Renal colic can be insufferable for patients and physicians alike. Although NSAIDs are typically sufficient, you will with some frequency encounter individuals where NSAIDs and possibly even opioids aren’t enough. Here, we review alternatives to managing pain related to renal colic.
Is lidocaine a good alternative to opioids for the treatment of acute pain due to renal colic in the emergency department?
Lidocaine has been used for many types of pain, including acute postoperative pain, chronic severe neuropathic pain, central pain, and visceral pain (1). In 2012, Soleimanpour et al. (2) sought to determine if lidocaine could effectively treat pain from renal colic. They published a study in BMJ Urology in 2012, a single-center randomized double-blinded control trial of 240 patients from an emergency room in Iran who were randomized to receive either a single dose of morphine 0.1mg/kg IV or lidocaine 1.5mg/kg IV for the treatment of renal colic. The diagnosis was made initially via clinical symptoms of flank pain radiating to the groin and the presence of hematuria on UA, later confirmed with KUB or ultrasound. These patients graded their pain according to the Visual Analogue Pain Scale (VAS) at 5, 10, 15, and 30 minutes. They found that patients who received lidocaine had a statistically significant improvement in their pain scores compared to those who received morphine at 5 minutes and at the completion of treatment.
ACEP suggests a multimodal approach to treating renal colic, including lidocaine 1.5mg/kg IV in a 100mL saline bag delivered over 10 minutes, 1L of normal saline, ketorolac 15mg IV, and acetaminophen 975mg PO or IV.
Answer: Lidocaine is a good alternative to opioid medication to treat renal colic in the emergency department for non-pregnant patients without significant cardiac or seizure history.
How does lidocaine compare to ketorolac, and can we just use lidocaine alone?
Although Soliemanpour’s study made a strong case for IV lidocaine over morphine in the treatment of renal colic, most of us reach for NSAIDs (i.e., ketorolac) as our first-line treatment for renal colic. Indeed, ketorolac, an NSAID that can be given IV, IM, or PO, has a well-established efficacy in treating many types of pain and is particularly adept at treating renal colic. This is due in part to its analgesic effects via the COX pathway as well as prostaglandin-mediated smooth muscle relaxation effects in the ureters (3). In a systematic review of 12 studies examining morphine, ketamine, acetaminophen, and ketorolac for the treatment of renal colic, ketorolac demonstrated the greatest decrease in pain scores at 30 and 60 minutes. Interestingly, acetaminophen showed the fastest reduction in pain scores, followed by ketorolac (4).
A study published by Motov et al. in the American Journal of Emergency Medicine in 2020 (5) randomized 150 subjects into 3 groups to receive either lidocaine, ketorolac, or both. Their double-blinded study found that pain scores at 30 minutes were significantly better in the combined lidocaine/ketorolac group compared to the lidocaine alone group, although a comparable number of patients required rescue analgesia at 60 minutes. Their results showed that lidocaine in combination with ketorolac was more effective than lidocaine alone in treating renal colic, although it was not superior to ketorolac alone.
Answer: Lidocaine is unlikely to be superior to ketorolac in the treatment of renal colic.
What else do I need to know before giving lidocaine for renal colic in the ED?
There is good evidence for lidocaine’s role in treating renal colic. However, emergency practitioners should be aware of the side effects and toxicity. Lidocaine’s mechanism involves blockage of sodium channels, which can have significant cardiac effects. ACEP recommends cardiac monitoring while the patient is receiving the infusion of lidocaine to monitor for arrhythmias, as well as having intralipid on hand in the event of local anesthetic systemic toxicity (LAST). It is heralded by symptoms such as dizziness, perioral numbness, paresthesias, muscle fasciculations, and tremors, followed by CNS depression, seizures, hemodynamic instability, and deadly arrhythmias. Although a dose of 1.5 mg/kg is below the 5 mg/kg toxicity threshold for lidocaine, errors can occur. Therefore, ensuring that toxicity can be rapidly recognized and reversed with intralipid on hand is imperative before giving lidocaine IV for renal colic (6,7).
Answer: Be wary of lidocaine’s cardiotoxic potential and ensure that intralipid is available prior to administration.
Authored by Vladimir Bernstein, MD
Resources:
MAP: Intravenous Lidocaine for Renal Colic Tool. www.acep.org. Accessed April 1, 2024. https://www.acep.org/patient-care/map/map-intravenous-lidocaine-for-renal-colic-tool
Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;12:13. Published 2012 May 4. doi:10.1186/1471-2490-12-13
Zhen N, De-Sheng C, Yan-Jun Y, Hua L. The analgesic effect of ketorolac addition for renal colic pain: A meta-analysis of randomized controlled studies. Am J Emerg Med. 2021;43:12-16. doi:10.1016/j.ajem.2020.12.073
Alghamdi YA, Morya RE, Bahathiq DM, et al. Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis. Am J Emerg Med. 2023;73:187-196. doi:10.1016/j.ajem.2023.08.029
Motov S, Fassassi C, Drapkin J, et al. Comparison of intravenous lidocaine/ketorolac combination to either analgesic alone for suspected renal colic pain in the ED. Am J Emerg Med. 2020;38(2):165-172. doi:10.1016/j.ajem.2019.01.048
DeJulio P, Oswald J. More Than a Local Agent: 10 Pearls of IV Lidocaine Use for Pain in the ED. www.acep.org. https://www.acep.org/painmanagement/newsroom/jan2021/more-than-a-local-agent-10-pearls-of-iv-lidocaine-use-for-pain-in-the-ed
Swaminathan A. Local Anesthetic Systemic Toxicity (LAST). REBEL EM - Emergency Medicine Blog. Published May 18, 2017. https://rebelem.com/local-anesthetic-systemic-toxicity-last/