What is the recommended pain management approach for a patient with ureteral calculi (kidney stones)?

From the Guidelines

The most effective pain management approach for ureteral calculi involves the use of NSAIDs as first-line therapy, with alpha-blockers such as tamsulosin (0.4 mg daily) as an adjunct to facilitate stone passage and reduce pain. The use of NSAIDs, specifically diclofenac 50 mg orally or 75 mg intramuscularly, or ketorolac 10 mg intravenously, is recommended to reduce ureteral smooth muscle spasm and inflammation that cause severe colicky pain 1. For patients who cannot take NSAIDs or have inadequate pain relief, opioids like morphine (0.1 mg/kg IV) or hydromorphone (1-2 mg IV) can be added as second-line agents.

Some key points to consider in the management of ureteral calculi include:

• The use of alpha-blockers, which have been shown to facilitate stone passage and reduce pain, with a statistically significant 29% (CI: 20% to 37%) more patients passing their stones with alpha blocker therapy than with control patients 1
• The importance of adequate hydration, although forced hydration has not been shown to provide additional benefit
• The need for patients to strain their urine to catch passed stones for analysis
• The potential for urological intervention for severe, uncontrolled pain or stones unlikely to pass spontaneously (>10 mm)

It is also important to note that the management of ureteral calculi may involve ureteroscopy, which has been shown to be a safe and effective modality for the treatment of stones in all locations in the ureter, with high stone-free rates and low complication rates 1. However, the primary focus should be on managing pain and facilitating stone passage, with urological intervention reserved for cases where this is not possible.

From the FDA Drug Label

2 DOSAGE AND ADMINISTRATION

Morphine sulfate injection is intended for intravenous administration. ... Individualize treatment in every case, using non-opioid analgesics, opioids on an as needed basis and/or combination products, and chronic opioid therapy in a progressive plan of pain management such as outlined by the World Health Organization, the Agency for Healthcare Research and Quality, and the American Pain Society.

For pain management in patients with ureteral calculi, non-opioid analgesics and opioids (such as morphine) on an as-needed basis can be considered. The treatment should be individualized for each patient, taking into account their prior analgesic treatment experience, medical status, and the type and severity of their pain.

• Non-opioid analgesics may be used as a first-line treatment for mild to moderate pain.
• Opioids, such as morphine, may be used for moderate to severe pain, with careful monitoring for side effects.
• Combination products may also be considered as part of a progressive plan of pain management. 2

From the Research

Pain Management for Ureteral Calculi

For patients with ureteral calculi, several options can be considered for pain management, including:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ketorolac, diclofenac, and ibuprofen 3
• Opioids like oxycodone and acetaminophen combination tablets 4
• Alpha-blockers like tamsulosin, which can help increase stone expulsion rates and reduce pain 5, 6
• Calcium channel blockers like nifedipine XL, which can help relax the ureteral muscles and increase stone passage rates 4
• Steroids like prednisone, which can help reduce inflammation and swelling in the ureter 4

Medications for Pain Relief

The following medications can be used for pain relief in patients with ureteral calculi:

• Ketorolac, which may result in little to no difference in renal colic pain at 30 minutes compared to diclofenac 3
• Diclofenac, which may reduce renal colic pain in 30 minutes compared to placebo 3
• Ibuprofen, which may be more effective than ketorolac in reducing renal colic pain 3
• Tamsulosin, which can reduce the mean number of episodes of pain and mean days to stone expulsion 5

Factors Affecting Pain Management

Several factors can affect pain management in patients with ureteral calculi, including:

• Stone location, with proximal or mid-ureteral calculi being more likely to require multiple analgesic doses and result in revisits to the emergency department 7
• Stone size, with larger stones being less likely to pass spontaneously and requiring more aggressive treatment 6
• Patient characteristics, such as age and medical history, which can affect the choice of pain medication and treatment approach 4, 3, 7, 5, 6