Nephrolithiasis Medication
- Author: J Stuart Wolf Jr, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
Medication Summary
Please see Cystinuria, Hypercalciuria, Hyperoxaluria, Hyperuricosuria and Gouty Diathesis, Hypocitraturia, and struvite topics for specific information regarding medical therapy for stone disease. The medications listed below include those used in the emergency department (ED) and in outpatient management of renal (ureteral) colic, as well as selected antibiotics
Analgesics, Narcotic
Class Summary
Narcotic analgesics act at the central nervous system (CNS) mu receptors and are the standard of care for treatment of renal colic. They are inexpensive and proven effective. Disadvantages include sedation, respiratory depression, smooth muscle spasm, and potential for abuse and addiction.
Butorphanol (Stadol)
Butorphanol is a mixed agonist-antagonist narcotic with central analgesic effects for moderately severe to severe pain. It causes less smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh these advantages against the increased cost of butorphanol.
Morphine sulfate (Astramorph, Infumorph 200, Infumorph 500)
Morphine is the principal opium alkaloid product. It is the drug of choice for parenteral use in the immediate management of pain due to renal (ureteral) colic.
Oxycodone and acetaminophen (Percocet, Endocet, Roxicet, Tylox)
Oxycodone-acetaminophen is a drug combination indicated for oral relief of moderate to severe pain. It is employed in medical expulsive therapy (MET).
Hydrocodone and acetaminophen (Vicodin, Vicodin ES, Lortab, Norco)
Hydrocodone is also combined with acetaminophen. This drug combination is indicated for oral relief of moderate to severe pain.
Meperidine (Demerol)
Meperidine is a narcotic analgesic with multiple actions similar to those of morphine. It may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Nalbuphine
Nalbuphine is a synthetic opioid agonist-antagonist potent analgesic. It stimulates kappa opioid receptor in the CNS, which causes inhibition of ascending pain pathways. It is indicated for the relief of moderate to severe pain.
Analgesics, Miscellaneous
Class Summary
Analgesics such as acetaminophen can be used to provide relief of mild to moderate pain.
Acetaminophen
Acetaminophen is a nonopioid analgesic that is effective in relieving mild to moderate pain; however, it has no peripheral anti-inflammatory effects but can be used in pregnancy.
Nonsteroidal anti-inflammatory drugs
Class Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit pain and inflammatory reactions by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. Both properties are beneficial in the management of renal (ureteral) colic.
These agents are at least as effective as narcotic analgesics in numerous randomized controlled trials. NSAIDs cause less nausea and less sedation than narcotic analgesics, do not cause respiratory depression, and have no abuse potential. Their principal disadvantage is cost. Potential adverse effects on renal function, gastrointestinal (GI) mucosa, and platelet aggregation do not appear clinically important when they are used for short-term pain relief.
Ketorolac
Ketorolac is the only NSAID approved for parenteral use in adults in the United States. Its onset of action is evident within 10 min.
Ketorolac intranasal (Sprix)
Intranasal ketorolac inhibits cyclooxygenase, an early component of the arachidonic acid cascade, resulting in reduced synthesis of prostaglandins, thromboxanes, and prostacyclin. It elicits anti-inflammatory, analgesic, and antipyretic effects. It is indicated for short-term (up to 5 d) management of moderate to moderately severe pain. Bioavailability of a 31.5-mg intranasal dose (2 sprays) is approximately 60% of a 30-mg intramuscular (IM) dose. The intranasal spray delivers 15.75 mg per 100-µL spray; each 1.7-g bottle contains 8 sprays.
Ibuprofen (Motrin, Advil)
Ibuprofen is an oral NSAID. It has antipyretic, analgesic, and anti-inflammatory properties and is used for outpatient management.
Corticosteroids
Class Summary
These are strong anti-inflammatory agents that reduce ureteral inflammation. They also have profound metabolic and immunosuppressive effects.
Prednisone
Prednisone has been used in MET. Only a short course of prednisone therapy (5-10 d) should be administered.
Prednisolone (Prelone, Pediapred, Millipred, Orapred, Orapred ODT)
In combination with nifedipine or tamsulosin, prednisolone is proven to facilitate spontaneous passage of a ureteral stone in several small prospective studies. Only a short course of therapy (5-10 d) should be administered.
Calcium channel blockers
Class Summary
Calcium channel blockers are smooth-muscle relaxants. In combination with prednisolone, they have facilitated ureteral stone passage in several small prospective studies.
Nifedipine (Nifedical XL, Procardia, Procardia XL, Adalat CC)
Nifedipine facilitates the passage of ureteral stones. The extended-release formulation simplifies treatment and encourages compliance. Only short-term therapy (10 d) should be considered for this indication.
Alpha blockers
Class Summary
Alpha-blockers are smooth-muscle relaxants. They have been shown to facilitate ureteral stone passage.
Tamsulosin (Flomax)
Tamsulosin, an alpha-1 selective blocker, is indicated for the treatment of lower urinary tract symptoms due to prostatic enlargement. An off-label use, as discussed above, is to facilitate passage of ureteral stones. Only short-term therapy (10 d) should be considered for this indication.
Terazosin (Hytrin)
Terazosin is indicated for the treatment of hypertension, as well as lower urinary tract symptoms due to prostatic enlargement. An off-label use is to facilitate passage of ureteral stones. Only short-term therapy (10 d) should be considered for this indication.
Uricosuric agents
Class Summary
Uricosuric agents help prevent nephropathy. They also help prevent recurrent calcium oxalate calculi.
Allopurinol (Zyloprim)
Allopurinol inhibits xanthine oxidase, the enzyme that synthesizes uric acid from hypoxanthine. It reduces the synthesis of uric acid without disrupting the biosynthesis of vital purines.
Alkalinizing agents, oral
Class Summary
Oral alkalinizing agents are used for the treatment of metabolic acidosis. They are also employed when long-term maintenance of alkaline urine is desirable.
Potassium citrate (Polycitra-K, Urocit K)
Potassium citrate is absorbed and metabolized to potassium bicarbonate, thus acting as a systemic alkalizer. Its effects are essentially those of chlorides before absorption and those of bicarbonates subsequently. Oxidation is virtually complete so that < 5% of the potassium citrate is excreted in the urine unchanged. It is highly concentrated and, when administered after meals and before bedtime, allows maintenance of an alkaline urinary pH at all times, usually without necessity of 2 AM dose. In the recommended dosage, it alkalinizes urine without producing systemic alkalosis.
Antiemetics
Class Summary
Patients with acute renal colic frequently experience intense nausea and/or vomiting. Effective pain control often is accompanied by resolution of nausea and vomiting, but some patients may require antiemetics in addition to analgesics. Various antiemetic medications are used, including phenothiazines and butyrophenones.
Metoclopramide (Reglan)
Metoclopramide is the only antiemetic that has been studied specifically in treatment of renal colic. In 2 small double-blinded studies, it provided relief of nausea and pain relief equal to that of narcotic analgesics. Metoclopramide's antiemetic effect is due to blockade of dopaminergic receptors in chemoreceptor trigger zone in CNS. Metoclopramide does not possess antipsychotic or tranquilizing activity and is less sedating than other central dopamine antagonists. Onset of action is 1-3 min after intravenous (IV) injection and 10-15 min after IM injection.
Antibiotics
Class Summary
Infected hydronephrosis mandates IV antibiotic therapy in addition to urgent drainage via percutaneous nephrostomy or urethral stent placement. Aerobic gram-negative enteric organisms, including Escherichia coli and Klebsiella, Proteus, Enterobacter, and Citrobacter species, are typical pathogens. Enterococcal infection occasionally is seen in patients recently on antibiotics. Candida albicans sometimes is responsible in diabetic or immunosuppressed patients. Initial empiric antibiotic therapy should cover common bacterial pathogens.
Ampicillin
Ampicillin is a beta-lactam aminopenicillin antibiotic. Non–penicillinase-producing staphylococci and most streptococci are susceptible. Ampicillin is effective against E coli and Proteus and Enterococcus species, but most Klebsiella, Serratia, Acinetobacter, indole-positive Proteus, and Pseudomonas species and Bacteroides fragilis are resistant. Ampicillin is usually combined with gentamicin.
Gentamicin
Gentamicin is an aminoglycoside antibiotic, which is active against Staphylococcus aureus and Enterobacteriaceae organisms including E coli and Proteus, Klebsiella, Serratia, Enterobacter, and Citrobacter species. Pseudomonas aeruginosa is usually sensitive, although its sensitivity varies somewhat. When used in combination with ampicillin, gentamicin also effective against Enterococcus faecalis.
Ticarcillin and clavulanic acid (Timentin)
Ticarcillin is an extended-spectrum penicillin, beta-lactam antibiotic. Clavulanic acid is a beta-lactamase inhibitor that, in combination with ticarcillin, extends the spectrum of ticarcillin to include many beta-lactamase–producing bacteria. Ticarcillin-clavulanate is excreted via the urinary tract.
This combination is active against most staphylococci and streptococci and gram-negative organisms including E coli, Morganella morganii, Proteus mirabilis, Proteus vulgaris, Neisseria gonorrhoeae, and Pseudomonas and Providencia species; the anaerobic spectrum includes Peptococcus and Peptostreptococcus species, Clostridium perfringens, Clostridium tetani, and Bacteroides species, including many strains of B fragilis. It is not effective against Enterococcus species or methicillin-resistant staphylococci.
Ciprofloxacin (Cipro, Proquin XR)
Ciprofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones are active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and Streptococcus pneumoniae. Ciprofloxacin is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
Levofloxacin (Levaquin)
Levofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones are active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae. Levofloxacin is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
Ofloxacin
Ofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. It is active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae. It is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
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| *Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients.† This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost.‡ These include significant allergic responses and renal failure. | ||
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