What type of diuretic is recommended for ureteric calculi?

Alpha Blockers Are the Recommended Diuretic for Ureteric Calculi

Alpha blockers, not traditional diuretics, are the recommended medication for facilitating the passage of ureteric calculi due to their superior efficacy in increasing stone-free rates and reducing expulsion time. 1

Medical Expulsive Therapy (MET) with Alpha Blockers

• Alpha blockers are recommended as first-line medical expulsive therapy for ureteric calculi, with the greatest benefit observed for stones >5mm in the distal ureter 1
• Meta-analysis demonstrates that alpha blockers increase stone passage rates by 29% (95% CI: 20% to 37%) compared to control treatments 1
• Alpha blockers work by decreasing intra-ureteral pressure and increasing fluid passage, which facilitates stone expulsion 2
• The stone-free rate with alpha blockers is approximately 81% compared to control groups 1

Evidence Supporting Alpha Blockers Over Traditional Diuretics

• Traditional diuretics (like furosemide) are not recommended for ureteric calculi management based on available evidence 3
• A Cochrane systematic review found no reliable evidence supporting the use of diuretics or high-volume fluid therapy for people with acute ureteric colic 3
• Alpha blockers have been shown to reduce:
  • Stone expulsion time by approximately 2.91 days 2
  • Number of pain episodes 2
  • Need for analgesic medication 2
  • Risk of hospitalization by 65% 2

Clinical Approach to Ureteric Calculi Management

For stones <10mm with controlled symptoms:

• Observation with medical expulsive therapy using alpha blockers is the recommended first-line approach 4
• Monitor stone position and assess for hydronephrosis with periodic imaging 4

For stones requiring intervention:

• Both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments 4
• Stone-free rates for SWL vary by location: 82% for proximal ureter, 73% for mid-ureter, and 74% for distal ureter 1
• URS demonstrates higher stone-free rates: 81% for proximal ureter, 86% for mid-ureter, and 94% for distal ureter 1

Pain Management During Acute Episodes

• NSAIDs (diclofenac, ibuprofen, metamizole) are first-line treatment for renal colic 1
• Ketorolac can be used for pain control in conjunction with alpha blockers 4
• Opioids should be considered second-line analgesics when NSAIDs are contraindicated or insufficient 1

Important Considerations and Precautions

• For sepsis and/or anuria in an obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is required before definitive treatment 1
• Alpha blockers may cause mild adverse effects, though most do not require cessation of therapy 2
• Contraindications to specific treatments should be considered:
  • NSAIDs may impact renal function in patients with low GFR 1
  • SWL is contraindicated in pregnancy and bleeding disorders 1

Conclusion for Clinical Practice

Alpha blockers should be the primary medication used for medical expulsive therapy in ureteric calculi, as they have demonstrated superior efficacy compared to traditional diuretics or placebo in facilitating stone passage, reducing pain, and decreasing the need for surgical intervention.