What medications are used to treat kidney pain due to stones?

Medications for Kidney Stone Pain Management

NSAIDs are the first-line treatment for kidney stone pain due to their superior efficacy and lower side effect profile compared to opioids. 1

First-Line Pain Management

NSAIDs

• Ibuprofen: 400 mg every 6-8 hours (daily maximum 3200 mg) 1, 2
• Diclofenac: Effective for renal colic 1, 3
• Ketorolac: 15-30 mg IV for short-term use (maximum 5 days) 1

NSAIDs are preferred because they:

• Reduce inflammation and pressure within the urinary collecting system 2
• Decrease ureteral smooth muscle tone and ureteral spasm causing kidney stone pain 1
• Result in less need for rescue medication compared to opioids 3, 4
• Have fewer side effects, particularly less vomiting 4

Second-Line Pain Management

Opioids

Only when NSAIDs are contraindicated or insufficient:

• Hydromorphone, pentazocine, or tramadol are recommended 1
• Avoid pethidine/meperidine due to higher rates of vomiting and greater likelihood of requiring additional analgesia 1, 4

Special Considerations

NSAID Precautions

• Use lowest effective dose due to potential cardiovascular, gastrointestinal, and renal risks 1
• Monitor closely in patients with:
  • Age >60 years
  • Cardiovascular disease
  • Renal insufficiency
  • History of peptic ulcer disease 1
• Short-term use (days) may be acceptable even in CKD patients with careful monitoring 5

Kidney Function Considerations

• For patients with significantly reduced kidney function:
  • Acetaminophen: 650 mg every 4-6 hours (maximum 3-4g/day) may be safer 1
  • Buprenorphine appears to be a safer opioid option due to its partial agonism 5

Adjunctive Treatments

Medical Expulsive Therapy

• Alpha-blockers (e.g., tamsulosin) are beneficial for stones >5mm in the distal ureter 1, 2, 6
• Helps relax smooth muscle in the intramural ureteral tract, making stone expulsion easier 6

Hydration

• Increased fluid intake to produce at least 2-2.5 liters of urine per day 2
• Adults should consume 3.5-4 liters of fluid daily 2

Monitoring and Follow-up

• Monitor for NSAID toxicities: blood pressure, renal function, GI symptoms 1
• If pain persists or worsens, or if fever develops, urgent medical evaluation is needed 1
• In cases of sepsis or anuria with an obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is required 1

Common Pitfalls to Avoid

1. Overuse of opioids: Opioids should be reserved for patients who have failed NSAID therapy due to higher rates of adverse effects 5, 4

2. Prolonged NSAID use: Limit duration to reduce risk of renal, GI, and cardiac toxicities 1

3. Inadequate hydration: Insufficient fluid intake can worsen stone formation and pain 2

4. Missing signs of infection: Fever with kidney stones requires immediate attention and antibiotics 1

5. Failure to consider stone size: Stones >5mm may benefit from medical expulsive therapy in addition to pain management 1, 2