Intranasal ketamine shows similar pain relief to IV opioids for renal colic in ED meta-analysis

BACKGROUND AND IMPORTANCE: Renal colic pain is typically managed using intravenous opioids, but the intranasal route has emerged as a less invasive and time-efficient alternative. Intranasal ketamine has shown promise as a safe and effective analgesic for acute pain in emergency settings. OBJECTIVE: To compare the efficacy and safety of intranasal ketamine versus intravenous opioids for renal colic pain management in the emergency department. DESIGN, SETTINGS, AND PARTICIPANTS: PubMed, Embase, and Cochrane were systematically searched for randomized controlled trials (RCTs) comparing intranasal ketamine to intravenous morphine or intravenous fentanyl in patients with renal colic. INTERVENTION OR EXPOSURE: Intranasal ketamine as the primary intervention; comparators were intravenous morphine or fentanyl. OUTCOMES, MEASURE, AND ANALYSIS: The primary outcome was pain intensity at various time points, measured using the Visual Analog Scale (VAS) and Numerical Rating Scale (NRS). Secondary outcomes: need for rescue analgesia, incidence of adverse events, nausea, and dizziness. Data were pooled using random-effects models to calculate mean differences for continuous outcomes and risk ratios for binary outcomes, with 95% confidence intervals (CIs). All statistical analyses were performed using R Software, version 4.2.3. MAIN RESULTS: We included four RCTs, involving 454 patients, of whom 230 (50.6%) received intranasal ketamine. There were no significant differences between groups in pain scores at 5 min (mean difference: -0.41 VAS/NRS, 95% CI: -1.88 to 1.07, P  = 0.59), 15 min (mean difference: -0.20 VAS/NRS, 95% CI: -0.86 to 0.46, P  = 0.56), and 30 min (mean difference: 0.53 VAS/NRS, 95% CI: -0.08 to 1.13, P  = 0.09). No significant differences were found between groups in the need for rescue analgesia or in the incidence of adverse events, nausea, or dizziness. CONCLUSION: Intranasal ketamine demonstrated analgesic efficacy comparable to intravenous opioids at 5, 15, and 30 min, with no increase in adverse events or rescue analgesia requirements.