British Journal of Urology (1990), 66,602-605 0I990 British Journal of Urology
0007-1 331/90/0066-0602/$10.00
Treatment of Renal Colic by Prostaglandin Synthetase Inhibitors and Avafortan (Analgesic Antispasmodic) A. E. EL-SHERIF, R. FODA. L. J. NORLEN and H. YAHIA Department of Urology and Accident and Emergency Department, Hamad General Hospital, Doha, Qatar
Summary-In a study of the pain-relieving effect of 3 drugs commonly used to treat acute renal colic in this hospital, intravenous indomethacin and intramuscular diclofenac (prostaglandin synthetase inhibitors) were compared with intravenous Avafortan (analgesic antispasmodic). As first-line analgesics, prostaglandin synthetase inhibitors, if given intravenously, offer an effective alternative to Avafortan. Of 145 patients studied, 32 required a second injection for complete relief of pain. Administering a second dose of prostaglandin synthetase inhibitors resulted in equally significant pain relief rate even though the route was intramuscular. The pain in acute renal colic is believed to result from increased pelviureteric pressure and distension of the renal capsule (Risholm, 1954). This increase in renal pelvic pressure stimulates the synthesis of prostaglandin in the papillary region of the renal medulla (Nishikawa et al., 1977). One of these prostaglandins, PGE2, has diuretic properties (Flannigan et al., 1983). Thus an increase in prostaglandin synthesis results in increased diuresis and increased intensity of renal colic. Non-steroidal analgesic anti-inflammatory drugs have been used to treat acute renal colic. Although they differ chemically, all appear to be effective as a result of their ability to inhibit the production of biologically active prostaglandin. Indomethacin was first shown to have an effect in ureteric and biliary colic by Holmlund and Sjodin (1978). The aim of this study was, firstly, to compare the pain-relieving effect of intravenous Avafortan (Asta-Werke, Germany) with that of intravenous indomethacin (Indocid) and intramuscular diclofenac (Voltaren) and, secondly, to observe whether a further injection of prostaglandin synthetase inhibitors would still give significant pain relief when compared with antispasmodic analgesics in the case of patients who required a second injection for complete pain relief.
Accepted for publication 23 February 1990
Patients and Methods The series comprised 153 patients with the diagnosis of acute renal colic, based on history, clinical, urinary and radiological examination. Eight patients were excluded because of missing data. In a 2-week prospective randomised study, patients received either 50 mg intravenous indomethacin, or 50 mg intramuscular diclofenac or 4 ml intravenous Avafortan (camylofine bis, sodium phenyldimethyl-pyrazonolone-methylamino-methane sulphonate). The latter has a papaverine-like action and is used in cases of biliary and urinary tract colic. Pain relief was rated as “no relief’, “partial relief’ and “complete relief ’. It was anticipated that the use of an analogue visual scale for assessment of pain relief would be difficult because most of our patients are expatriates with diverse ethnic and social backgrounds. The pain-relieving effect of the drug was assessed 10, 20 and 30min after injection. After 30min, patients who had obtained no relief or only partial pain relief, and who required more analgesics, were offered a second injection of the same drug. Reassessment was continued at l0-min intervals for another 30min. If the pain persisted 30min after the second injection, the patient was given intravenous pethidine and admitted to the ward. Randomisation was judged effective because there were no statistically significant differences
602
TREATMENT OF RENAL COLIC BY PROSTAGLANDIN SYNTHETASE INHIBITORS AND AVAFORTAN
Table 1 Age, Sex and Pain Distribution Avafortan (n = 54)
Indocid (n = 44)
Age (years) (SD) Range Sex
33.4k9.2 13-50 48 M/5 F
35k8.6 33.7k8.5 33.9k8.8 21-61 14-53 13-61 41 M/3 F 42 M / 4 F 131 M/ 12 M
Pain Severe Moderate
26 28
20 24
Voltaren (n = 47)
17 30
Total (n = 145)
63 82
between the patients in terms of age, sex or severity of pain (Table 1). Differences between means were assessed by Student’s t test and analysis of variance. Differences in frequencies between groups were analysed with the x2 test and Fisher’s exact probability test. Significance levels of P < 0.05 were set (2-tailed).
Results Following the first injection, patients receiving intravenous indomethacin had the highest complete pain relief rate (84.1%). In the intravenous Avafortan group the rate was 83.3%. This difference was not statistically significant. The intramuscular diclofenac group had the lowest complete pain relief rate (66%) (Fig. 1). There was a statistically 100
90 80 A
&? v
70
c1 In
c 60
.-+0 m
*P 0
p
50 40
30 20
10
Fig. 1 Response to first injection.
603
significant difference between the indomethacin and diclofenac groups ( P < 0.01) and between the Avafortan and diclofenac groups (P< 0.05). After the first 10 minutes, no patient in the diclofmac group had partial pain relief compared with 11 patients given Avafortan (20%) and 5 given indomethacin (1 1%) (P
0007-1 331/90/0066-0602/$10.00
Treatment of Renal Colic by Prostaglandin Synthetase Inhibitors and Avafortan (Analgesic Antispasmodic) A. E. EL-SHERIF, R. FODA. L. J. NORLEN and H. YAHIA Department of Urology and Accident and Emergency Department, Hamad General Hospital, Doha, Qatar
Summary-In a study of the pain-relieving effect of 3 drugs commonly used to treat acute renal colic in this hospital, intravenous indomethacin and intramuscular diclofenac (prostaglandin synthetase inhibitors) were compared with intravenous Avafortan (analgesic antispasmodic). As first-line analgesics, prostaglandin synthetase inhibitors, if given intravenously, offer an effective alternative to Avafortan. Of 145 patients studied, 32 required a second injection for complete relief of pain. Administering a second dose of prostaglandin synthetase inhibitors resulted in equally significant pain relief rate even though the route was intramuscular. The pain in acute renal colic is believed to result from increased pelviureteric pressure and distension of the renal capsule (Risholm, 1954). This increase in renal pelvic pressure stimulates the synthesis of prostaglandin in the papillary region of the renal medulla (Nishikawa et al., 1977). One of these prostaglandins, PGE2, has diuretic properties (Flannigan et al., 1983). Thus an increase in prostaglandin synthesis results in increased diuresis and increased intensity of renal colic. Non-steroidal analgesic anti-inflammatory drugs have been used to treat acute renal colic. Although they differ chemically, all appear to be effective as a result of their ability to inhibit the production of biologically active prostaglandin. Indomethacin was first shown to have an effect in ureteric and biliary colic by Holmlund and Sjodin (1978). The aim of this study was, firstly, to compare the pain-relieving effect of intravenous Avafortan (Asta-Werke, Germany) with that of intravenous indomethacin (Indocid) and intramuscular diclofenac (Voltaren) and, secondly, to observe whether a further injection of prostaglandin synthetase inhibitors would still give significant pain relief when compared with antispasmodic analgesics in the case of patients who required a second injection for complete pain relief.
Accepted for publication 23 February 1990
Patients and Methods The series comprised 153 patients with the diagnosis of acute renal colic, based on history, clinical, urinary and radiological examination. Eight patients were excluded because of missing data. In a 2-week prospective randomised study, patients received either 50 mg intravenous indomethacin, or 50 mg intramuscular diclofenac or 4 ml intravenous Avafortan (camylofine bis, sodium phenyldimethyl-pyrazonolone-methylamino-methane sulphonate). The latter has a papaverine-like action and is used in cases of biliary and urinary tract colic. Pain relief was rated as “no relief’, “partial relief’ and “complete relief ’. It was anticipated that the use of an analogue visual scale for assessment of pain relief would be difficult because most of our patients are expatriates with diverse ethnic and social backgrounds. The pain-relieving effect of the drug was assessed 10, 20 and 30min after injection. After 30min, patients who had obtained no relief or only partial pain relief, and who required more analgesics, were offered a second injection of the same drug. Reassessment was continued at l0-min intervals for another 30min. If the pain persisted 30min after the second injection, the patient was given intravenous pethidine and admitted to the ward. Randomisation was judged effective because there were no statistically significant differences
602
TREATMENT OF RENAL COLIC BY PROSTAGLANDIN SYNTHETASE INHIBITORS AND AVAFORTAN
Table 1 Age, Sex and Pain Distribution Avafortan (n = 54)
Indocid (n = 44)
Age (years) (SD) Range Sex
33.4k9.2 13-50 48 M/5 F
35k8.6 33.7k8.5 33.9k8.8 21-61 14-53 13-61 41 M/3 F 42 M / 4 F 131 M/ 12 M
Pain Severe Moderate
26 28
20 24
Voltaren (n = 47)
17 30
Total (n = 145)
63 82
between the patients in terms of age, sex or severity of pain (Table 1). Differences between means were assessed by Student’s t test and analysis of variance. Differences in frequencies between groups were analysed with the x2 test and Fisher’s exact probability test. Significance levels of P < 0.05 were set (2-tailed).
Results Following the first injection, patients receiving intravenous indomethacin had the highest complete pain relief rate (84.1%). In the intravenous Avafortan group the rate was 83.3%. This difference was not statistically significant. The intramuscular diclofenac group had the lowest complete pain relief rate (66%) (Fig. 1). There was a statistically 100
90 80 A
&? v
70
c1 In
c 60
.-+0 m
*P 0
p
50 40
30 20
10
Fig. 1 Response to first injection.
603
significant difference between the indomethacin and diclofenac groups ( P < 0.01) and between the Avafortan and diclofenac groups (P< 0.05). After the first 10 minutes, no patient in the diclofmac group had partial pain relief compared with 11 patients given Avafortan (20%) and 5 given indomethacin (1 1%) (P
