What are the recommendations for pain management in patients with kidney stones?

Pain Management in Kidney Stones

NSAIDs are the first-line treatment for pain management in patients with kidney stones, with acetaminophen as an alternative for those who cannot tolerate NSAIDs or have contraindications. 1, 2, 3

First-Line Analgesics

• NSAIDs are superior to opioids for acute renal colic, providing greater reduction in pain scores, decreased need for rescue medications, and fewer vomiting events 1, 3
• Acetaminophen is the safest first-line medication for patients with kidney stones who have contraindications to NSAIDs, with a maximum daily dose of 3000 mg/day (typically 650 mg every 6 hours) 4
• NSAIDs should be used with caution in patients at high risk for renal, GI, cardiac toxicities, thrombocytopenia, or bleeding disorders 5
• Short-term use of ketorolac (15-30 mg IV, three times daily for maximum of 5 days) can be considered for acute management 5

Special Considerations for Kidney Disease

• NSAIDs should generally be avoided in patients with chronic kidney disease (CKD) due to their nephrotoxic effects 4, 6
• For patients with CKD or end-stage kidney disease (ESKD), acetaminophen is the preferred first-line agent 4, 6
• Topical analgesics such as lidocaine 5% patch and diclofac gel can be used for localized pain without significant systemic absorption in patients with kidney disease 4, 7

Second-Line Options for Moderate to Severe Pain

• If pain is not controlled with first-line agents, consider adding adjuvant medications:
  • Gabapentin or pregabalin can be used for neuropathic pain components but require significant dose adjustment in patients with kidney disease 4, 7
  • Gabapentin should start at 100-300 mg at night with careful titration in patients with kidney disease 4

Opioid Management for Severe Pain

• Opioids should be reserved for patients with severe pain who have failed other therapies 6
• Fentanyl and buprenorphine are the safest opioids for patients with kidney disease due to their favorable pharmacokinetic profiles 4, 6
• When using opioids, implement risk mitigation strategies and obtain informed consent after discussing goals, expectations, risks, and alternatives 4, 8
• Use the lowest effective dosage for the shortest duration consistent with individual patient treatment goals 8
• Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy 8
• Proactively prescribe laxatives for prophylaxis and management of opioid-induced constipation 4

Non-Pharmacological Approaches

• Application of local heat can provide significant relief for musculoskeletal pain without affecting renal function 4, 7
• Physical activity/exercise programs should be considered as initial treatment for musculoskeletal pain 4
• For chronic pain, prescribe analgesics on a regular basis rather than "as required" schedule 4

Monitoring and Follow-up

• Regular pain assessment using validated tools is essential for quality care 5, 4
• Monitor for NSAID toxicities with baseline blood pressure, BUN, creatinine, liver function studies, CBC, and fecal occult blood tests; repeat every 3 months 5
• Always include rescue doses of medications for breakthrough pain episodes 4
• Discontinue NSAIDs if BUN or creatinine doubles, if hypertension develops or worsens, or if liver function studies increase beyond normal limits 5

Recent Trends in Pain Management

• Recent data shows a significant decrease in opioid use for kidney stone management in US emergency departments between 2015 and 2021 (annual odds ratio: 0.87) 9
• This trend suggests improved opioid stewardship in response to the national opioid epidemic 9
• Medical expulsive therapy (MET) is recommended for patients with uncomplicated distal ureteral stones 10 mm in diameter or less 2