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NSAIDs = opioids for biliary colic

Clinical Question:
Are nonsteroidal antiinflammatory drugs as effective as opioids to treat pain and decrease complications in patients with biliary colic?

Bottom Line:
Injectable nonsteroidal antiinflammatory drugs (NSAIDs), primarily diclofenac (Voltaren) in these studies, decreased cholecystitis and produced pain relief equivalent to meperidine in patients with acute biliary pain due to cholelithiasis. (LOE = 1a-)

Colli A, Conte D, Della Valle S, Sciola V, Fraquelli M. Meta-analysis: nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 2012;35(12):1370-1378.  [PMID:22540869]

Study Design:
Meta-analysis (randomized controlled trials)

Self-funded or unfunded

Inpatient (any location)

These Italian authors searched several databases, including the Cochrane Register, and identified 11 randomized controlled trials comparing NSAIDs with no treatment, placebo, or other drugs in patients with biliary colic. All the authors independently selected articles for inclusion; 2 authors extracted the data and determined methodologic quality. They included studies with or without masking, published or not, in any language. There was no evidence of publication bias. NSAIDs administered in the emergency department (injectable diclofenac was the most commonly studied) resulted in significantly more patients being pain-free within 2 hours than did placebo (relative risk [RR] = 3.77; 95% CI, 1.65 - 8.61) and also decreased the risk of cholecystitis by approximately half, again as compared with placebo (RR = 0.52; .31-.89). Ketorolac (Toradol) and flurbiprofen (Ansaid) given intramuscularly were as effective as meperidine at various doses. The quality of the included studies was fair and there was significant heterogeneity among the studies, but it makes sense to start with an injectable NSAID, following up with opioid treatment if pain is not quelled.


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