Holdgate A, Pollock T
Department of Emergency Medicine, St George Hospital, Kogarah, NSW, Australia.
Cochrane Database Syst Rev. 2004(1):CD004137. doi: 10.1002/14651858.CD004137.pub2.
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.
To examine the benefits and disadvantages of NSAIDs and opioids for the management of pain in acute renal colic.
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.
Randomised controlled trials (RCTs) comparing any opioid with any NSAID, regardless of dose or route of administration were included.
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.
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.
REVIEWER'S 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.
肾绞痛是急性剧痛的常见病因。阿片类药物和非甾体抗炎药（NSAIDs）均被推荐用于治疗，但这些药物的相对疗效尚不确定。
探讨NSAIDs和阿片类药物在急性肾绞痛疼痛管理中的利弊。
我们检索了Cochrane肾脏组的专门注册库（2003年5月）、Cochrane随机对照试验中心注册库（CENTRAL - Cochrane图书馆2003年第2期）、MEDLINE（1966年至2003年1月31日）、EMBASE（1980年至2003年1月31日），并手工检索了所获文章的参考文献列表。
纳入比较任何阿片类药物与任何NSAIDs的随机对照试验（RCTs），无论剂量或给药途径如何。
由两名评价员独立提取数据并进行质量评估，分歧通过讨论解决。二分法结果报告为相对危险度（RR），连续量表测量结果报告为加权均数差（WMD）及95%置信区间。尽可能按研究质量、药物类型和药物途径进行亚组分析，以探讨异质性的原因。
共识别出来自9个国家的20项试验，总计1613名参与者。NSAIDs和阿片类药物均使患者报告的疼痛评分出现临床上显著的下降。由于存在无法解释的异质性，这些结果无法合并，尽管13项研究中有10项报告接受NSAIDs治疗的患者疼痛评分较低。接受NSAIDs治疗的患者需要急救药物的可能性显著更低（RR 0.75，95% CI 0.61至0.93，P = 0.007），不过这些试验大多使用了哌替啶。大多数试验显示接受阿片类药物治疗的患者不良事件发生率更高，但研究间存在显著异质性，因此结果无法合并。接受NSAIDs治疗的患者呕吐明显更少（RR 0.35，95% CI 0.23至0.53，P < 0.00001）。特别是，与接受NSAIDs治疗的患者相比，接受哌替啶治疗的患者呕吐发生率要高得多。未报告胃肠道出血和肾功能损害情况。
NSAIDs和阿片类药物在急性肾绞痛中均可提供有效的镇痛作用。阿片类药物不良事件发生率更高，尤其是呕吐。鉴于使用阿片类药物，特别是哌替啶时呕吐发生率较高，且需要进一步镇痛的可能性更大，我们建议如果要使用阿片类药物，不应使用哌替啶。
