Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Nitroglycerin for renal colic
- Harvey D. Sanders (11 June 2004)
-
Two single thin needles for renal colic
- harold j. bueno de mesquita (13 June 2004)
-
Is there a place for smooth mucle relaxants in the treatment of renal colic?
- Sanjay Purkayastha (14 June 2004)
-
Pseudo-objectivity in the Conduct and Reporting of Systematic Reviews: an example
- David L. Schriger (15 July 2004)
-
Opioids and non-steroidal anti-inflammatory drugs may no longer be the only options for renal colic.
- Kim Davenport, Anthony G Timoney, Francis X Keeley Jr (19 July 2004)
|
|
|||
|
Harvey D. Sanders, Retired 3395 Ayr Ave., North Vancouver, BC. Canada V7R 1K4
Send response to journal:
|
I am a retired internist and clinical pharmacologist. During the course of my career in medicine I have had occasion to treat approximately 10 patients and, unfortunately, also myself for renal colic. I have used morphine in most of the cases but in the last three, including myself, I have used Nitrospray. In all cases the relief was almost instantaneous, occurring in 2 - 3 minutes. Logically, this makes more sense than using either narcotics or NSAIDs as it attacks the smooth muscle directly. I was not in a position to carry out a clinical trial at the time I was in practice but I certainly believe that someone should do it. It does have the advantage, at least theoretically, of relieving the ureteral spasm sufficiently that a small stone could pass into the bladder. Is anyone out there interested? Competing interests: None declared |
|||
|
|
|||
|
harold j. bueno de mesquita, family-physician JERUSALEM 93384
Send response to journal:
|
Dear Sir, Next time one has a patient with acute renal colic it is worth trying the following very quick and simple treatment. I tried it a few times and it was very effective ,just like published in the Journal of Traditional Chinese Medicine vol 13,no.4 [december 1993],page 265. Stick an [acupuncture] needle bilateral in the following point: stomach 36 [zusanli]. Localisation of the point: at the height of the tuberositas tibiae ,measure a distance of one thumb- breath lateral to the tibia and stick there a needle vertically,one to two inches deep. One may twist the needle or just leave it for a a few minutes in,till the attack disappears. could it be simpler?? Competing interests: LOVE FOR SIMPLE , NON-DANGEROUS METHODS |
|||
|
|
|||
|
Sanjay Purkayastha, SHO General Surgery Wexham Park Hospital, Berkshire, SL2 4HL
Send response to journal:
|
Dear Sir, Holdgate and Pollock have been comprehensive in the comparison of opiates versus non steroidal antiinflammatory drugs (NSAIDs) in the treatment of renal colic. However the ureter is composed of smooth mucle and thus it begs the question if there is a place for the use of smooth muscle relaxants such as hyoscine butylbromide (Buscopan)? Intuitively one would think that such antimuscarinics would reduce ureteric peristalsis and aid pain relief and even fascilitate passage of the offending calculus. Currently I do not know of any protocols that advocate their use in renal colic, nor is is cited in pharmacological texts such as the British National Formulary. The current literature has both favourable and unfavourable evidence for such antispasmodics. Is this something that the authors would advocate or is it this something that needs further evaluation? Competing interests: None declared |
|||
|
|
|||
|
David L. Schriger, Professor of Emergency Medicine UCLA School of Medicine and Centre for Statistics in Medicine, University of Oxford
Send response to journal:
|
I begin with a proviso. While I write in response to the paper by Holdgate and Pollack [1], I could just as easily have written about many systematic reviews published in this and other reputable journals. I want these authors and those who read this letter to understand that the only thing unusual about their paper is that it came across my desk while I was thinking about these issues. I do not intend to impugn or single out this paper or these authors. They have done nothing out of the ordinary. The problem is that the ordinary is not good enough. Holdgate and Pollack’s systematic review illustrates the danger of offering conclusions that are not supported by the evidence. The paper presents an analysis of RCTs that compared opioids and NSAIDS for renal colic and concludes “We therefore recommend a NSAID rather than an opioid.” One might expect that, in the spirit of evidence-based medicine, such a recommendation would be justified by the evidence reviewed in the manuscript. Unfortunately such justification is nowhere to be found. Alas, despite all of the fancy manipulations of the systematic review process, the conclusion is no better justified than one in an opinion- based editorial. A conclusion of the kind offered by the authors would require the following minimum information if it is to flow logically from the evidence: 1) An assessment of the effectiveness of each drug for one or more important clinical outcomes. 2) An assessment of the side effect profile of each drug 3) An assessment of the cost of each agent 4) A specification of the loss function that describes the trade-off between benefits and harms. This systematic review addresses only the first of these elements. Therefore, even if this was a perfect systematic review with an adequate number of well designed studies that directly addressed the clinical question, the only conclusion that could be logically supported is that one drug produces better outcomes than the other with respect to the primary endpoints. This is insufficient information to recommend one drug in preference to the other. For those who doubt this, consider a systematic review of 100 RCTs each of which enrolled 10,000 subjects and showed that drug A decreased pain as measured by visual analog scale by 20 to 30 mm compared to drug B. This evidence, far better than we will ever see in medicine, is insufficient to support a recommendation that drug A be used. I simply need to tell you that drug A kills 1 in every 100 patients who receive it while B kills none to deflate its value. I could do the same by telling you that A costs £100,000 while B costs £10. With less extreme values we would need to know the loss function (e.g. how many side effects is one willing to accept to produce additional reduction in pain, or how many pounds is one willing to spend to produce an additional reduction in pain?) to know which drug is preferred. Having only studied one of the four elements, the authors are in no position to offer such a recommendation in the context of an evidence- based report. The danger of any scripted process is that it creates the appearance of objectivity and certainty when neither is assured. The casual reader who glances at this article, notes that it is a systematic review and, reassured by the format, reads the aforementioned conclusion and goes away thinking that there is evidence that NSAIDs are preferred has been grossly deceived. Deceived too is the practitioner who is handed a reprint (with the appropriate bits highlighted) and some samples of NSAIDs from a pharmaceutical representative. I will not review the many reasons why the evidence in this systematic review is insufficient to support the more limited conclusion that NSAIDs provide more pain relief than opiods. The important point is that the only reasonable conclusion from this systematic review is that there are so many holes in the available data that we cannot make any evidence-based recommendation about opioids vs. NSAIDS for renal colic. Any other interpretation is based on opinion and speculation - both of which are fine, necessary, and wholly appropriate in clinical medicine but not in a systematic review.[2] It is difficult to show restraint after expending the substantial effort required to perform a systematic review. There is huge pressure to reach a helpful conclusion. Doing so, however, makes the systematic review into a dangerous act of alchemy. The illusion of certainty is more dangerous than ignorance. It can kill patients and slow progress in science. That this paper (and so many others like it) was published with its conclusion intact suggests that authors and editors have been lulled into complacency by the formalistic pseudo-objectivity of the systematic review process. It is time we awaken and recognize that for the vast majority of topics in medicine the evidence will be insufficient to logically support a clinical recommendation and that the standard recipe for conducting a systematic review is insufficient to ensure an unbiased conclusion. In 1993, I argued that in the name of honesty “evidence-based medicine” should be renamed “evidence-informed medicine.”[2] A decade of half- truths has not diminished the need for such a change. 1. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ. 2004:12;328:1401. 2. Alderson P, Green S, Higgins JPT, editors. Formulating the problem. Cochrane Reviewers’ Handbook 4.2.2 [updated March 2004]; Section 4.9. http://www.cochrane.org/resources/handbook/hbook.htm (accessed 10 July 2004). 3. Schriger DL, Cantrill SV, Greene CS. The origins, benefits, harms, and implications of emergency medicine clinical policies. Ann Emerg Med. 1993;22:597-602. Competing interests: None declared |
|||
|
|
|||
|
Kim Davenport, Clinical Fellow in Endourology Southmead Hospital, Bristol, BS10 5NB, Anthony G Timoney, Francis X Keeley Jr
Send response to journal:
|
EDITOR – I found it interesting that the review on non-steroidal anti -inflammatory drugs (NSAID) and opioids for acute renal colic made no mention of the risks associated with using NSAIDs in renal colic. NSAIDs effectively reduce pain but potentially they interfere with the renal autoregulatory response to obstruction by decreasing renal blood flow (1). This is well tolerated in healthy individuals but renal failure may be induced in those patients with pre-existing renal disease. Dehydration secondary to vomiting may also contribute to impair renal function. In addition, in patients with cardiac disease, there is a risk of promoting heart failure and cardiac decompensation (2). These factors need to be taken into account prior to administration and renal function should be closely observed in any patients in whom obstruction is suspected. Although comprehensive in terms of reviewing the available literature on conventional opiates and NSAIDs, there was no mention of newer suggested alternatives. Due to the side effect profiles associated with both these groups, alternative methods of treatment have been and are being sought. At present, suitable alternative analgesics include tramadol and selective cyclo-oxygenase (Cox) II inhibitors, predominately rofecoxib. Tramadol is an opioid analgesic with fewer opioid side effects, notably, less respiratory depression, constipation and potential for addiction. When used for the treatment of renal colic, tramadol 100mg was found to be as effective as pethidine 50mg (3). Tramadol requires more research but may prove to be a suitable alternative to conventional opioids. Selective inhibition of Cox II improves gastrointestinal tolerance but still has a detrimental effect on renal and cardiac function in those with pre-existing disease. Selective Cox II inhibitors have been suggested to be a suitable alternative to NSAIDs and include rofecoxib, celecoxib and parecoxib. Although, Cox II inhibition reduces ureteric muscle activity as effectively as indomethacin in human ureteric segments in vitro (4), there is currently no data available regarding its use in the treatment of renal colic. Alternative drugs showing promise include calcium channel antagonists, especially nifedipine (5, 6), nitrates (7) and alpha-receptor antagonists, namely tamsulosin (8). Many cardiovascular drugs, known to exert their action by relaxation of smooth muscle, are showing promising results in clinical trials when used in the treatment of renal colic. These groups warrant further attention to determine their value in the management of ureteric calculi with regards to pain and the possibility of increasing spontaneous stone passage rates. Finally, local active warming of the loin area during the emergency transfer of these patients appears to be an effective method of providing analgesia and anxiolysis prior to arrival at hospital (9). 1 Perlmutter A, Miller L, Trimble LA, Marion DN, Vaughan ED jr, Felson D. Toradol, an NSAID used for renal colic, decreases renal perfusion and ureteral pressure in a canine model of unilateral ureteral obstruction. J Urol 1993; 149: 926-930. 2 Bleumink GS, Feenstra J, Sturkenboom MC, Stricker BH. Non-steroidal anti-inflammatory drugs and heart failure. Drugs 2003; 63(6): 525-534 3 Salehi M, Ghaserni H, Shiery H, Roshani A, Khosropanah I, Asgari A. Intramuscular tramadol versus intramuscular pethidine for treatment of acute renal colic. J Endourol 2003; 17 supp 1: A243 4 Nakada SY, Jerde TJ, Bjorling DE, Saban R. Selective cyclo- oxygenase inhibitors reduce ureteral contraction in vitro: A better alternative for renal colic? J Urol 2000; 163: 607-612 5 Borghi L, Meschi T, Amato F et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: A randomised, double-blind, placebo-controlled study. J Urol 1994; 152: 1095-1098. 6 Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureteric stones. Urol 2000; 56 (4): 579-582. 7 Kekec Z, Yilmaz U, Sozuer E. The effectiveness of tenoxicam versus isosorbide dinitrate plus tenoxicam in the treatment of acute renal colic. BJU Int 2000; 85: 783-785 8 Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. J Urol 2003; 170: 2202-2205. 9 Kober A, Dobrovits M, Djavan B et al. Local active warming: An effective treatment for pain, anxiety and nausea caused by renal colic. J Urol 2003; 170: 741-744 Competing interests: None declared |
|||