Indomethacin Suppositories Versus Intravenously Titrated Morphine for the Treatment of Ureteral Colic

Study objectives: To develop a protocol for the blinded IV titration of morphine and to compare the analgesic efficacy and side effect profile of indomethacin suppositories versus IV morphine in the treatment of acute ureteral colic. Design: Randomized, double-blind, double-dummy, two-period crossover study. Setting: Emergency department of a central-city, teaching hospital. Participants: Patients 18 to 75 years of age with pain suggestive of ureteral colic. Exclusions included pregnancy, adverse reactions to the study drugs, chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or any pain medicine taken within four hours of ED admission. Interventions: Patients were randomized to one of two groups: indomethacin 100-mg rectal suppository or morphine by IV titration (5-mg loading dose and up to two additional 2.5-mg doses if needed). At the end of 30 minutes, if adequate pain relief had not been obtained, treatment was crossed over. Measurements: Verbal analog scale (initial pain) and visual analog pain relief scale. Main results: Seventy-five patients were entered into the study. Only data from those patients with stone presence confirmed by IV pyelogram or stone passage were analyzed. Twenty-four could not be evaluated (23 who did not meet criteria for stone presence and one whose pain resolved spontaneously before study medications could be administered). Of the remaining 51 patients, 31 received indomethacin first and 20 received morphine first. Morphine recipients reported more pain relief at ten minutes ( P = .02), but at 20 and 30 minutes, no significant difference ( P = .17 and .74, respectively) existed between the two groups. Conclusion: IV morphine produced more rapid analgesia than rectally administered indomethacin. There were no significant differences in vital sign changes or number of side effects between the two treatment groups. This study is the first to compare an NSAID with morphine administered by IV titration, considered by many to be the "gold standard" for relief of acute, severe pain. Future studies could evaluate the simultaneous administration of an opioid combined with an NSAID or compare an IV titrated opioid with an IV NSAID. [Cordell WH, Larson TA, Lingeman JE, Nelson DR, Woods JR, Burns LB, Klee LW: Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic. Ann Emerg Med February 1994;23:262-269.]