UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: Alpha-Blockers for the Management of Ureteral Stones

Keywords: Ureteral stones, Alpha-blockers (PubMed Search)

Posted: 9/2/2017 by Wesley Oliver (Updated: 9/26/2017)
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Takeaways

Alpha-blockers (tamsulosin, alfuzosin, doxazosin, and terazosin) are antagonists of alpha1A-adrenoreceptors, which results in the relaxation of ureteral smooth muscle.    Current evidence suggests alpha-blockers may be useful when ureteral stones are 5-10 mm; however, there is no evidence to support the use of alpha-blockers with stones <5 mm.  Patients with ureteral stones >10 mm were excluded from studies utilizing these medications.

The size of most ureteral stones will be unknown due to the lack of need for imaging able to measure stone size. Given that the median ureteral stone size is <5 mm, most patients will not benefit from the use of an alpha-blocker.

Also, keep in mind that the data for adverse events with alpha-blockers used for ureteral stones is limited and that these medications have a risk of hypotension.

 

In-Depth

Ferre RM et al. Tamsulosin for ureteral stones in the emergency department: a randomized, controlled trial. Ann Emerg Med 2009.

  • 77 patients

  • Ibuprofen + oxycodone + tamsulosin vs. ibuprofen + oxycodone

  • Stone expulsion at 14 days: Tamsulosin group=77.1% vs. Standard therapy=64.9%

-Difference=12% (95% CI: -8.4-32.8%)

  • No clinically/statistically significant differences

 

Pickard R et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015.

  • 1,136 patients

  • Tamsulosin vs. nifedipine vs. placebo

  • No further intervention at 4 weeks: Tamsulosin=81% vs. Nifedipine=80% vs. Placebo=80%

  • No clinically/statistically significant differences

 

Furyk JS et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med 2016.

  • 403 patients

  • Tamsulosin vs. placebo

  • Stone passage at 28 days: Tamsulosin=87% vs. Placebo=81.9%

-Difference=5% (95% CI: -3-13%)

  • Found difference in subgroup analysis of large stones (5-10 mm)

-Tamsulosin=83.3% vs. Placebo=61%

-Difference=22.4% (95% CI: 3.1-41.6%)

  • No other clinically/statistically significant differences

 

Hollingsworth JM et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016.

  • Meta-analysis of 55 trials

  • No benefit in patients with smaller stones (<5 mm): RR=1.19 (95% CI: 1.00-1.98)

  • Benefit in patients with larger stones (5-10 mm): RR=1.57 (95% CI: 1.39-1.61)

References

1.) Ferre RM, Wasielewski JN, Strout TD, Perron AD. Tamsulosin for ureteral stones in the emergency department: a randomized, controlled trial. Ann Emerg Med 2009;54:432-9.

2.) Furyk JS, Chu K, Banks C, et al. Distal ureteric stones and tamsulosin: a double-blind, placebo-controlled, randomized, multicenter trial. Ann Emerg Med 2016;67:86-95.

3.) Hollingsworth JM, Canales BK, Rogers MAM, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355:i6112.

4.) Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015;386:341-9.