{"id":1200,"date":"2016-12-07T20:00:07","date_gmt":"2016-12-07T20:00:07","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1200"},"modified":"2017-08-21T10:34:06","modified_gmt":"2017-08-21T10:34:06","slug":"primary-care-corner-with-geoffrey-modest-md-alpha-blockers-help-with-ureteral-stone-passage","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/12\/07\/primary-care-corner-with-geoffrey-modest-md-alpha-blockers-help-with-ureteral-stone-passage\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: alpha blockers help with ureteral stone passage"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A recent meta-analysis\/systematic review confirmed that a-blockers are efficacious in the treatment of patients with ureteral stones\u00a0(see\u00a0doi.org\/10.1136\/bmj.i6112 ).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>55 unique\u00a0RCTs, with 5990 randomized patients, mostly in European and Asian subjects. Mean stone size 5.7 mm, tamsulosin was the\u00a0a-blocker in 40 studies, mean follow-up of 28 days<\/li>\n<li>Primary outcome: proportion of patients\u00a0who passed their stone<\/li>\n<li>Secondary outcomes: time to passage of stone, number of pain episodes, and proportion of patients who had surgery\/were admitted to hospital\/experienced adverse events<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>a-blockers\u00a0facilitated the passage of stone, with risk ratio (RR)=1.49 (1.39-1.61), a 49% higher likelihood\u00a0of stone passage (moderate qualityevidence)\n<ul>\n<li>The pooled risk difference was 0.27, meaning that 4 patients needed treatment for 1 to get benefit<\/li>\n<li>The pooled % for stone passage was\u00a075.8% in the\u00a0a-blocker group vs 48.4% in the control group. this was basically independent of the type of\u00a0a-blocker used or if imaging was done to assess stone passage<\/li>\n<\/ul>\n<\/li>\n<li>Subgroup analysis\n<ul>\n<li>No benefit for\u00a0those with small stones, RR=1.19 (1.00-1.48), though\u00a0on the cusp of being\u00a0significant\n<ul>\n<li>Review of their figure of stone size:\n<ul>\n<li>Small\u00a0trend to benefit if &lt;5mm, increasing trend if &lt;6mm<\/li>\n<li>Reasonably clear benefit if &gt;6mm, and esp if &gt;8mm<\/li>\n<\/ul>\n<\/li>\n<li>In those with larger stones,\u00a0RR=1.57\u00a0(1.39-1.61), a 57% higher likelihood\u00a0of stone passage<\/li>\n<li>No difference based on where the stone was located (upper or middle ureteral\u00a0stones)<\/li>\n<\/ul>\n<\/li>\n<li>Secondary analyses, benefit of\u00a0a-blocker:\n<ul>\n<li>Shorter time to stone passage, mean decrease of\u00a03.79 days (3.14 to\u00a04.45 days),\u00a0moderate\u00a0quality evidence<\/li>\n<li>Fewer episodes of pain, mean decrease of 0.74 (0.21 to 1.28), low quality\u00a0evidence<\/li>\n<li>Lower risk of surgical intervention, RR 0.44 (0.37-0.52),\u00a0moderate quality\u00a0evidence<\/li>\n<li>Lower risk of hospital admission, RR 0.37 (0.22-0.64),\u00a0moderate quality\u00a0evidence<\/li>\n<li>Similar risk of adverse events, low\u00a0quality\u00a0evidence<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>This meta-analysis\/systematic review follows on the tail of a recent RCT (see Pickard R. Lancet 2015; 386: 341),\u00a0finding that neither tamsulsin4 mg nor nifedipine 30mg decreased the need for further intervention for stone clearance within 4 weeks of randomization. I am often concerned that we all tend to give disproportionate weight to the newest study. In fact this Pickard study, though a large one with 1136 patients, had 75% of them with stone size &lt;5mm (which pass pretty easily on their own, and the above meta-analysis did not find much benefit to the a-blocker), and though the remaining 25% were &gt;5mm, they do not indicate whether this was mostly 5.5mm or 9.8mm. And, likely because of the small size of the stones overall, 80% of the patients did not need any further urologic intervention in the ensuing month in either the intervention or control groups.<\/li>\n<li>I should also reiterate the caveat that meta-analyses and systematic reviews are not the be-all and end-all, but are fraught with their own limitations, and are not considered very high on the evidence-based medicine hierarchy (and not even included in the pyramid of the most thoughtful pyramids, to my thinking. See <a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/11\/21\/primary-care-with-geoffrey-modest-md-lessons-ive-learned-from-looking-at-the-medical-literature\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/11\/21\/primary-care-with-geoffrey-modest-md-lessons-ive-learned-from-looking-at-the-medical-literature\/<\/a> )<\/li>\n<\/ul>\n<p>So, bottom line is that this review does support the use of a-blockers in those with ureteral stones, especially if &gt;5-6mm in size. There are also studies showing that calcium-channel blockers help (most studied being nifedipine), and the data are mixed as to whether the\u00a0a-blockers or\u00a0calcium channel blockers are better.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: alpha blockers help with ureteral stone passage [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/12\/07\/primary-care-corner-with-geoffrey-modest-md-alpha-blockers-help-with-ureteral-stone-passage\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1200","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1200","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1200"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1200\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1200"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1200"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1200"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}