Gu Hui-Yun, Luo Jie, Wu Jun-Yi, Yao Qi-Sheng, Niu Yu-Ming, Zhang Chao
Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
Department of Emergency, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
Front Pharmacol. 2019 Feb 22;10:96. doi: 10.3389/fphar.2019.00096. eCollection 2019.
Currently, although non-steroidal anti-inflammatory drugs (NSAIDs) were recommended for acute renal colic in the 2018 European Association of Urology guidelines, there are no specific NSAIDs and no specific routes of administration in this guideline. The clinical practice of advocating intravenous opioids as the initial analgesia is still common out of the fear of adverse events from NSAIDs. To comprehensively assess the efficacy and safety of NSAIDs, opioids, paracetamol, and combination therapy for acute renal colic. Ovid MEDLINE, Ovid EMbase, the Cochrane Library, Clinical Trials Registry Platform for Clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched through February 2, 2018. Two reviewers selected all randomized controlled trails (RCTs) regarding NSAIDs, opioids, paracetamol, combination therapy, and placebo were identified for analysis. We designed a three-stage strategy based on classification and pharmacological mechanisms in the first stage, routes of administration in the second stage, and specific drug branches with different routes in the third stage using network meta-analysis. The pain variance at 30 min was seen as the primary outcome. 65 RCTs with 8633 participants were involved. Comparing different classification and pharmacological mechanisms, combination therapy with more adverse events was more efficient than NSAIDs for the primary outcomes. Opioids gave rise to more nonspecific adverse events and vomiting events. NSAIDs were superior to opioids, paracetamol, and combination therapy after a full consideration of all outcomes. Comparing different routes of administration, NSAIDs with IV or IM route ranked first from efficacy and safety perspective. Comparing different specific drug branches with different routes, ibuprofen via IV route, ketorolac via IV route and diclofenac via IM route were superior for the management of acute renal colic. The results from diclofenac using IM route were more than those from ibuprofen used with IV route and ketorolac with IV route. In patients with adequate renal function, diclofenac via the IM route is recommended for patients without risks of cardiovascular events. Ibuprofen and ketorolac with IV route potentially superior to diclofenac via IM route remain to be investigated. Combination therapy is an alternative choice for uncontrolled pain after the use of NSAIDs.
目前，尽管2018年欧洲泌尿外科学会指南推荐非甾体抗炎药（NSAIDs）用于急性肾绞痛，但该指南中没有具体的NSAIDs药物和给药途径。出于对NSAIDs不良事件的担忧，提倡静脉注射阿片类药物作为初始镇痛方法的临床实践仍然很常见。为了全面评估NSAIDs、阿片类药物、对乙酰氨基酚及联合治疗对急性肾绞痛的疗效和安全性。检索了截至2018年2月2日的Ovid MEDLINE、Ovid EMbase、Cochrane图书馆、Clinicaltrials.gov临床试验注册平台和世界卫生组织国际临床试验注册平台。两名评审员筛选出了所有关于NSAIDs、阿片类药物、对乙酰氨基酚、联合治疗和安慰剂的随机对照试验（RCT）进行分析。我们设计了一个三阶段策略，第一阶段基于分类和药理机制，第二阶段基于给药途径，第三阶段基于不同途径的特定药物分支，采用网状Meta分析。将30分钟时的疼痛差异视为主要结局。共纳入65项RCT，涉及8633名参与者。比较不同的分类和药理机制，不良事件较多的联合治疗在主要结局方面比NSAIDs更有效。阿片类药物会引发更多非特异性不良事件和呕吐事件。在全面考虑所有结局后，NSAIDs优于阿片类药物、对乙酰氨基酚和联合治疗。比较不同的给药途径，静脉注射或肌肉注射途径的NSAIDs在疗效和安全性方面排名第一。比较不同途径的不同特定药物分支，静脉注射途径的布洛芬、静脉注射途径的酮咯酸和肌肉注射途径的双氯芬酸在急性肾绞痛的治疗中更具优势。肌肉注射途径双氯芬酸的结果优于静脉注射途径布洛芬和静脉注射途径酮咯酸的结果。对于肾功能正常且无心血管事件风险的患者，建议采用肌肉注射途径的双氯芬酸。静脉注射途径的布洛芬和酮咯酸是否潜在优于肌肉注射途径的双氯芬酸仍有待研究。联合治疗是使用NSAIDs后疼痛无法控制时的一种替代选择。
