EBQ:Alpha-blockers for ureteral stone expulsion
Clinical Question
Do alpha-blockers expedite ureteral stone passage?
Pro Argument
- Current Cochrane Review concludes: "the use of alpha-blockers in adult patients with ureteral stones appears to expedite spontaneous passage, with only minor potential adverse effects."[1][2]
- There is evidence that the subgroup of large distal stones >5mm benefit from tamulosin (passage rate of 83.3% with tamulosin versus 61.0% with placebo)[3]
Trial 1
Trial 2
Trial 3
Con Argument
- Although meta-analyses of previous randomized controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, a randomized placebo-controlled trial demonstrated that no difference was noted between active treatment and placebo (p=0.78), or between tamsulosin and nifedipine (p=0.77).[4][5]
Trial 1
Trial 2
Trial 3
Conclusion
- Alpha-blockers (tamsulosin) increase spontaneous stone passage rate for distal ureteral stones
- Number needed to treat (NNT) of approximately 4-5 for distal ureteral stones
- Benefit is most pronounced for stones 5-10mm in the distal ureter
Major Points
- Medical expulsive therapy (MET) with alpha-blockers facilitates stone passage by relaxing ureteral smooth muscle
- Tamsulosin 0.4mg daily is the most studied alpha-blocker for this indication
- The SUSPEND trial (2015) challenged prior positive meta-analyses, finding no benefit of tamsulosin or nifedipine
- Subsequent meta-analyses including SUSPEND still show overall benefit, primarily for larger distal stones
- Alpha-blockers also appear to reduce pain episodes and analgesic requirements during stone passage
Study Design
- Meta-analysis of randomized controlled trials
- Included multiple RCTs comparing alpha-blockers vs placebo or standard care for ureteral stone expulsion
Population
Inclusion Criteria
- Adults with confirmed ureteral stones (typically <10mm)
- Stones located in the distal ureter in most studies
Exclusion Criteria
- Stones requiring urgent intervention (complete obstruction, infection, renal failure)
- Pregnancy
- Stones >10mm in most studies
Interventions
- Alpha-blocker therapy (most commonly tamsulosin 0.4mg daily) for 2-4 weeks
- Control: placebo or standard analgesic care without alpha-blockers
Outcomes
Primary Outcome
- Stone passage rate: alpha-blockers associated with higher spontaneous passage rates (pooled RR approximately 1.4-1.5)
Secondary Outcomes
- Reduced time to stone passage
- Reduced analgesic use
- Lower rates of surgical intervention
- Side effects: orthostatic hypotension, dizziness (generally mild)
Criticisms
- Significant heterogeneity across included studies in terms of stone size, location, and treatment duration
- Many earlier studies were small and of lower methodological quality
- The SUSPEND trial (largest single RCT) was negative, raising questions about publication bias in earlier meta-analyses
- Benefit appears limited to larger stones (5-10mm) in the distal ureter; unclear benefit for smaller or proximal stones
- Alpha-blockers are used off-label for this indication
Funding
- Variable across included trials
See Also
References
- ↑ Welch JL and Cooper DD. Systematic review Snapshot. Annals of Emergency Medicine. January 2016. 67(1):117-118.
- ↑ Campschroer et al. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Databse Syst Rev. 2014(4):CD008509
- ↑ Furyk, JS, et al. Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial. Annals of Emergency Medicine. 2016; 67(1):86-95.e2.
- ↑ Singh A, et al. A systematic review of medical therapy to facilitate the passage of ureteral calculi. Annals of Emerg Med. 2007; 552-563.
- ↑ Pickard R, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet. 2015; epub.