What is the recommended pain management regimen for a patient with a kidney stone?

Pain Management for Kidney Stones

NSAIDs should be the first-line treatment for kidney stone pain, with opioids reserved for cases where NSAIDs are contraindicated or insufficient for pain control. 1, 2, 3

First-Line Treatment: NSAIDs

• NSAIDs are more effective than placebo and antispasmodics for renal colic pain 3
• They reduce the need for rescue medications compared to placebo 3
• Examples of appropriate NSAID options:
  • Oral ibuprofen: 400-800 mg every 6-8 hours
  • Oral naproxen: 500 mg initially, then 250 mg every 6-8 hours
  • Intravenous ketorolac: 30 mg initially, then 15-30 mg every 6 hours if needed

Cautions with NSAIDs

• Use with caution in patients with chronic kidney disease (CKD) 4
• Avoid in patients with:
  • Advanced CKD (eGFR <30 ml/min)
  • Active gastrointestinal bleeding
  • History of NSAID allergy
  • Severe heart failure

Second-Line Treatment: Opioids

When NSAIDs are contraindicated or insufficient for pain control:

• Oral oxycodone: 5-15 mg every 4-6 hours as needed 5
• Start at the lowest effective dose and titrate based on pain response
• For severe chronic pain, administer on a regularly scheduled basis 5
• Monitor closely for respiratory depression, especially within the first 24-72 hours 5

Adjunctive Treatments

• Alpha-blockers (e.g., tamsulosin) can facilitate spontaneous stone passage 6, 7
• Increased fluid intake (target >2L/day urine output) to help pass the stone 1
• For patients with cystine stones, target higher fluid intake (>4L/day) 1

Long-Term Management

For patients with recurrent kidney stones:

• Thiazide diuretics for patients with high urinary calcium and recurrent calcium stones 8, 1
• Potassium citrate for patients with low urinary citrate or pH 1
• Dietary modifications:
  • Normal calcium intake (1,000-1,200 mg/day) 8, 1
  • Sodium restriction (<2,300 mg/day) 8, 1
  • Limit oxalate-rich foods for calcium oxalate stones 8
  • Limit animal protein intake 1

Follow-up and Monitoring

• Regular imaging (renal ultrasound every 12-24 months) to monitor for new stone formation 1
• 24-hour urine collection to assess metabolic abnormalities 1
• For stones <10 mm, active surveillance or medical expulsive therapy is appropriate 1
• For stones >10 mm, consider referral for procedural intervention 1

Remember that pain management should be initiated promptly, with NSAIDs as the preferred first-line therapy unless contraindicated, to provide effective relief while minimizing opioid exposure and potential dependence.