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Managing acute renal colic

Editor—The article by Wright et al on managing the pain of ureteric colic in the community has raised some concerns.1 The paper implies that a strategy of administering intramuscular diclofenac in the community would reduce the need for admitting patients to emergency departments. Although we welcome any attempt to reduce the number of unnecessary admissions to emergency departments, we raise the following points about using intramuscular diclofenac. 
 
Firstly, diclofenac causes pain on injections with a concomitant rise in serum phosphokinase activity. Cases of necrotising fasciitis have been recorded.2 
 
Secondly, other non-steroidal anti-inflammatory drugs may be used, such as sublingual piroxicam or intramuscular keterolac, that may prove as effective as diclofenac without damaging tissues.3,4 
 
Thirdly, cyclo-oxygenase 2 inhibitors may also prove effective in the treatment of renal colic and confer benefits in terms of their gastric protective effects. While clinical information is lacking in this area we believe that it is worthy of further analysis. 
 
The defence unions have stated that intramuscular injections of diclofenac into the thigh are the least safe. The Committee on Safety for Medicines has received reports concerning this issue. None of the cases that were opened were defensible, and one of the recommendations suggested that alternative routes of administration be used where possible.5 Such practice must therefore be able to withstand scrutiny in the event of a complaint or litigation. 
 
Our trust has taken the step of withdrawing intramuscular diclofenac from the trust formulary. We prefer to use rectal diclofenac or one of the cyclo-oxygenase 2 inhibitors.