Calcium Channel Blockers as an Emergency Treatment for Renal Colic
Date First Published:
February 20, 2008
Last Updated:
February 22, 2008
Report by:
Helen Blackhurst, SPR Emergency Medicine (Cheltenham General Hospital)
Search checked by:
Faye Dagger, Cheltenham General Hospital
Three-Part Question:
In [patients presenting with renal colic] are [calcium channel blockers] a [useful emergency department treatment]?
Clinical Scenario:
A 42 year old man attends the Emergency Department with an episode of renal colic. PR voltarol has not provided any relief. You wonder if a calcium channel blocker would facilitate passage of the stone and allow for earlier discharge from the Emergency Department.
Search Strategy:
Medline 1966 - 08 using the OVID interface
Search Details:
[Ureteral Calculi/ or renal colic.mp or Kidney Calculi] AND [calcium channel blockers.mp. or Calcium Channel Blockers]
Limit to human and English
Limit to human and English
Outcome:
12 papers were found of which 5 were relevant
Search of references revealed another 2 papers
Search of references revealed another 2 papers
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A systematic review of medical therapy to facilitate passage of ureteral calculi Singh A. Alter HJ. Littlepage A 2007 USA | Pooled analysis of 16 studies using alpha antagonist and 9 studies using calcium channel blocker | Meta-analysis Included non-English studies |
Stone expulsion rates, time to expulsion of stone | Medical therapy using calcium channel blockers significantly increases stone expulsion rate. NNT was 3.9. Time to expulsion was significantly reduced - range 2-14 days | |
| Medical therapy to facilitate urinary stone passage: a meta-analysis Hollingsworth JM, Rogers MAM, Kaufman SR 2006 USA | Pooled data from 9 trials | Meta-analysis | Stone expulsion rates | Patients given calcium channel blockers or alpha blockers had a 65% greater likelihood of stone passage than if given no treatment. NNT was 4 | 3 studies gave multiple drugs to their treatment group making analysis difficult |
| A comparative in vitro study to determine the beneficial effect of calcium-channel and alpha 1-adrenoceptor antagonism on human ureteric activity Davenport K. Timoney AG. Keeley FX 2006 UK | 210 strips of human ureter | Prospective trial | Relaxant effect on ureter | Nifedipine produced greater ureteric relaxation in vitro than diclofenac | Relevant to question? |
| Randomised trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi Dellabella M. Milanese G. 2005 Italy | 210 symptomatic patients with distal ureteral calculi. Randomly allocated to receive phloroglucinol, tamsulosin or nifedipine (70 in each group) | Randomised prospective trial | Stone expulsion rates, time to expulsion of stone | Expulsion rate significantly higher with tamsulosin (97%) than phloroglucinol (64.3%) or nifedipine (77.1%) | Not blinded No control group |
| Effectiveness of nifedipine and deflazacort in the management of distal ureter stones Porpiglia F. Destefanis P. Fiori C. Fontana D. 2000 Italy | 96 patients with radiopaque stones of <1cm in the distal ureter. Randomly divided into 2 groups. Group A (n=48) given deflazacort + nifedipine. Group B no drugs | Randomised controlled trial | Stone expulsion rates, time to expulsion of stone | Statistically significant increased stone expulsion rate and time in treatment group (79% and 7 days for treatment compared to 35% and 20 days for control) | Initial patient selection not randomised. Treatment group given both deflazacort and nifedipine |
| Intensive medical management of ureteral calculi Cooper JT. Stack GM. Cooper TP 2000 USA | 70 consecutive patients with renal calculi. 35 randomised to control given ketorolac, oxycodone and acetaminophen combination tablets. Treatment group given the above + nifedipine, prednisolone, trimethoprim/sulfa and acetaminophen | Randomised controlled trial | Stone expulsion rates, time to expulsion of stone, work days lost, visits to Emergency Department | Treatment arm had significantly higher stone passage rates (86% vs 56%) + lost fewer work days. ED visits reduced from 4 in control arm to 1 in treatment arm | No blinding. Treatment arm received 4 extra medications compared to control, therefore unable to ascertain which drug was having beneficial effect |
| Nifedipine versus tamsulosin for the management of lower ureteral stones Porpiglia F. Ghignone G. Fiori C. 2004 Italy | 86 patients with stones <1cm in lower ureter. Randomly divided into 3 groups. Gp 1 received deflazacort and nifedipine, gp 2 deflazacort and tamsulosin, gp 3 control (no drugs) | Randomised controlled trial | Stone expulsion rates, time to expulsion of stone | Groups 1 and 2 significantly increased expulsion rate compared to control. No significant difference between groups 1 and 2 | Initial selection not randomised. No blinding. Why were group 3 not given deflazacort - makes results difficult to interpret |
Author Commentary:
The calcium channel blocker most frequently used was nifedipine 30mg/day. The above studies and 2 meta-analyses all showed a benefit in increasing stone passage rates when medical therapy with a calcium channel blocker or alpha blocker was used. Time to expulsion of stone was also significantly reduced, however, even with medical therapy this ranged from 2 to 14 days. In an Emergency Department setting calcium channel blockers are unlikely to change management i.e. whether a patient needs to be admitted while a stone is passed, however starting medical therapy prior to discharge in a patient who has urology follow up may be a consideration.
Bottom Line:
Calcium channel blockers enhance stone passage over days rather than hours, therefore are not a definitive Emergency Department treatment
References:
- Singh A. Alter HJ. Littlepage A. A systematic review of medical therapy to facilitate passage of ureteral calculi
- Hollingsworth JM, Rogers MAM, Kaufman SR. Medical therapy to facilitate urinary stone passage: a meta-analysis
- Davenport K. Timoney AG. Keeley FX. A comparative in vitro study to determine the beneficial effect of calcium-channel and alpha 1-adrenoceptor antagonism on human ureteric activity
- Dellabella M. Milanese G.. Randomised trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi
- Porpiglia F. Destefanis P. Fiori C. Fontana D.. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones
- Cooper JT. Stack GM. Cooper TP. Intensive medical management of ureteral calculi
- Porpiglia F. Ghignone G. Fiori C.. Nifedipine versus tamsulosin for the management of lower ureteral stones