From the Guidelines
Pain management for kidney stone patients should typically involve NSAIDs like ibuprofen (600-800mg every 6-8 hours) as first-line treatment, which reduce inflammation and ureteral spasms. For patients with kidney stones, the primary goal is to alleviate pain while also considering the potential for renal impairment. According to the available evidence, NSAIDs are generally preferred for their anti-inflammatory effects and ability to reduce ureteral spasms, which are key contributors to the pain experienced by patients with kidney stones.
When considering opioid use, it's crucial to use caution and select opioids that are safer in the context of renal impairment, such as fentanyl and buprenorphine via the transdermal route or intravenously, especially in patients with chronic kidney disease stages 4 or 5, as noted in 1. However, opioids should be used judiciously and at reduced doses and frequency due to the potential for adverse effects in patients with renal impairment.
Key considerations in managing kidney stone pain include:
- The use of NSAIDs as first-line treatment for their anti-inflammatory and spasm-reducing effects.
- The cautious use of opioids, with a preference for those that are safer in renal impairment, such as fentanyl and buprenorphine.
- Ensuring adequate hydration to help flush out stones and prevent new formation.
- Application of heat to the affected area for additional comfort.
- The potential need for anti-emetics if nausea accompanies the pain.
- Tailoring the treatment approach to the severity of pain, stone size, and location.
It's also important for patients to seek immediate medical attention if they experience uncontrollable pain, develop a fever, or are unable to urinate, as these symptoms may indicate complications requiring urgent intervention. While guidelines such as those from 1 discuss the medical management of kidney stones, including dietary and lifestyle modifications, the immediate concern for patients with kidney stones is often the management of acute pain.
From the FDA Drug Label
Use the lowest effective dose for the shortest duration consistent with individual patient treatment goals Although naproxen tablets, naproxen suspension, naproxen delayed-released tablets, and naproxen sodium tablets all circulate in the plasma as naproxen, they have pharmacokinetic differences that may affect onset of action Onset of pain relief can begin within 1 hour in patients taking naproxen. Patients With Moderate to Severe Renal Impairment Naproxen-containing products are not recommended for use in patients with moderate to severe and severe renal impairment (creatinine clearance < 30 mL/min) The recommended starting dose of naproxen is 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required.
Naproxen is not recommended for patients with moderate to severe renal impairment. For patients with kidney stones and normal renal function, naproxen may be considered for pain management, with a recommended starting dose of 500 mg, followed by 500 mg every 12 hours or 250 mg every 6 to 8 hours as required. However, caution is advised and the lowest effective dose should be used for the shortest duration. 2
From the Research
Pain Management for Kidney Stones
The recommended pain management for patients with kidney stones includes:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) as the preferred analgesia for acute renal colic, due to their efficacy in reducing pain and fewer side effects compared to opioids 3
- Opioids may be used in some cases, but their use has decreased significantly in recent years due to concerns about dependence and abuse 4
- Paracetamol (acetaminophen) may also be used, but its efficacy is similar to NSAIDs and it may require more frequent dosing 3
Comparison of Pain Relievers
Studies have compared the efficacy of different pain relievers for kidney stones, including:
- NSAIDs vs. opioids: NSAIDs have been shown to have a marginal benefit over opioids in initial pain reduction, and require fewer rescue treatments and have lower vomiting rates 3
- NSAIDs vs. paracetamol: NSAIDs have been shown to be equivalent to paracetamol in relieving acute renal colic pain, but require fewer rescue treatments and have fewer adverse events 3
Treatment Guidelines
Treatment guidelines for kidney stones recommend:
- Ruling out conditions requiring immediate referral to an emergency department, then alleviating pain with a nonsteroidal anti-inflammatory drug 5
- Conservative management consisting of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging to monitor stone position and assess for hydronephrosis 5
- Lifestyle modifications such as increased fluid intake, and prescription of thiazide diuretics, allopurinol, or citrates for patients with recurrent calcium stones 5