SGEM#389: Does Dex, Dex, Dex, Dexamethasone Help with Renal Colic?

Date: January 13, 2023 Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Dr. Kevan Sternberg Guest Skeptic: Dr. Kevan Sternberg is a urologist/endourologist. His focus is on the medical and surgical management of kidney stone disease. Dr. Sternberg did his medical school and residency training at the University of Buffalo (SUNY) and endourology fellowship at the University of Pittsburgh Medical Center. Kevan was on the SGEM Xtra episode three years ago that brought together Emergency Medicine, Radiologists and Urologists to discuss ultrasound vs CT scans for suspected renal colic. You can listen to the SGEM podcast to hear what he thinks the impact of this initiative has been. Case: A 38-year-old female presents to the emergency department (ED) with a five-hour history of acute onset left flank pain.  The pain comes in waves, radiates into her left groin and is associated with nausea and vomiting.  She noticed darkening of her urine, but does not have dysuria, fever, or vaginal discharge. Background: We have looked at many different therapies to treat renal colic on the SGEM. That has included things like fluid bolus or diuretics (SGEM#32), tamsulosin (SGEM#4, #71, #154, #230), acupuncture (SGEM#220) and lidocaine (SGEM#202). The SGEM bottom line to these different treatment options: You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones. Medical expulsive therapy with tamsulosin is unnecessary for stones < 5mm. If a benefit does exist for Tamsulosin it's with distal ureteral stones > 5 mm. Acupuncture is not superior to morphine for renal colic. The evidence doesn’t support the use of lidocaine for renal colic. Glucocorticoids (steroids) act as anti-inflammatories, immunosuppressants, antiproliferative drugs, and have vasoconstrictive effects. It has been hypothesized that adding a long-acting glucocorticoid like dexamethasone may help with pain and vomiting associated with passing a kidney stone and decrease opioid use. Clinical Question: Should we be adding a dexamethasone to NSAIDs for the management of suspected acute renal colic? Reference: Razi et al. Dexamethasone and ketorolac compare with ketorolac alone in acute renal colic: A randomized clinical trial. AJEM 2022 Population: Patients presenting to the ED with flank pain and presumed renal colic Exclusions: Pregnancy (confirmed or possible), analgesic therapy during six hours before admitted to the emergency unit, near history of hemorrhagic diathesis, addiction or recent methadone use, use of warfarin and other anticoagulants, acute abdomen, fever, BP ≥ 180/100 mmHg; any contra- indication for ketorolac including hypersensitivity to aspirin or other NSAIDs, active or history of peptic ulcer disease, a recent history of GI bleeding or perforation or suspected or confirmed cerebrovascular bleeding, advanced hepatic or renal disease, patients at risk for renal failure, hyperkalemia, and uncontrolled severe heart failure; and any contraindications for the use of dexamethasone Intervention: Ketorolac 30mg IV plus dexamethasone 8mg IV Comparison: Ketorolac 30mg IV Outcome: Primary Outcome: Change in pain on a 10-cm visual analog scale (VAS) at 30 minutes and 60 minutes Secondary Outcomes: Grade of vomiting and the need for antiemetics and need for opioids Type of Trial: Single-centered, triple-blind, randomized clinical trial from Iran Authors’ Conclusions: “In comparison with the patients who just received ketorolac, adding dexamethasone provided improved pain control after 30 min of therapy”. Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes