What prescription should a patient with a 10 mm distal obstructing ureteral calculi (kidney stone) be sent home with for pain control and to help pass the stone?

From the Guidelines

For a patient with a 10 mm distal obstructing ureteral calculi, I would recommend a combination of medications for pain control and to facilitate stone passage, including an NSAID such as ibuprofen 600-800 mg orally every 6-8 hours with food, and an alpha-blocker such as tamsulosin (Flomax) 0.4 mg daily, as evidenced by the 2007 guideline for the management of ureteral calculi 1. The primary pain medication should be an NSAID, as they target both pain and inflammation at the site of obstruction. For breakthrough pain, oxycodone 5-10 mg every 4-6 hours as needed can be prescribed.

• The patient should also be instructed to maintain adequate hydration by drinking 2-3 liters of water daily.
• However, it's essential to note that a 10 mm stone is relatively large and has a lower probability of spontaneous passage, as suggested by the guideline for the management of ureteral calculi 1.
• The patient should be informed that if pain becomes uncontrollable, fever develops, or no improvement occurs within 1-2 weeks, they should seek immediate medical attention as surgical intervention may be necessary.
• Alpha-blockers, such as tamsulosin, have been shown to facilitate ureteral stone passage while reducing the time to stone expulsion, with a statistically significant 29% increase in stone passage compared to control patients 1.
• The beneficial effects of these drugs are likely attributed to ureteral smooth muscle relaxation mediated through either inhibition of calcium channel pumps or alpha-1 receptor blockade, as explained in the 2007 guideline for the management of ureteral calculi 1.

From the Research

Pain Control and Medical Expulsive Therapy for Ureteral Calculi

• For a patient with a 10 mm distal obstructing ureteral calculi, pain control and medical expulsive therapy (MET) are crucial for managing symptoms and facilitating stone passage.
• Studies have shown that tamsulosin, an alpha-blocking agent, can be effective in enhancing spontaneous stone passage and reducing pain 2, 3, 4.
• A study published in The Canadian Journal of Urology found that tamsulosin therapy increased the stone passage rate and reduced the time to stone passage for distal ureteral stones, including those between 7-10 mm in size 2.
• Another study published in the Journal of Emergencies, Trauma, and Shock found that MET, including tamsulosin, can facilitate stone expulsion and reduce the need for analgesic therapy, hospitalization, and surgery 3.
• However, not all studies have shown a significant benefit of tamsulosin in facilitating stone passage. A study published in Annals of Emergency Medicine found that tamsulosin did not substantially improve outcomes compared to standard therapy with ibuprofen and oxycodone alone 5, 6.

Prescription Recommendations

• Based on the available evidence, a prescription for tamsulosin, in addition to pain control medications such as ibuprofen and oxycodone, may be considered for a patient with a 10 mm distal obstructing ureteral calculi 2, 3, 4.
• The patient should also be advised to stay hydrated and follow up with a healthcare provider to monitor stone passage and adjust treatment as needed.
• It is essential to note that the effectiveness of tamsulosin may vary depending on the size and location of the stone, as well as individual patient factors 5, 6.