Razi A, Farrokhi E, Lotfabadi P, et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. Am J Emerg Med. 2022 Aug;58:245-250. doi: 10.1016/j.ajem.2022.05.054. Epub 2022 Jun 2. (Original study)

BACKGROUND: Multidrug pain control can be beneficial in relieving pain and limiting narcotic use in renal colic. The purpose of this study was to evaluate the effects of adding dexamethasone to ketorolac on pain control in acute renal colic.

METHODS: One hundred twenty patients with renal colic were randomized into comparison and intervention groups to investigate the effect of 8 mg of dexamethasone with 30 mg ketorolac administered immediately after the patient's admission. The primary outcome was pain intensity based on the visual analog scale (VAS), which was assessed at the baseline and after 30 and 60 min of drugs treatment. Also, grade of vomiting and narcotic or antiemetic requirement were measured at the baseline and after the 60-min intervention.

RESULTS: A total of 120 patients were included in the final analysis, with 60 patients (50%) randomized to the comparison group (just ketorolac) and 60 (50%) randomized to the intervention group (ketorolac + dexamethasone). There were no significant demographic differences between groups (P > 0.05 for all). Differences in VAS scores were significantly lower in the intervention group after 30 min of drug administration (P = 0.009, compared with the control). However, there was not a significant difference in the median VAS score between groups at the baseline and end of the study (P > 0.05). At the end of the study, the percent of patients who need to narcotics (35% vs. 58%, P = 0.01) and/or antiemetic (12% vs. 28%, P = 0.022) were significantly lower in the intervention group compared with the controls.

CONCLUSIONS: In comparison with the patients who just received ketorolac, adding dexamethasone provided improved pain control after 30 min of therapy. Furthermore, it decreased opioid requirements and decreased an antiemetic need at the end of the study. Dexamethasone should be considered an important multimodal adjunct for controlling pain and nausea in renal colic.

Discipline Area Score
Emergency Medicine 6 / 7
Special Interest - Pain -- Physician 6 / 7
Nephrology 5 / 7
Comments from MORE raters

Emergency Medicine rater

Rapidly effective analgesia for patients with suspected renal colic in the emergency department is a top priority for patients. While opioids are generally effective, the ongoing opioid epidemic is catalyzing efforts to identify non-opioid alternatives. NSAIDs are generally first-line therapy but as the authors note, glucocorticoids have a biologically plausible expectation to provide additive analgesia. This is a therapy that I haven't considered. Although these single-center results with predominantly male population and undefined ethnic diversity are compelling, the results are not yet practice-changing without additional confirmatory trials. Nonetheless, readers would likely be interested in this approach to non-opioid analgesia.

Nephrology rater

Keep in mind some limitations: this is a single-center study; no information on how many patients received imaging to confirm kidney stones; and no information is provided on the size of the kidney stone (if it's a single stone). Findings need to be confirmed before widely adopting adding dexamethasone for acute renal colic.

Nephrology rater

Hard to understand how a steroid could have any effect over such a short time period as 30 minutes.

Special Interest - Pain -- Physician rater

Potentially interesting but needs independent confirmation. There is a need for opiate administration that is poorly defined since other modalities of analgesia are possible, including supplemental NSAIDs.

Special Interest - Pain -- Physician rater

Patients were recruited after diagnosis and excluded if they consumed an analgesic less than 6 hours before admission to the ED. We usually start treatment before diagnosis and dexamethasone might have a negative effect in diagnoses other than renal colic. Results should be confirmed in another larger study in patients presumed to have renal colic.
Comments from EvidenceAlerts subscribers

Dr. Mark Frydenborg (7/24/2022 7:09 AM)

The abstract says nothing about whether there was double-blinding. This could be a significant source of bias in the study.