What can be given for kidney stone discomfort?

Management of Kidney Stone Discomfort

NSAIDs are the first-line treatment for kidney stone pain, with opioids reserved as second-line therapy only when NSAIDs are contraindicated or ineffective. 1, 2

First-Line Pain Management

• NSAIDs (such as diclofenac, ibuprofen) are more effective than opioids for kidney stone pain and should be used as first-line treatment when not contraindicated 1, 2
• NSAIDs not only provide pain relief but also decrease ureteral smooth muscle tone and ureteral spasm that causes kidney stone pain 1
• For patients with cardiovascular, renal, or gastrointestinal risk factors, carefully weigh the risks and benefits of NSAID use, considering dose and duration 1

Hydration and Medical Expulsive Therapy

• Increase fluid intake to achieve a urine volume of at least 2.5 liters daily to help with stone passage 1, 2
• Medical expulsive therapy (MET) using alpha-blockers shows greatest benefit for stones >5mm in the ureter and should be considered for appropriate patients 2
• Certain beverages may be associated with lower risk of stone formation beyond their impact on urine volume, including coffee (caffeinated and decaffeinated), tea, and orange juice 1

Adjunctive Treatments

• For calcium stones with low urinary citrate, potassium citrate therapy can help with discomfort by alkalinizing urine and potentially facilitating stone passage 1
• For uric acid stones, potassium citrate to raise urinary pH to 6.0 can increase stone solubility and reduce discomfort 1
• For cystine stones, potassium citrate to raise urinary pH to 7.0 along with increased fluid intake is recommended 1

When to Consider Opioids

• Opioids should only be used as second-line therapy when NSAIDs are contraindicated or ineffective 1, 2
• If opioids are necessary, use the lowest effective dose for the shortest duration possible 1
• Be aware that opioid use for kidney stones has been decreasing in emergency departments, reflecting improved stewardship in response to the opioid epidemic 3

Indications for Urgent Medical Attention

• Development of fever, signs of infection, or sepsis requires immediate medical attention 2
• Intractable pain despite appropriate analgesic therapy may indicate need for surgical intervention 2
• Anuria or signs of renal impairment require urgent decompression via percutaneous nephrostomy or ureteral stenting 2

Prevention of Recurrence

• Limit sodium intake and consume 1,000-1,200 mg per day of dietary calcium 1
• For calcium oxalate stones, limit intake of oxalate-rich foods while maintaining normal calcium consumption 1
• For patients with recurrent calcium stones and low urinary citrate, potassium citrate therapy should be offered 1
• For patients with uric acid stones, potassium citrate is first-line therapy rather than allopurinol 1

Common Pitfalls to Avoid

• Avoiding fluids due to pain can worsen the condition; adequate hydration is crucial for stone passage 1, 2
• Using sodium citrate instead of potassium citrate may increase urine calcium excretion and worsen stone formation 1
• Restricting dietary calcium can actually increase risk of stone formation; normal calcium intake (1,000-1,200 mg/day) is recommended 1
• Delaying treatment for signs of infection can lead to sepsis and increased morbidity 2

Remember that while managing acute discomfort is important, addressing underlying metabolic abnormalities through dietary modifications and appropriate medications is essential for preventing recurrence and improving long-term outcomes.