From the Guidelines
For urolithiasis, the ideal pain reliever is typically a nonsteroidal anti-inflammatory drug (NSAID) such as ketorolac or diclofenac, as they not only relieve pain but also reduce inflammation and ureteral spasms that contribute to kidney stone pain. When considering the management of ureteral calculi, studies have shown that medical expulsive therapy (MET) can be efficacious in facilitating stone passage, with alpha blockers being the preferred agents 1. However, the primary concern in urolithiasis is often the management of pain.
Key Considerations for Pain Management
- NSAIDs like ketorolac (30mg intravenously or 60mg intramuscularly) or diclofenac are commonly used for severe pain in emergency settings, followed by oral NSAIDs such as ibuprofen (400-800mg every 6-8 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) for ongoing pain management.
- For patients who cannot take NSAIDs due to kidney problems, stomach ulcers, or other contraindications, opioid medications like morphine or hydrocodone may be necessary, though these are generally considered second-line due to side effects and addiction potential.
- Adequate hydration (2-3 liters of water daily) is essential alongside pain medication to help pass the stone.
- If pain is severe and uncontrolled with these medications, this may indicate complications requiring immediate medical attention. While alpha blockers like tamsulosin have been shown to facilitate ureteral stone passage and reduce pain by relaxing ureteral smooth muscle 1, the primary approach to pain management in urolithiasis remains the use of NSAIDs, given their efficacy in reducing both pain and inflammation.
From the Research
Ideal Pain Reliever for Urolithiasis
The ideal pain reliever for urolithiasis (kidney stones) is a topic of ongoing research and debate. Several studies have investigated the efficacy of different pain relief options, including nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and alpha-blockers.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
- NSAIDs are commonly used to treat renal colic, a common symptom of urolithiasis 2, 3.
- Studies have shown that NSAIDs can reduce pain in adult patients with renal colic compared to placebo 2.
- Comparing one NSAID against another, IV ketorolac may be less effective than IV ibuprofen, and pirprofen may result in less need for rescue medication than indomethacin 2.
- NSAIDs may have a lower risk of adverse events, such as vomiting, compared to opioids 3.
Alpha-Blockers
- Alpha-blockers, such as tamsulosin, are commonly used as medical expulsive therapy (MET) to improve stone passage 4, 5.
- Studies have shown that alpha-blockers can increase stone clearance, but may also slightly increase the risk of major adverse events 5.
- Subgroup analyses suggest that alpha-blockers may be less effective for smaller stones (5 mm or smaller) than for larger stones (greater than 5 mm) 5.
Comparison of Pain Relief Options
- A systematic review and meta-analysis found that NSAIDs were equivalent to opioids or paracetamol in relieving acute renal colic pain at 30 minutes 3.
- However, NSAIDs required fewer rescue treatments and had lower vomiting rates compared to opioids 3.
- Another study found that alpha-blockers likely increase stone clearance, but probably also slightly increase the risk of major adverse events 5.