title: Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Randomized, double-blind, double-dummy, two-period crossover study.
  
  
  METHODS
  Emergency department of a central-city, teaching hospital.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Verbal analog scale (initial pain) and visual analog pain relief scale.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Emergency Medicine and Trauma Center Methodist Hospital of Indiana, Indianapolis 46202.
authors.forename: W H
authors.initials: WH
authors.lastname: Cordell
authors.forename: T A
authors.initials: TA
authors.lastname: Larson
authors.forename: J E
authors.initials: JE
authors.lastname: Lingeman
authors.forename: D R
authors.initials: DR
authors.lastname: Nelson
authors.forename: J R
authors.initials: JR
authors.lastname: Woods
authors.forename: L B
authors.initials: LB
authors.lastname: Burns
authors.forename: L W
authors.initials: LW
authors.lastname: Klee
mesh_terms: D000328:Adult; D000368:Aged; D003085:Colic / Q000188:drug therapy* / Q000209:etiology; D004311:Double-Blind Method; D004630:Emergencies; D005260:Female; D006801:Humans; D007213:Indomethacin / Q000008:administration & dosage / Q000627:therapeutic use*; D007262:Infusions, Intravenous; D007669:Kidney Calculi / Q000150:complications; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000627:therapeutic use*; D013488:Suppositories; D017186:Titrimetry; D014515:Ureteral Diseases / Q000188:drug therapy* / Q000209:etiology
chemical_list: D013488:Suppositories; D009020:Morphine; D007213:Indomethacin