What is the role of Drotaverine in the management of urolithiasis?

Role of Drotaverine in the Management of Urolithiasis

Drotaverine is not included in major urological guidelines for urolithiasis management and is not recommended as a first-line treatment for renal colic or medical expulsive therapy. 1

Pain Management in Urolithiasis

• NSAIDs (diclofenac, ibuprofen, metamizole) are the first-line treatment for renal colic due to their superior efficacy in reducing the need for additional analgesia compared to opioids 1
• Opioids are recommended as second-choice analgesics when NSAIDs are contraindicated or insufficient 1
• Alpha-blockers (as an off-label class effect) are recommended for medical expulsive therapy (MET), particularly for stones >5 mm in the distal ureter 1

Drotaverine's Mechanism and Potential Application

• Drotaverine is an antispasmodic drug chemically related to papaverine that acts as a phosphodiesterase inhibitor 2
• It works by relaxing smooth muscle, which theoretically could help with ureteral spasms during stone passage 2
• While some general practitioners report prescribing drotaverine for nephrolithiasis (89% according to one survey), this practice is not supported by major urological guidelines 2

Evidence for Drotaverine in Urolithiasis

• There is a notable absence of drotaverine in the European Association of Urology (EAU) guidelines on urolithiasis treatment, which are based on systematic reviews and meta-analyses of randomized controlled trials 1
• The EAU guidelines specifically recommend alpha-blockers for medical expulsive therapy rather than antispasmodics like drotaverine 1
• No high-quality studies supporting drotaverine use in urolithiasis were identified in the systematic reviews that form the basis of current guidelines 1

Pharmacology of Drotaverine

• Drotaverine is well-absorbed after oral administration and is primarily excreted through bile as beta-glucuronide (67% in stool) with only 20% eliminated in urine 3
• Its distribution in the body is not specific to the urinary tract, which may limit its targeted efficacy for urolithiasis 3
• Patient surveys indicate that drotaverine is perceived as effective for abdominal pain and cramps in general, but these are subjective reports not specific to urolithiasis 2

Clinical Decision Making

• For acute renal colic, follow the evidence-based approach of using NSAIDs as first-line treatment 1
• For promoting stone passage, alpha-blockers are the recommended medical expulsive therapy 1
• In cases of sepsis or anuria with obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is strongly recommended rather than pharmacological management alone 1

Potential Pitfalls

• Using drotaverine instead of recommended first-line treatments may delay effective pain relief and stone passage 1
• Relying on antispasmodics without addressing the need for adequate hydration and appropriate follow-up imaging could lead to complications 1, 4
• Self-medication with drotaverine without proper diagnosis could mask symptoms of serious conditions requiring urgent intervention, such as obstructive uropathy with infection 1, 2