Comparison of dexketoprofen trometamol and dipyrone in the treatment of renal colic

Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute renal colic

BACKGROUND

Urolithiasis (urinary stones) is a common disease with an increasing incidence globally. It often presents with renal colic, which is characterised by acute and intense abdominal pain. The first step in the management of renal colic is pain control. Various medications, including narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), antispasmodics, and others, have been used for this condition. NSAIDs are amongst the most commonly used drugs for renal colic. They act by reducing inflammation and lowering the pressure inside the urinary collecting system. This review updates a previous Cochrane Systematic Review (Afshar 2015), focusing exclusively on NSAIDs.

OBJECTIVES

To assess the benefits and harms of different nonsteroidal anti-inflammatory drugs (NSAIDs) for the management of pain in adults with acute renal colic.

SEARCH METHODS

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Google Scholar, trial registries, and conference proceedings up to 25 August 2023. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included randomised (or quasi-randomised) controlled trials (RCTs) assessing the effects of NSAIDs in the management of renal colic adult patients (i.e. study participants over 16 years of age). We included studies that compared NSAIDs versus placebo, one NSAID versus another, or different doses or routes of administration of the same NSAID.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data from the included studies. Primary outcomes included pain up to one hour after treatment as measured by a validated patient-reported tool, the need for rescue medication up to six hours after treatment, and serious adverse events up to one week after treatment. Secondary outcomes included pain recurrence, significant pain relief, and minor adverse events. We performed meta-analysis using the random-effects model. We rated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

Our search identified 29 RCTs for inclusion in the review. The 29 studies involved a total of 3593 participants who were randomly allocated to treatment with an NSAID or placebo. The mean age of participants ranged from 27 to 47 years across the studies. Participants used a 10 cm visual analogue scale (VAS) to indicate the extent of their pain. NSAIDs versus placebo NSAIDs may reduce renal colic pain in 30 minutes compared to placebo (mean difference (MD) -3.84 cm, 95% confidence interval (CI) -6.41 to -1.27; I2 = 95%; 3 studies, 250 participants; low-certainty evidence). The evidence is very uncertain about the effect of NSAIDs on the need for rescue medication (risk ratio (RR) 0.24, 95% CI 0.11 to 0.53; I2 = 73%; 4 studies, 280 participants; very low-certainty evidence). NSAID versus NSAID Piroxicam may result in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD 0.01 cm, 95% CI -1.50 to 1.52; I² = 78%; 2 studies, 144 participants; low-certainty evidence). Parecoxib likely results in little to no difference in renal colic pain at 30 minutes compared to ketoprofen (MD 0.03 cm, 95% CI -0.59 to 0.65; 1 study, 337 participants; moderate-certainty evidence). Lornoxicam likely results in little to no difference in renal colic pain at 30 minutes compared to other NSAIDs (MD -0.22 cm, 95% CI -0.69 to 0.24; I² = 12%; 2 studies, 170 participants; moderate-certainty evidence). Ketorolac may result in little to no difference in renal colic pain at 60 minutes (MD 0.23 cm, 95% CI -1.16 to 1.62, 1 study, 57 participants; low-certainty evidence) and need for rescue medication within 120 minutes (RR 1.76, 95% CI 0.73 to 4.24; I² = 0%; 2 studies, 114 participants; low-certainty evidence) compared to diclofenac. Intravenous (IV) ketorolac may result in little to no difference in renal colic pain at 30 minutes compared to IV ibuprofen (MD 1.36 cm, 95% CI 0.85 to 1.87; I² = 84%; 2 studies, 361 participants; low-certainty evidence). IV ketorolac may result in less chance of significant pain relief within 30 minutes compared to IV ibuprofen (RR 0.17, 95 CI 0.04 to 0.73; 1 study, 240 participants; low-certainty evidence). Ketoprofen likely results in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD -0.43 cm, 95% CI -1.18 to 0.32; 1 study, 80 participants; moderate-certainty evidence). The evidence is very uncertain about the effect of ketoprofen on significant pain relief within 40 minutes compared to diclofenac (RR 1.38, 95% CI 1.08 to 1.78; 1 study, 80 participants; very low-certainty evidence). Indomethacin likely results in little to no difference in renal colic pain at 30 minutes compared to diclofenac (MD 0.20 cm, 95% CI -0.90 to 1.30; 1 study, 83 participants; moderate-certainty evidence). Pirprofen may result in a large reduction in the need for rescue medication within 30 minutes compared to indomethacin (RR 0.58, 95% CI 0.41 to 0.82; 1 study, 205 participants; low-certainty evidence). Intravenous NSAIDs likely result in little to no difference in renal colic pain at 30 minutes compared to intramuscular NSAIDs (MD -0.34 cm, 95% CI -1.19 to 0.51; I2 = 42%; 2 studies, 134 participants; moderate-certainty evidence). Intravenous NSAIDs may reduce the need for rescue medication within 30 minutes compared to rectal NSAIDs (RR 0.35, 95% CI 0.14 to 0.88; 1 study, 116 participants; low-certainty evidence). The evidence is uncertain regarding the potential harms of NSAIDs. Risk of bias We judged the risk of bias in the studies to be moderate to high. This was due to a high proportion of unknown risk judgments for concealment bias and a high risk of selective reporting bias.

AUTHORS' CONCLUSIONS

NSAIDs may reduce pain in adult patients with renal colic compared to placebo. Comparing one NSAID against another, IV ketorolac may be less effective than IV ibuprofen, and pirprofen may result in less need for rescue medication than indomethacin. The intravenous route of administration is probably similar to the intramuscular route but may be better than the rectal route. The evidence is uncertain regarding the potential harms of NSAIDs. We were not able to perform subgroup analysis based on our predefined criteria because there were no eligible studies.

Metamizole-associated adverse events: a systematic review and meta-analysis

Background

Metamizole is used to treat pain in many parts of the world. Information on the safety profile of metamizole is scarce; no conclusive summary of the literature exists.

Objective

To determine whether metamizole is clinically safe compared to placebo and other analgesics.

Methods

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and several clinical trial registries. We screened the reference lists of included trials and previous systematic reviews. We included randomized controlled trials that compared the effects of metamizole, administered to adults in any form and for any indication, to other analgesics or to placebo. Two authors extracted data regarding trial design and size, indications for pain medication, patient characteristics, treatment regimens, and methodological characteristics. Adverse events (AEs), serious adverse events (SAEs), and dropouts were assessed. We conducted separate meta-analyses for each metamizole comparator, using standard inverse-variance random effects meta-analysis to pool the estimates across trials, reported as risk ratios (RRs). We calculated the DerSimonian and Laird variance estimate T² to measure heterogeneity between trials. The pre-specified primary end point was any AE during the trial period.

Results

Of the 696 potentially eligible trials, 79 trials including almost 4000 patients with short-term metamizole use of less than two weeks met our inclusion criteria. Fewer AEs were reported for metamizole compared to opioids, RR = 0.79 (confidence interval 0.79 to 0.96). We found no differences between metamizole and placebo, paracetamol and NSAIDs. Only a few SAEs were reported, with no difference between metamizole and other analgesics. No agranulocytosis or deaths were reported. Our results were limited by the mediocre overall quality of the reports.

Conclusion

For short-term use in the hospital setting, metamizole seems to be a safe choice when compared to other widely used analgesics. High-quality, adequately sized trials assessing the intermediate- and long-term safety of metamizole are needed.

Systematic review of dexketoprofen in acute and chronic pain

BACKGROUND

Dexketoprofen, an NSAID used in the management of acute and chronic pains, is licensed in several countries but has not previously been the subjected of a systematic review. We used published and unpublished information from randomised clinical trials (RCTs) of dexketoprofen in painful conditions to assess evidence on efficacy and harm.

METHODS

PubMed and Cochrane Central were searched for RCTs of dexketoprofen for pain of any aetiology. Reference lists of retrieved articles and reviews were also searched. Menarini Group produced copies of published and unpublished studies (clinical trial reports). Data were abstracted into a standard form. For studies reporting results of single dose administration, the number of patients with at least 50% pain relief was derived and used to calculate the relative benefit (RB) and number-needed-to-treat (NNT) for one patient to achieve at least 50% pain relief compared with placebo.

RESULTS

Thirty-five trials were found in acute pain and chronic pain; 6,380 patients were included, 3,381 receiving dexketoprofen. Information from 16 trials (almost half the total patients) was obtained from clinical trial reports from previously unpublished trials or abstracts. Almost all of the trials were of short duration in acute conditions or recent onset pain.All 12 randomised trials that compared dexketoprofen (any dose) with placebo found dexketoprofen to be statistically superior. Five trials in postoperative pain yielded NNTs for 12.5 mg dexketoprofen of 3.5 (2.7 to 4.9), 25 mg dexketoprofen of 3.0 (2.4 to 3.9), and 50 mg dexketoprofen of 2.1 (1.5 to 3.5). In 29/30 active comparator trials, dexketoprofen at the dose used was at least equivalent in efficacy to comparator drugs. Adverse event withdrawal rates were low in postoperative pain and somewhat higher in trials of longer duration; no serious adverse events were reported.

CONCLUSION

Dexketoprofen was at least as effective as other NSAIDs and paracetamol/opioid combinations. While adverse event withdrawal was not different between dexketoprofen and comparator analgesics, the different conditions and comparators studies precluded any formal analysis. Exposure was limited, and no conclusions could be drawn about safety in terms of serious adverse events like gastrointestinal bleeding or cardiovascular events.

Comparison of intravenous dexketoprofen and dipyrone in acute renal colic

OBJECTIVE

The aim of this study was to assess the efficacy and safety of a single intravenous (i.v.) bolus of dexketoprofen trometamol compared with an i.v. infusion of dipyrone in patients with moderate to severe pain due to renal colic.

METHODS

A total of 308 patients with renal colic and visual analog scale (VAS) score >/=40 mm participated in a multicenter, randomized, double blind, double-dummy, parallel, and active-controlled study and were randomized to dexketoprofen 25 mg (n = 101), dexketoprofen 50 mg (n = 104), and dipyrone 2 g (n = 103).

RESULTS

Mean [+/- standard deviation (SD)] total pain relief (TOTPAR) scores were similar in the dexketoprofen 50 mg (15.3 +/- 8.6) and dipyrone (15.5 +/- 8.6) and slighly higher than in dexketoprofen 25 mg (13.5 +/- 8.6), although significant differences were not achieved. In the same way, patients in the dexketoprofen 50 mg and dipyrone groups showed higher scores in the sum of pain intensity differences (SPID) and the sum of analogue pain intensity differences (SAPID) than patients in the dexketoprofen 25 mg group, reaching statistical significance in comparison with dexketoprofen 25 mg and dipyrone for SPID and SAPID (p < 0.05). The time-effect course for pain intensity differences and pain relief showed significantly higher values for both doses of dexketoprofen during the first 30 min after drug administration (p < 0.05). Dexketoprofen 50 mg and dipyrone groups had 66% and 70%, respectively, of patients with at least 50% of maximum obtainable TOTPAR in comparison with 56% in the dexketoprofen 25 mg group. The study medications were well tolerated.

CONCLUSIONS

Dexketoprofen 50 mg administered as a single i.v. bolus was effective for the relief of moderate to severe pain in patients with renal colic, with a good safety profile and efficacy similar to i.v. dipyrone 2 g. Dexketoprofen produced analgesia that was faster in onset.

Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic

BACKGROUND

Renal colic is a common cause of acute severe pain. Both opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for treatment, but the relative efficacy of these drugs is uncertain.

OBJECTIVES

To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register (May 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 2, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles. Most recent search date: January 2005

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included.

DATA COLLECTION AND ANALYSIS

Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity.

MAIN RESULTS

Twenty trials from nine countries with a total of 1613 participants were identified. Both NSAIDs and opioids lead to clinically significant falls in patient-reported pain scores. Due to unexplained heterogeneity these results could not be pooled although 10/13 studies reported lower pain scores in patients receiving NSAIDs. Patients treated with NSAIDs were significantly less likely to require rescue medication (RR 0.75, 95% CI 0.61 to 0.93, P = 0.007), though most of these trials used pethidine. The majority of trials showed a higher incidence of adverse events in patients treated with opioids, but there was significant heterogeneity between studies so the results could not be pooled. There was significantly less vomiting in patients treated with NSAIDs (RR 0.35, 95% CI 0.23 to 0.53, P < 0.00001). In particular, patients receiving pethidine had a much higher rate of vomiting compared with patients receiving NSAIDs. Gastrointestinal bleeding and renal impairment were not reported.

AUTHORS' CONCLUSIONS

Both NSAIDs and opioids can provide effective analgesia in acute renal colic. Opioids are associated with a higher incidence of adverse events, particularly vomiting. Given the high rate of vomiting associated with the use of opioids, particularly pethidine, and the greater likelihood of requiring further analgesia, we recommend that if an opioid is to be used it should not be pethidine.