Accepted Manuscript

Comparison of intravenous dexketoprofen trometamol, fentanyl,

and paracetamol in the treatment of patients admitted to the
emergency department for renal colic: A randomized controlled
trial

Behcet Al, Mehmet Mustafa Sunar, Suat Zengin, Mustafa Sabak,

Mustafa Bogan, Basri Can, Seval Kul, M. Murat Oktay, Sevki
Hakan Eren

PII: S0735-6757(17)30743-X
DOI: doi: 10.1016/j.ajem.2017.09.019
Reference: YAJEM 56964
To appear in:
Received date: 3 August 2017
Revised date: 9 September 2017
Accepted date: 13 September 2017

Please cite this article as: Behcet Al, Mehmet Mustafa Sunar, Suat Zengin, Mustafa Sabak,
Mustafa Bogan, Basri Can, Seval Kul, M. Murat Oktay, Sevki Hakan Eren , Comparison
of intravenous dexketoprofen trometamol, fentanyl, and paracetamol in the treatment of
patients admitted to the emergency department for renal colic: A randomized controlled
trial, (2017), doi: 10.1016/j.ajem.2017.09.019

This is a PDF file of an unedited manuscript that has been accepted for publication. As
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 ACCEPTED MANUSCRIPT

Comparison of Intravenous Dexketoprofen Trometamol, Fentanyl, and Paracetamol in

the Treatment of Patients Admitted to the Emergency Department for Renal Colic a
Randomized Controlled Trial

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Prof. Dr. MD. Behcet Al behcetal@gmail.com, Emergency department of Medicine

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MD. Phy. Mehmet Mustafa Sunar, sunarmehmet@hotmail.com (Emergency department of

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Medicine Faculty, Gaziantep University/Turkey)

Assoc Prof MD, Suat Zengin, szengin@gantep.edu.tr, Emergency department of Medicine

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Faculty, Gaziantep University/Turkey

MD. Phy. Mustafa Sabak, mustafasabak@hotmail.com, (Emergency department of Medicine

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Faculty, Gaziantep University/Turkey)

MD. Phy. Mustafa Bogan, mustafabogan@hotmail.com, (Emergency department of

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Medicine Faculty, Gaziantep University/Turkey)

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MD. Phy. Basri Can, dr_bc@windowslive.com (Emergency department of Medicine Faculty,

Gaziantep University/Turkey)
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Assoc Prof MD Seval Kul, sevalkul@gantep.edu.tr, Biostatisticsdepartment of Medicine Faculty,

Gaziantep University/Turkey)
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MD. Phy. M. Murat Oktay mmurat_ok@yahoo.com (Emergency department of Medicine

Faculty, Gaziantep University/Turkey)

Prof. Dr. MD, Sevki Hakan Eren, shakanere@gmail.com, Emergency department of

Medicine Faculty, Gaziantep University/Turkey
 ACCEPTED MANUSCRIPT

This study has been awarded with the best oral presentation third prize in 13th National
Emergency Medicine, 4th International Emergency Medicine and 4th International Critical
Care and Emergency Medicine congresses held by the Emergency Physician Association of
Turkey (EPAT) ĠN Antalya 18-21 May 2017/TURKEY

Conflicts of interest: All authors attest that they don’t have any potential conflicts of interest
for current study.

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Word count: 3490

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Registration number: Unfortunately, we couldn’t have registration number just before starting

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to study.

Author contributions: Al B and Sunar MM conceived the study, designed the trial, and
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undertook recruitment of participating centers and patients and managed the data, including
quality control. Zengin S and Sabak M, and Bogan M supervised the conduct of the trial and
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data collection. Kul S provided statistical advice on study design and analyzed the data. Can
B, and Oktay MM drafted the manuscript. Eren HS chaired the data oversight committee. Al
B and takes responsibility for the paper as a whole; and all authors contributed substantially to
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its revision.
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Abstract
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Objective: In this study, we aimed to compare the analgesic efficacy of intravenous

Dexketoprofen Trometamol, Fentanyl, and Paracetamol in patients presenting to the
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emergency department with renal colic.

Materials and Method: Data obtained from the emergency departments of Gaziantep
University's Hospital for Research and Practice along with two other state hospitals in
Gaziantep, Turkey between January 2016 and January 2017 was used for this study. A total of
three hundred patients (n=300), who presented to the ER with complaints most common to
renal colic whose diagnoses were subsequently confirmed with Computerized Tomography
were included in the study. Patients' pain scores were recorded using the Visual Analogue
Scale, at admission (immediately before drug administration), then at the 15th, and 30th
 ACCEPTED MANUSCRIPT

minutes. SPSS 22.0 software package was used for analysis. P<0.05 was considered
significant.

Results: At the 15th minute comparison,, the efficacies of the three groups of drugs were not
superior to one other, but at the 30th minute, dexketoprofen trometamol was statistically more
effective than paracetamol and fentanyl. There was no statistically significant difference
between fentanyl and paracetamol. The need for additional analgesia in the group receiving
dexketoprofen trometamol was found to be lower. Dexketoprofen trometamol was statistically

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superior to the other two agents in achieving full analgesia at the end of the thirty-minute
period. Fentanyl was found to be statistically significant in achieving moderate analgesia.

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Conclusion: As a Non-steroidal antiinflammatory drug dexketoprofen trometamol is superior

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to paracetamol and fentanyl in achieving analgesia and reducing the need for additional drugs
for the treatment of renal colic.
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KeyWords: Analgesic, Dexketoprofen Trometamol, Fentanyl, Paracetamol, Renal Colic,
Visual Analogue Scale, Efficacy, Emergency Department.
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Introduction

RC is a urological emergency described by patients as a severely painful condition (1).

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Abdominal pain lasting less than 12 hours, back pain or costovertebral angle tenderness
(CVAT) , and the presence of hematuria are the most important clinical symptoms (2). Renal,
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adrenal, ureteral, bladder, seminal vesicle, prostate, vascular, gynecological, and

intraperitoneal pathologies should be considered in the differential diagnosis (3). Although
direct urinary system graphy, ultrasonography, and intravenous pyelography are used for
imaging in the diagnosis, Computerized Tomography (CT) is the gold standard (4-8). The
purpose of the treatment is to relieve the patient from pain in the acute phase, to clear the
urinary system from stones to the best of our ability, and to prevent the formation of new
stones or the growth of existing ones in the next stage (3). The most direct request of RC
patients is pain relief followed by comfort and discharge from the hospital whereas the
responsibility of health workers is to find a fast-acting treatment that has fewer side effects
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accompanied by high patient satisfaction. The most common approach is the conservative
approach which includes the introduction of fluids and pain relief therapy (9). Non-steroidal
anti-inflammatory drugs (NSAID) are the more preferred agents for pain relief because they
are non-addictive and for having fewer side effects unlike other agents with side effects such
as constipation, respiratory depression, and mental changes (10,11).

Other than that, opioids –notably morphine sulfate (12), paracetamol (13), calcium channel
blockers, alpha antagonists, and local heat application (9,14) are used in the treatment of RC.

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Most comparative studies have been done with NSAIDs, paracetamol and morphine sulfate
(15,16). The most important advantage of Fentanyl is that it provides a very high level of

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analgesia and that its effect starts rapidly and ends early. Although there are studies on its
efficacy in the treatment of RC in the literature, there aren't a sufficient number of randomized

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clinical trials comparing its effect with other agents.
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In this study, the efficacies of intravenous DKT, fentanyl, and paracetamol in patients
presenting with an RCcomplain to the emergency department were compared with a
randomized controlled trial. The study is particularly important in terms determining the role
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of fentanyl, which has a very high efficacy in pain-killing, in the treatment of RC, and the
potential this has for contributing to the literature.
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MATERIALS AND METHOD

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Ethics committee approval (Decision no. 2015/342) was obtained from the Gaziantep
University Faculty of Medicine on 14.12.2015 for this study, which was planned as a
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randomized double blind study. It was carried out in accordance with the Declaration of
Helsinki protocols. A total of three hundred (n=300) patients who presented to the emergency
departments of Gaziantep University's Hospital for Research and Practice along with two
other state hospitals in Gaziantep, Turkey (Dr. Ersin Arslan State Hospital and ġehit Kamil
State Hospital) with complaints of clinically manifest RC and whose diagnoses were
confirmed with CT were included in the study.

Inclusion Criteria:

1. Patients with suspected renal colic before definitive diagnosis

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2. Male and female patients aged between 16-65 years

3. who started having bilateral/unilateral flank pain within the last 12 hours,
4. whose pain was at a level of 4 cm (or 40 mm) or above according to the VAS scale at
the time of admission,
5. and whose diagnosis of RC were confirmed on CT.

Exclusion criteria:

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1. Patients aged below 16 years and over 65 years,
2. Those with a side pain complaint lasting longer than 12 hours,

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3. Those with a history of direct blunt trauma to the CVAT within the last week,
4. Patients who marked the VAS at <40 mm or <4 cm at the zeroth minute in the

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emergency department,
5. Patients with a history of allergy to the drugs to be used in the study,
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6. Patients with a systolic arterial blood pressure of <90 mmHg at the time of admission
to the emergency department,
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7. Patients with a history of prostate, renal and adrenal, and bladder malignancy or a
history of surgery on these regions within the last six months,
8. Patients with any history of chronic pain syndrome,
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9. Patients with a history of pain-killer, antidepressant, anticonvulsant, muscle relaxant,

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or steroid use for any reason within the past 12 hours,

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10. Patients with a history of substance or alcohol dependency,

11. Pregnant women, nursing mothers, and women with pelvic inflammatory disease
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(PID),
12. Patients not diagnosed with RC as a result of imaging and laboratory tests. Patients
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who had been treated with renal colic suspicion at the time of admission but
who's diagnosis was not confirmed by CT as renal colic were excluded from the
study
All patients were evaluated with detailed physical examination and detailed
history. Complete blood count (CBC), complete urinalysis, C-reactive protein (CRP),
International Normalized Ratio (INR), urea, and creatinine lab tests were requested for all
patients as well. All patients were monitored during drug administration.
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Drug selection:
The drugs in the groups were numbered from one to one hundred. They were
appointed to one of the study groups according to the study number. This procedure was
prepared by someone outside the emergency department in the form of random octal blocks
with the help of a computer. Only this person knew which drugs the numbers signified. The
numbers pertaining to the study groups were placed in opaque envelopes that did not show
through. Drug preparation and administration were organized by two designated nurses in the
emergency department. The first nurse took the trial medication out of the envelopes and

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made them ready for use. The second nurse was responsible for blindly administering the trial
medication.

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The drugs and the routes of administration:

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Three study groups were formed for intravenous (IV) DKT, fentanyl, and paracetamol. 50
mgr of DKT (Arveles ampuoule® , 50 mg/ml dexketoprofen trometamol, Menarini
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International, Italy) in the form of an IV rapid infusion in 100 ml of isotonic saline, 2
micrograms/kg of fentanyl (Talinat ampoule®, 0.5 mg/10 ml fentanyl citrate, VEM Ġlaç,
Turkey), and 10 mg of paracetamol (Parol vial®, 10 mg/ml, 100 ml vial paracetamol, Atabey
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Kimya San, Turkey) were administered to the groups given drugs. The paracetamol was
drawn from the vial and injected into a 100 cc physiological saline solution by the first nurse.
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All three drugs were adjusted run out within five minutes in a 100 cc physiological saline
solution.
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Before the trial drug was administered, the basal pain values of the patients were
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assessed with the Visual Analogue Scale (VAS) consisting of values between 0 and 10 at the
0th, (immediately before drug administration), 15th, and 30th minutes. It was established that
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the patient did not see the previous VAS when marking the VAS. Three identical VAS rulers
were used for this. At the thirtieth minute, the patients were asked whether they needed
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additional analgesics. Rescue medication was administered to those who needed them. The
same dose of the drug used in the study and one of the other two drugs used in the study, in
addition to diclofenac sodium or tramadol HCL were used as rescue medication. Here, the
choice was left up to the physician. Treatment related drug side effects (such as nausea,
vomiting, hypotension, arrhythmia, dizziness, and confusion) that developed in the patients
were recorded in the study form.

Diagnosis Of Renal Colic:

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Patients suspected with RC during their examinations underwent thin-section non-contrast

abdominal tomography for diagnosis and differential diagnosis. Patients who were reported in
favor of urolithiasis by urology specialists were included in the study.
A total of 49 patients were excluded from the study because four patients refused to
use the VAS during follow-up, three patients developing severe hypotension within the first
five minutes of treatment, two patients who were found to have renal artery thrombosis
instead of urolithiasis, three patients not responding to any of the treatments in the emergency
ward and were later placed in critical care, 23 patients arriving after having received pain

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killers from other centers, one patient being diagnosed with pregnancy in addition to
urolithiasis, two patients who were found to have acute appendicitis in addition to urolithiasis,

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six patients leaving the emergency ward without waiting for the thirtieth minute upon early

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relief of their symptoms, and five patients refusing to undergo CT.

Statistics
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In the analysis of the data, relationships between categorical variables were tested by
using the Chi square test and correlations between sequential variables were tested with the
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Spearman Rank correlation coefficient. The SPSS 22.0 software package was used for
analysis. P<0.05 was considered significant.
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RESULTS
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A total of 300 RC patients, 100 from each group, were included in the study. Of these,
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216 were male (72%) and 84 were female (28%). The majority of cases were between the
ages of 25-39 (49.7%) (p=0.001), and the average age was 42.2 years. There was no
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significant relationship between sex and the agents used (p=0,215). Nausea and vomiting
accompanied pain in 47.3% (n=142) of the patients at the time of admission. CVAT was
found positive in 256 (85.3%) patients. Patients receiving fentanyl developed more
complications (p=0.008) (Table 1).

The majority of patients (n=156) marked the VAS between 9-10 at first admission (p=0.001)
(Table 2). All three drugs significantly reduced the VAS score which was between 9-10 at the
fifteenth minute (p=0.001). Although, numerically, DKT (n=45) seemed to be more effective
than Paracetamol (n=40) and Fentanyl (n=36) inlowering the VAS score, this superiority
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was not statistically significant (p=0.672). When the reduction of VAS values at the thirtieth
minute was evaluated, DKT was found to be more effective (p=004) (Table 3, Figure 1)).

57% of the patients (n=171) needed rescue medication (p=0.006). The DKT group (31%) was
the one that least needed rescue medication, while the paracetamol group (53%) was the one
that needed it the most. DKT (n=45) was the rescue medication used most often (p=001).
Apart from the drugs in the study groups, diclofenac sodium was the most commonly used
rescue medication (Table 3).

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During discharge, the patients were verbally asked whether their pain was "mildly,
moderately, or completely gone". While, according to the verbal statements of the patients,

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Fentanyl (p=0.001) was statistically more effective in moderately reducing pain, DKT was

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found to be more effective in completely stopping the pain (p=0.001) (Table 3).

Systolic blood pressure was <140 mmHg in 283 (94%) of the patients at first admission,
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independent of basal blood pressure. There was no correlation between the VAS level and the
level of systolic blood pressure (p=0.545). At the time of admission, the pain was in the right
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costovertebral region in 54.7% (n=164) of the patients, and on the left side in the rest (n=136).
There was no significant relationship between pain localization and the VAS score at first
admission (p=0.200).
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DISCUSSION
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In the United States, more than 1 million patients visit the emergency clinics due to
RC (17). In Europe, acute RC is the cause of 7-9% of emergency ambulatory service calls
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made due to pain (18). Its prevalence rate in the whole world varies between 12% and 15%
(19). There are not enough records or information in our country in this regard (1). A person's
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risk of having an RC attack throughout their entire life is between 1-10% (20).

In a study by Brown et al., in which more than one million patients were evaluated, it was
reported that patients who presented to emergency departments with RC were usually in the
middle age group and of the male sex (21). The fact that there is a male patient and middle
age predominance in RC is confirmed by the results of our study and other studies (23-25).
However, the ratio of male patients in our study was much higher compared to the literature.

Ayan et al. (26) have stated that IM diclofenac sodium is statistically more effective
than IV paracetamol in the pain treatment of RC. Pathon et al. ( 27 ) compared the efficacy of
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IM diclofenac sodium, IV paracetamol, and IV morphine in reducing pain at the end of the 30th
minute in 1070 RC patients. According to this it was found that IM diclofenac sodium was superior
to the other two agents in reducing pain by more than 50%, and that there was no statistical
difference between IV morphineand IV paracetamol in a randomized controlled trial they
conducted, Azizkhani et al. (28) found that IV morphine reduced RC pain more than IV paracetamol,
but caused more side effects. There are other studies which emphasize that NSAIDs are superior
to paracetamol and opioids in reducing RC pain (15.29). In contrast to these studies, Masoumi et
al. (30) have stated that IV paracetamol is more effective in reducing pain severity than IV morphine

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in their randomized controlled double blind study. Confirming this, Sin et al. (31) have stated that IV
paracetamol is superior to both IV morphine and IM diclofenac sodium in providing analgesia in

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RC. BektaĢ et al. (12) emphasize that the analgesic efficacies of IV paracetamol and IV morphine in

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RC are similar, but that both agents are superior to placebo. Serinken et al. (32) found that the pain-
killing effects of IV paracetamol and IV morphine were similar in a randomized double-blind study
they conducted on 73 patients with RC. Similar to the aforementioned last two studies, Ay et al. (33)
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compared IV DKT and IV meperidine in 52 RC patients in a randomized, double-blind study. At the
30th minute, the numerical grading scale and renal colic symptom scale were found to be similar in
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both groups.

There are numerous studies in the literature concerning the comparison of NSAIDs,
paracetamol, and opioids (especially morphine) in RC patients, as can be seen from the
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examples given above. However, no study was found comparing fentanyl, which provides
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much more analgesic effect than morphine, with NSAIDs. There are studies in which different
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forms of fentanyl are compared with each other or with morphine. Deaton et al. (34) divided
40 patients who presented to the emergency department with abdominal pain into two groups,
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and compared the efficacy of IV morphine (0.1 mg/kg) and nebulized fentanyl (2 μg/kg)
according to the VAS scores at the 10th, 20th, 30th, and 40th minutes. They indicated that
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nebulized fentanyl provided more significant analgesia at all time intervals. Imamoğlu et al.
(35) compared the VAS values of nebulized and IV fentanyl at the 30th minute by dividing
115 patients who presented to emergency service with the complaint of RC into two groups.
While, based on this, there was no statistically significant difference in pain values, it was
found that the IV form provided a faster analgesic effect, required fewer rescue medications,
and, while not statistically significant, caused more side effects compared to the nebulized
form. There are also studies comparing DKT, morphine, and paracetamol outside the context
of RC. It has been stated that DKT provides a better analgesic effect than paracetamol (36) for
operative hysteroscopy, that morphine provides a better analgesic effect than paracetamol for
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sciatic pain (37), and that paracetamol, DKT, and morphine are not superior to one another for
back pain (38). In our study, the relative difference between the efficacies of the three drugs at
the fifteenth minute according to the VAS was not statistically significant. In particular, the
numerical efficacy of fentanyl on the high VAS scores (VAS 9-10) at the fifteenth minute was
not statistically significant. DKT was found to be statistically more effective compared to
paracetamol and fentanyl at the thirtieth minute, while fentanyl and paracetamol were not
statistically superior to one another.

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The effectiveness of a drug given to patients with RC is also measured by whether or
not additional drugs need to be administered. Fentanyl has not been extensively studied in the

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literature with regard to this. Çevik et al. (39) compared DKT, tenoxicam, and lornoxicam in
terms of the need for additional drugs. They stated that at the end of the thirtieth minute, the

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group that received DKT needed less additional drugs. In two other RC studies comparing IV
paracetamol and IV morphine with regard to the need for additional drugs , the group receiving
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morphine needed more additional drugs (12,32). In a meta-analysis (15), it is emphasized that
NSAIDs require less additional pain relief medications compared to opioid drugs. In our
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study, the group receiving DKT statistically needed less additional drugs compared to the
other two groups when they were compared according to the need for additional analgesics at
the end of the thirtieth minute. No superiority has been found between fentanyl and
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paracetamol in this respect.

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In a meta-analysis study (15) by Holdgate et al. comparing NSAIDs and opioids for
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RC, it is reported that patients receiving opioids had more side effects, mostly in the form of
vomiting, and this is considered statistically significant. Grissa et al. (40) emphasize that IV
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paracetamol and IM piroxicam are not different in terms of side effects in patients with RC.
Serinken et al. (32) report that IV morphine causes more side effects than IV paracetamol,
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mostly in the form of dizziness. BektaĢ et al. (12) have found that morphine causes more nausea
and vomiting than paracetamol in patients with RC. As can be seen from the present literature
reviews, the side effects of opioid agents are greater than those of NSAIDs. The results of this
study also support this. However, due to the overcrowding of the emergency ward and busy
work schedule, patients could not be followed for a long period of time. Complications that
may have developed during the later course of these patients could not be recorded. One
reason for the higher incidence of side effects (nausea-vomiting, headache, dizziness, severe
hypotension) in the fentanyl group could be the rapid administration of fentanyl in order to
observe the drug administration durations specified in the study.
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In this study, we asked patients to verbally assess their pain at discharge after the treatment
had ended, compared to their state at first admission. Based on this, DKT was statistically
more effective in the group that declared that the pain was "completely gone", while there was
no statistical difference between fentanyl and paracetamol. Fentanyl's pain-relieving effect
was found to be statistically significant in the group that expressed their pain to have
"moderately decreased", while similar results were obtained for DKT and paracetamol.

The fact that the half-lives and onset times of the drugs used in the study were not taken into

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consideration, the possibility that side effects may be different when each drug is
administered within the same duration of time, and that the patients could not be followed for

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long-term side effects are important limitations. The use of a medication that is not widely
available; the lack of comparison to a more commonly used NSAID to treat renal colic,

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and the short patient follow-up duration can be also considered as limitation points.
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In conclusion, this study has shown that IV NSAIDs (DKT) are superior to both paracetamol
and fentanyl in terms of both analgesia and side effects in RC patients. Although fentanyl is
known to be a very powerful pain killer, it is not as effective as NSAIDs in RC. However, it
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can be given together with NSAIDs for achieving rapid, early analgesia. NSAIDs should be
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the first choice for the treatment of RC in emergency departments. If they are not found,
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paracetamol or opioids should be tried. or opioids should be tried. Patients should be followed
for a longer period in terms of complications after the use of fentanyl.
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Acknowledgement : We would lıke to give thanks to Dr.Abdullah Ahmadou for hıs

contrıbutıons to thıs study.
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References

1. Müslümanoğlu AY, Tepeler A. Renal Kolik Tanı ve Tedavisi. Marmara Med Jour
2008;21: 187-192.
2. Eskelinen M, Ikonen J, Lipponen P. Usefulness of history-taking, physical
examination and diagnostic scoring in acute renal colic. Eur Urol 1998;34:467-473.
3. Hunter Wessells M, Jack W. McAninch. Urological Emergencies A Practical Guide.
Vol. . ed. New Yersey: Humana Press; 2005.
 ACCEPTED MANUSCRIPT

4. Hamm M, Wawroschek F, Weckerman D, Knöpfle E, Häckel T, Häuser H, Krawczak

G, Harzman R. Unenhanced helical computed tomography in the evaluation acute
flank pain. EurUrol 2001; 39:460-465.
5. Patlas M, Farkas A, Fisher D, Zaghal I, Hadas-Halpern I. Ultrasound vs CT fort he
detection of ureteric Stones in patients with renal colic.Br J Radiol 2001;74:901-904.
6. Shokeir AA, Abdulmaaboud M, Farag Y, Mutabagani H. Resistive index in Renal
colic: the effect of nonsteroidal anti-inflammatory drugs. BJU Int 1999;84:249-251.
7. Krishna NS, Morrison L, Campbell C. Is spiralcomputed tomography the imaging

PT
modality of choice for renal colic? Postgrad Med J 2001; 77: 124-132
8. Meagher T, Sukumar VP, Collingwood J, et al. Lowdose computed tomography in

RI
suspected acute renalcolic. Clin Radiol 2001; 56: 873-876

SC
9. Esquena S, Millán Rodríguez F, Sánchez-Martín FM, Rousaud Barón F, Marchant F,
Villavicencio Mavrich H. Renal colic: revision of literature and scientific evidence.
NU
Actas Urol Esp. 2006;30:268–80.
10. Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Mercler GD. Ürolojik
TaĢ hastalığı. Tintinalli Acil Tıp, Kapsamlı Bir çalıĢma Kılavuzu.7. baskı, Nobel Tıp
MA

Kitabevleri, 2013: 97:651-656.

11. Türk C, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. European Association Of
D

Urology 2011 Guidelines on Urolithiazis. 2011:17-20.

12. Bektas F, Eken C, Karadeniz O, Goksu E, Cubuk M, Cete Y. Intravenous Paracetamol
E

or Morphine for the Treatment of Renal Colic: A Randomized, Placebo-Controlled

PT

Trial. Annals of Emergency Medicine. 2009; 54(4): 568–574.

13. Bannwarth B et al. Single and multiple dose pharmacokinetics of paracetamol in
CE

polymedicated very old patients with rheumatic pain. J Rheumatol 2001; 34:79-81.
14. Koçak Ġ. Kolik renal ve akut obstrüksiyonlar. Türkiye Klinikleri J Surg Med Sci.
AC

2007;3(20):3-8.
15. Holdgate, Anna; Pollock, Tamara. Systematic review of the relative efficacy of non-
steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic.
Bmj, 2004, 328.7453: 1401.
16. B. Safdar, L.C. Degutis, K. Landry, et al. Intravenous morphine plus ketorolac is
superior to either drug alone for treatment of acute renal colic Ann Emerg Med, 48
(2006), pp. 173–181
17. Jeremy B. Diagnostic and treatment patterns for renal colic in US Emergency
Departments. Int Urol Nephrol. 2006; 38(1): 87-92
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18. Thakore S, McGuan EA, Morrison W. Emergency ambulance dispatch: is there a case
for triage?. J R Soc Med 2002;95:126-9.
19. Kim HH, Jo MK, Kwak C, Park SK. Prevelance and epidemiologic characteristics of
urolithiasis in Seoul Korea. Urology 2002; 59:517-521.
20. Shokeir AA. Renal colic: pathophysiology, diagnosis and treatment. Eur Urol
2001;39:241-249
21. Brown J. Diagnostic and treatment patterns for renal colic in US Emergency
Departments. Int Urol and Nephr 2006;38:87-92.

PT
22. Jose A, Pérez H, Palmes P, Ferrer J, Urdangarain OO, Nunez AB. Renalcolic
atemergency departments. epidemiologic, diagnostic and etiopathogenic study.

RI
Arch.Esp. Urol. 2010; 63(3):173-187.

SC
23. Marcia L. Edmonds, MD, MSc; Justin W. Yan, MD; Robert J. Sedran, MD, MSc;
Shelley L.McLeod, MSc; Karl D. Theakston, MD, MSc. The utility of renal
NU
ultrasonography in the diagnosis of renal colic in emergency department patients.
CJEM 2010; 12(3).
MA

24. Chauhan V, Eskin B, Allegra JR, Cochrane DG. Effect of season, age and gender on
renal colic incidence. Am j Emerg Med. 2004;22(7):560-63.
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25. Serinken, Mustafa, et al. Analysis of clinical and demographic characteristics of

patients presenting with renal colic in the emergency department. BMC research notes,
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2008, 1.1: 79.

PT

26. Ayan, Murat, et al. Compare the Analgesic Effectiveness of Diclofenac and
Paracetamol in Patients with Renal Colic. Journal of Clinical and Analytical Medicine.
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2013;4(1): 16-8
27. Pathan SA, Mitra B, Straney LD, Afzal MS, Anjum S at al. Delivering safe and
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effective analgesia for management of renal colic in the emergency department: a

double-blind, multigroup, randomised controlled trial. Lancet. 2016 May
14;387(10032)
28. Azızkhanı, Reza, et al. Comparing the analgesic effect of intravenous acetaminophen
and morphine on patients with renal colic pain referring to the emergency department:
A randomized controlled trial. Journal of research in medical sciences: the official,
September, 2013.
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29. Kaynar, Mehmet, at al. Comparison of the efficacy of diclofenac, acupuncture,

andacetaminophen in the treatment of renal colic. American Journal of Emergency
Medicine 33 (2015) 749–753.
30. Masoumi, Kambiz, et al. Comparison of clinical efficacy of intravenous
acetaminophen with intravenous morphine in acute renal colic: a randomized, double-
blind, controlled trial. Emergency medicine international, 2014, 2014.
31. Sin B, Koop K, Liu M, Yeh JY, Thandi P.Intravenous Acetaminophen for Renal
Colic in the Emergency Department: Where Do We Stand?.Am J Ther. 2017

PT
Jan/Feb;24(1)
32. Serinken, Mustafa, et al. Intravenous paracetamol versus morphine for renal colic in

RI
the emergency department: a randomised double-blind controlled trial.Emergency

SC
Medicine Journal, 2011, emermed-2011-200165.
33. Ay, Mehmet Oguzhan, et al. Comparison of the analgesic efficacy of dexketoprofen
NU
trometamol and meperidine HCl in the relief of renal colic. American journal of
therapeutics, 2014, 21.4: 296-303.
34. Deaton T, Auten JD, Darracq MA. (2015). Nebulized fentanyl vs intravenous
MA

morphine for ED patients with acute abdominal pain: a randomized double-blinded,

placebo-controlled clinical trial. The American Journal of Emergency Medicine 33,
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791-795.
35. Imamoğlu, melih,at al. A retrospective analysis of nebulized versus intravenous
E

fentanyl for renal colic.American Journal of Emergency Medicine (2017).

PT

36. Koçum, Aysu, et al. Günübirlik operatif histeroskopi sonrası intravenöz parasetamol
ve deksketoprofen trometamol' ün analjezik etkinliklerinin karĢılaĢtırılması:
CE

Randomize, çift kör, plasebo kontrollü çalıĢma.AĞRI 2014;26(1):15-22

37. Serinken, Mustafa, et al. Comparison of Intravenous Morphine Versus Paracetamol in
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Sciatica: A Randomized Placebo Controlled Trial.Academic Emergency

Medicine.Volume 23, Issue 6, pages 674–678, June 2016
38. Eken, Cenker, et al. Intravenous paracetamol versus dexketoprofen versus morphine in
acute mechanical low back pain in the emergency department: a
randomised double-blind controlled trial. Emergency Medicine Journal, 2013,
emermed-2012-201670
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39. Cevik, Erdem, et al. Comparing the efficacy of intravenous tenoxicam, lornoxicam,
and dexketoprofen trometamol for the treatment of renal colic.Am J Emerg Med. 2012
Oct;30(8):1486-90.
40. Grissa, Mohamed Habib, et al. Paracetamol vs piroxicam to relieve pain in renal colic.
Results of a randomized controlled trial. The American journal of emergency
medicine, 2011, 29.2: 203-206

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Table1: Comparison of drugs used and sex, age, and complications developed.

Drug Used
DKT Paracetamol Fentanyl Total
n(%) n(%) n(%) n(%)
Sex
Female 22 (22.0) 33 (33.0) 29 (29.0) 84 (28.0)
Male 78 (78.0) 67 (67.0) 71 (71.0) 216 (72.0)
Age Groups
16-24 13 (13.0) 15 (15.0) 25 (25.0) 53 (17.7)

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25-39 58 (58.0) 48 (48.0) 43 (43.0) 149 (49.7)
40-54 25 (25.0) 20 (20.0) 28 (28.0) 73 (24.3)
55-64 1 (1.0) 17 (17.0) 2 (2.0) 20 (6.7)

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>65 3 (3.0) 0 (0.0) 2 (2.0) 5 (1.7)
Drug

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complication
Hypotension - - 3 (3.0) 3 (1.0)
Dizziness 1 (1.0) 1 (1.0) 9 (9.0) 11 (3.7)
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Headache - - 1 (1.0) 1 (0.3)
Vomiting 1 (1.0) 1 (1.0) 1 (1.0) 3 (1.0)
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Table 2:Comparison of Drug Efficacy and VAS Values at the 0th 15th and 30th Minutes
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DKT PARACETAMOL FENTANYL

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n (%) n (%) n (%)

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VAS <5 5-6 7-8 9-10 <5 5-6 7-8 9-10 <5 5-6 7-8 9-10

Prior to 10 31 59 2 65 33 8 28 64
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treatment 0 (50.0) (25.0) (37.8) 0 (10.0) (52.4) (21.2) 0 (40.0) (22.6) (41.0)

15th 45 32 18 5 40 34 23 3 36 40 22 2
Minute (45.0) (32.0) (18.0) (5.00) (40.0) (34.0) (23.0) (3.0) (36.0) (40.0) (22.0) (2.0)

30th 85 11 2 2 70 10 19 1 73 10 14 3
Minute (85.0) (11.0) (2.0) (2.00) (70.0) (10.0) (19.0) (1.0) (73.0) (10.0) (14.0) (3.0)
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Table 3: Comparison of Rescue Medications and Drugs Used and the state of pain at
discharge

Drug Used
DKT Paracetamol Fentanyl Total
n(%) n(%) n(%) n(%)
Rescue Medication

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DKT 1 (1.0) 13 (13.0) 31 (31.0) 45 (15.0)
Paracetamol 11 (11.0) 0 (0.0) 2 (2.0) 13 (4.3)

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Fentanyl 12 (12.0) 8 (8.0) 0 (0.0) 20 (6.7)

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Tramadol 3 (3.0) 16 (16.0) 4 (4.0) 23 (7.7)
Diclofenac sodium 4 (4.0) 31 16 (16.0) 53 8 (8.0) 28 (9.3)
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Total (31,0) (53.0) 45 (45.0) 129 (43.0)
Pain at discharge
Slightly Reduced 5 (5.0) 17 (17.0) 3 (3.0) 25 (8.3)
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Moderately Reduced 49 (49.0) 44 (44.0) 66 (66.0) 159 (53.0)

Completely Gone 46 (46.0) 39 (39.0) 31 (31.0) 116 (38.7)
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Figure 1: Comparison of Drug Efficacy and VAS Values at the 15th and 30th Minutes

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