Can deflazacort be used to treat ureteric stones?

Deflazacort for Ureteric Stones

Deflazacort alone is not recommended as monotherapy for ureteric stones, but it can be used as an adjunct to alpha-blockers (tamsulosin) in medical expulsive therapy for distal ureteral stones 4-10 mm in size to potentially accelerate stone passage. 1, 2

Evidence-Based Treatment Approach

Primary Treatment Recommendations

The 2007 AUA guidelines establish that alpha-blockers are the preferred agents for medical expulsive therapy (MET), with a statistically significant 29% increase in stone passage rates compared to controls, while the benefit of adding corticosteroids was reported to be small. 3

However, more recent research provides nuanced findings:

• Deflazacort monotherapy (30 mg daily for 10 days) achieved only a 37.5% stone expulsion rate, which was not significantly better than the 33.3% control rate 2
• Tamsulosin monotherapy (0.4 mg daily) achieved a 60-64.8% expulsion rate 1, 2
• Combined therapy (tamsulosin + deflazacort) achieved the highest expulsion rate at 75.7-84.8%, which was statistically superior to all other groups 1, 2

Clinical Algorithm for Deflazacort Use

For distal ureteral stones 4-10 mm:

1. First-line MET: Tamsulosin 0.4 mg daily for up to 4 weeks 1, 2
2. Enhanced MET option: Add deflazacort 30 mg daily for 10 days maximum (not longer due to corticosteroid side effects) if rapid expulsion is desired 2, 4
3. Duration limitation: Deflazacort should be limited to 10 days, while tamsulosin can continue up to 4 weeks 1, 2

Key Clinical Considerations

Deflazacort reduces stone expulsion time when combined with tamsulosin (mean reduction in expulsion time was statistically significant), though the overall expulsion rate difference may be modest. 4

The combination therapy demonstrated:

• Significantly reduced analgesic consumption (27.3 mg vs 81 mg in controls) 2
• Fewer colic episodes during treatment 2
• No major drug-related side effects in clinical trials 1, 2

Important Caveats and Pitfalls

Do not use deflazacort as monotherapy - it is ineffective without concurrent alpha-blocker therapy, with expulsion rates similar to placebo. 2

Limit corticosteroid duration to 10 days to prevent adverse effects associated with prolonged steroid use, even though alpha-blockers can safely continue for 4 weeks. 1, 2

Patient selection matters: MET (with or without deflazacort) should only be offered to patients with:

• Well-controlled pain 3
• No clinical evidence of sepsis 3
• Adequate renal functional reserve 3
• Stones <10 mm in the distal ureter 1, 2

For septic patients with obstructing stones, urgent decompression with stenting or nephrostomy is mandatory before any medical therapy, and definitive stone treatment must be delayed until infection resolves. 3

When Deflazacort Should NOT Be Used

• Stones >10 mm: Surgical intervention (ureteroscopy or SWL) is more appropriate as first-line therapy 3
• Proximal or mid-ureteral stones: Evidence for corticosteroid benefit is limited to distal stones 1, 2
• Patients with contraindications to corticosteroids: Use tamsulosin alone, which remains highly effective (60% expulsion rate) 2, 4
• After 4-6 weeks of failed conservative management: Proceed to definitive surgical treatment rather than continuing medical therapy 3

Second-Line Consideration

If a first 10-day cycle of combined tamsulosin + deflazacort fails, a second cycle of tamsulosin alone (without deflazacort) for an additional 10 days achieved an 80% expulsion rate in one study, suggesting this as a reasonable option before proceeding to ureteroscopy. 5