Acute Renal Colic
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《新英格兰医药杂志》
To the Editor: Although generally comprehensive, Teichman's review of acute renal colic due to ureteral calculus (Feb. 12 issue)1 failed to mention the calcium-channel blocker nifedipine in the medical treatment of patients with ureteral colic. Three randomized, controlled trials have demonstrated the favorable effects of a combination of nifedipine, corticosteroids, and nonsteroidal antiinflammatory drugs (NSAIDs) on several clinically meaningful end points, including spontaneous stone expulsion, time to stone passage, and requirements for pain medication. These studies showed up to twofold improvements in rates of spontaneous stone passage and greater than 50 percent reductions in the time required to achieve this outcome.2,3,4 Since one study found that nifedipine had an effect beyond that of corticosteroids,4 we have used only nifedipine plus NSAIDs, omitting the corticosteroid to minimize adverse pharmacologic effects. In general, sustained-release nifedipine is well tolerated and appears most efficacious in patients with distal ureteral stones for whom urgent surgical intervention is unnecessary.2,3,4
The merits of nifedipine are increasingly recognized by urologic authorities5,6; we believe that evidence-based medical management of ureteral stones should include nifedipine XL at a dosage of 30 mg once daily. Ultimately, its effectiveness will depend on its acceptance and application by the greater medical community.
David C. Miller, M.D.
J.S. Wolf, Jr., M.D.
University of Michigan Medical School
Ann Arbor, MI 48109-0330
wolfs@umich.edu
References
Teichman JMH. Acute renal colic from ureteral calculus. N Engl J Med 2004;350:684-693.
Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. Urology 2000;56:579-582.
Cooper JT, Stack GM, Cooper TP. Intensive medical management of ureteral calculi. Urology 2000;56:575-578.
Borghi L, Meschi T, Amato F, et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study. J Urol 1994;152:1095-1098.
Clayman RV. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. J Urol 2002;167:797-798.
Preminger GM. The value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage. Urology 2000;56:582-583.
Dr. Teichman replies: The conservative management of renal colic need not only address pain but also may enhance spontaneous stone passage. Drs. Miller and Wolf correctly note that combinations of drugs can improve rates of stone passage and reduce expulsion times, presumably by targeting different mechanisms of ureteral pathophysiology.1,2 One prospective randomized trial1 demonstrated that the combination of daily deflazacort (30 mg), nifedipine XL (30 mg), and the gastroprotective agent misoprostol (200 μg twice daily) virtually eliminated the need for an NSAID (15 mg diclofenac per patient) and resulted in 79 percent of patients' passing the stone, as compared with 35 percent of patients in the diclofenac group (P<0.05). However, it is difficult to conclude which of the drugs increased the rate of stone passage.2 No studies have shown that monotherapy with either nifedipine or corticosteroids improves stone expulsion. The study by Borghi et al.3 compared nifedipine with placebo, but a corticosteroid was included in both treatment groups. Corticosteroids modulate inflammation and edema, and misoprostol is a powerful prostaglandin E1 analogue. Their effects cannot be separated clearly from the spasmolytic effects of nifedipine.
Thus, a combination of a corticosteroid and nifedipine XL, with or without misoprostol, and an NSAID for breakthrough pain is reasonable for stone-expulsion therapy.1,2 Another combination, tamsulosin (an alpha-blocker used primarily to treat bladder-outlet obstruction) and deflazacort, similarly improved stone-expulsion rates in a randomized, controlled trial involving patients with juxtavesical ureteral calculi.4 To my knowledge, no study has compared tamsulosin with nifedipine XL for this indication. With respect to safety, in the three studies in which nifedipine and corticosteroids were used, withdrawals due to adverse effects of the drug were most commonly the result of the cardiovascular effects of nifedipine — namely, palpitations and hypotension. I agree with Drs. Miller and Wolf that a reasonable approach to conservative management of ureteral stones might include an NSAID and nifedipine XL, while keeping in mind that all studies that supported this approach included a corticosteroid.
Joel M.H. Teichman, M.D.
University of British Columbia
Vancouver, BC V6Z 1Y6, Canada
References
Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. Urology 2000;56:579-582.
Cooper JT, Stack GM, Cooper TP. Intensive medical management of ureteral calculi. Urology 2000;56:575-578.
Borghi L, Meschi T, Amato F, et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study. J Urol 1994;152:1095-1098.
Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. J Urol 2003;170:2202-2205.
The merits of nifedipine are increasingly recognized by urologic authorities5,6; we believe that evidence-based medical management of ureteral stones should include nifedipine XL at a dosage of 30 mg once daily. Ultimately, its effectiveness will depend on its acceptance and application by the greater medical community.
David C. Miller, M.D.
J.S. Wolf, Jr., M.D.
University of Michigan Medical School
Ann Arbor, MI 48109-0330
wolfs@umich.edu
References
Teichman JMH. Acute renal colic from ureteral calculus. N Engl J Med 2004;350:684-693.
Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. Urology 2000;56:579-582.
Cooper JT, Stack GM, Cooper TP. Intensive medical management of ureteral calculi. Urology 2000;56:575-578.
Borghi L, Meschi T, Amato F, et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study. J Urol 1994;152:1095-1098.
Clayman RV. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. J Urol 2002;167:797-798.
Preminger GM. The value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage. Urology 2000;56:582-583.
Dr. Teichman replies: The conservative management of renal colic need not only address pain but also may enhance spontaneous stone passage. Drs. Miller and Wolf correctly note that combinations of drugs can improve rates of stone passage and reduce expulsion times, presumably by targeting different mechanisms of ureteral pathophysiology.1,2 One prospective randomized trial1 demonstrated that the combination of daily deflazacort (30 mg), nifedipine XL (30 mg), and the gastroprotective agent misoprostol (200 μg twice daily) virtually eliminated the need for an NSAID (15 mg diclofenac per patient) and resulted in 79 percent of patients' passing the stone, as compared with 35 percent of patients in the diclofenac group (P<0.05). However, it is difficult to conclude which of the drugs increased the rate of stone passage.2 No studies have shown that monotherapy with either nifedipine or corticosteroids improves stone expulsion. The study by Borghi et al.3 compared nifedipine with placebo, but a corticosteroid was included in both treatment groups. Corticosteroids modulate inflammation and edema, and misoprostol is a powerful prostaglandin E1 analogue. Their effects cannot be separated clearly from the spasmolytic effects of nifedipine.
Thus, a combination of a corticosteroid and nifedipine XL, with or without misoprostol, and an NSAID for breakthrough pain is reasonable for stone-expulsion therapy.1,2 Another combination, tamsulosin (an alpha-blocker used primarily to treat bladder-outlet obstruction) and deflazacort, similarly improved stone-expulsion rates in a randomized, controlled trial involving patients with juxtavesical ureteral calculi.4 To my knowledge, no study has compared tamsulosin with nifedipine XL for this indication. With respect to safety, in the three studies in which nifedipine and corticosteroids were used, withdrawals due to adverse effects of the drug were most commonly the result of the cardiovascular effects of nifedipine — namely, palpitations and hypotension. I agree with Drs. Miller and Wolf that a reasonable approach to conservative management of ureteral stones might include an NSAID and nifedipine XL, while keeping in mind that all studies that supported this approach included a corticosteroid.
Joel M.H. Teichman, M.D.
University of British Columbia
Vancouver, BC V6Z 1Y6, Canada
References
Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. Urology 2000;56:579-582.
Cooper JT, Stack GM, Cooper TP. Intensive medical management of ureteral calculi. Urology 2000;56:575-578.
Borghi L, Meschi T, Amato F, et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study. J Urol 1994;152:1095-1098.
Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. J Urol 2003;170:2202-2205.