik AB ,  Vaushan ED ,  Wein AJ editor. Campbell’s Urology . 7th ed.. Philadelphia, PA: W.B. Saunders; 1998;p. 2661–2705
  3. Curhan GC , Willett WC , Rimm EB , et al.   Family history and risk of kidney stones . J Am Soc Nephrol. . 1997;8:1568–1573
  4. Segura JW , Preminger GM , Assimos DG , et al.   Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi (the American Urological Association) . J Urol. . 1997;158:1915–1921
  5. Teichman JM . Clinical practice (acute renal colic from ureteral calculus) . N Engl J Med. . 2004;350:684–693
  6. Holdgate A , Pollock T . Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic . Cochrane Database Syst Rev. . 2004;1: CD004137
  7. Smally AJ . Analgesia in renal colic . Ann Emerg Med. . 1997;29:297–299
  8. Labrecque M , Dostaler LP , Rousselle R , et al.   Efficacy of nonsteroidal anti-inflammatory drugs in the treatment of acute renal colic (a meta-analysis) . Arch Intern Med. . 1994;154:1381–1387
  9. Tramer MR , Williams JE , Carroll D , et al.   Comparing analgesic efficacy of non-steroidal anti-inflammatory drugs given by different routes in acute and chronic pain (a qualitative systematic review) . Acta Anaesthesiol Scand. . 1998;42:71–79
  10. Martin JJ , Moore GP . Pearls, pitfalls, and updates for pain management . Emerg Med Clin North Am. . 1997;15:399–415
  11. Yealy DM . Ketorolac in the treatment of acute pain (the pendulum swings) . Ann Emerg Med. . 1992;21:985–986
  12. Nelson CE , Nylander C , Olsson AM , et al.   Rectal v. intravenous administration of indomethacin in the treatment of renal colic . Acta Chir Scand. . 1988;154:253–255
  13. Nissen I , Birke H , Olsen JB , et al.   Treatment of ureteric colic (intravenous versus rectal administration of indomethacin) . Br J Urol. . 1990;65:576–579
  14. Larkin GL , Peacock WFT , Pearl SM , et al.   Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic . Am J Emerg Med. . 1999;17:6–10
  15. Rainer TH , Jacobs P , Ng YC , et al.   Cost effectiveness analysis of intravenous ketorolac and morphine for treating pain after limb injury (double blind randomised controlled trial) . BMJ . 2000;321:1247–1251
  16. Duthie DJ , Nimmo WS . Adverse effects of opioid analgesic drugs . Br J Anaesth. . 1987;59:61–77
  17. O’Connor A , Schug SA , Cardwell H . A comparison of the efficacy and safety of morphine and pethidine as analgesia for suspected renal colic in the emergency setting . J Accid Emerg Med. . 2000;17:261–264
  18. Lehtonen T , Kellokumpu I . Intravenous indomethacin in the treatment of ureteral colic (a multicenter pilot study) . Scand J Urol Nephrol (Suppl). . 1983;75:37–38
  19. Jelinek GA . Ketorolac versus morphine for severe pain . BMJ . 2000;321:1236–1237
  20. Uden P , Rentzhog L , Berger T . A comparative study on the analgesic effects of indomethacin and hydromorphinechloride-atropine in acute, ureteral-stone pain . Acta Chir Scand. . 1983;149:497–499
  21. Persson NH , Bergqvist D , Melander A , et al.   Comparison of a narcotic (oxicone) and a non-narcotic anti-inflammatory analgesic (indoprofen) in the treatment of renal colic . Acta Chir Scand. . 1985;151:105–108
  22. Oosterlinck W , Philp NH , Charig C , et al.   A double-blind single dose comparison of intramuscular ketorolac tromethamine and pethidine in the treatment of renal colic . J Clin Pharmacol. . 1990;30:336–341
  23. Di Trolio RN , Sing RF , Bates GM . Use of ketorolac in renal colic . J Am Osteopath Assoc. . 1999;99:589–590
  24. Lee A, Cooper MC, Craig JC, et al. Effects of nonsteroidal anti-inflammatory drugs on post-operative renal function in normal adults [update in Cochrane Database Syst Rev. 2004;(2):CD002765] [update of Cochrane Database Syst Rev. 2000;(4):CD002765]. Cochrane Database Syst Rev. 2001;(2):CD002765.
  25. Reinhart DI . Minimising the adverse effects of ketorolac . Drug Safety . 2000;22:487–497
  26. Strom BL , Berlin JA , Kinman JL , et al.   Parenteral ketorolac and risk of gastrointestinal and operative site bleeding (a postmarketing surveillance study) . JAMA. . 1996;275:376–382
  27. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic [erratum appears in BMJ. 2004;329:1019]. BMJ. 1401;328:12.
  28. Cordell WH , Wright SW , Wolfson AB , et al.   Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic . Ann Emerg Med. . 1996;28:151–158
  29. Sandhu DP , Iacovou JW , Fletcher MS , et al.   A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic . Br J Urol. . 1994;74:690–693
  30. Foley KM . The treatment of cancer pain . N Engl J Med. . 1985;313:84–95
  31. Allen TBR . Opioids in Emergency Medicine (Concepts and Clinical Practice) . 4th ed.. St Louis, MO: Mosby; 1998;
  32. Cordell WH , Larson TA , Lingeman JE , et al.   Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic . Ann Emerg Med. . 1994;23:262–269
  33. Picard P , Bazin JE , Conio N , et al.   Ketorolac potentiates morphine in postoperative patient-controlled analgesia . Pain . 1997;73:401–406
  34. Wideman GL , Keffer M , Morris E , et al.   Analgesic efficacy of a combination of hydrocodone with ibuprofen in postoperative pain . Clin Pharmacol Ther. . 1999;65:66–76
  35. Manthey DE , Teichman J . Nephrolithiasis . Emerg Med Clin North Am. . 2001;19:633–654
  36. Bove P , Kaplan D , Dalrymple N , et al.   Reexamining the value of hematuria testing in patients with acute flank pain . J Urol. . 1999;162:685–687
  37. Todd KH . Clinical versus statistical significance in the assessment of pain relief . Ann Emerg Med. . 1996;27:439–441
  38. Gallagher EJ , Liebman M , Bijur PE . Prospective validation of clinically important changes in pain severity measured on a visual analog scale . Ann Emerg Med. . 2001;38:633–638
  39. Hedenbro JL , Olsson AM . Metoclopramide and ureteric colic . Acta Chir Scand. . 1988;154:439–440
  40. Physicians’ Desk. Torladol. 2002:3018-3022.
  41. Lacy CF AL , Goldman MP . Drug Information Handbook . 12th ed.. Hudson, OH: Lexington Comp Inc; 2003;
  42. Kolesnikov YA , Wilson RS , Pasternak GW . The synergistic analgesic interactions between hydrocodone and ibuprofen . Anesth Analg. . 2003;97:1721–1723
  43. Lashbrook JM , Ossipov MH , Hunter JC , et al.   Synergistic antiallodynic effects of spinal morphine with ketorolac and selective COX1- and COX2-inhibitors in nerve-injured rats . Pain . 1999;82:65–72
  44. Malmberg AB , Yaksh TL . Pharmacology of the spinal action of ketorolac, morphine, ST-91, U50488H, and L-PIA on the formalin test and an isobolographic analysis of the NSAID interaction . Anesthesiology . 1993;79:270–281
  45. O’Hara DA , Fanciullo G , Hubbard L , et al.   Evaluation of the safety and efficacy of ketorolac versus morphine by patient-controlled analgesia for postoperative pain . Pharmacotherapy . 1997;17:891–899
  46. Kim MH , Hahm TS . Plasma levels of interleukin-6 and interleukin-10 are affected by ketorolac as an adjunct to patient-controlled morphine after abdominal hysterectomy . Clin J Pain . 2001;17:72–77
  47. Nishikawa K , Morrison A , Needleman P . Exaggerated prostaglandin biosynthesis and its influence on renal resistance in the isolated hydronephrotic rabbit kidney . J Clin Invest. . 1977;59:1143–1150
  48. Kral JG . Analgesic effects of prostaglandin synthesis inhibition by diclofenac sodium . Semin Arthritis Rheum. . 1985;15:93–96
  49. Maves TJ , Pechman PS , Meller ST , et al.   Ketorolac potentiates morphine antinociception during visceral nociception in the rat . Anesthesiology . 1994;80:1094–1101

 Supervising editor: Knox H. Todd, MD, MPHAuthor contributions: BS, LCD, HCM, and GD conceived the study. BS, KL, LCD, and GD obtained research funding. BS, KL, and SRV assisted with the acquisition of data. BS, LCD, KL, SRV, HCM, and GD participated in the analysis and interpretation of data. BS, HCM, SRV, KL, and LCD provided administrative and technical support. BS, LCD, KL, HCM, and GD drafted the manuscript. All authors participated in critical review of the manuscript. BS takes responsibility for the paper as a whole.Funding and support: Partial funding was provided by the Connecticut Chapter of American College of Emergency Physicians.Publication dates: Available online April 27, 2006.

PII: S0196-0644(06)00410-0

doi: 10.1016/j.annemergmed.2006.03.013

Annals of Emergency Medicine
Volume 48, Issue 2 , Pages 173-181.e1 , August 2006