FPIN's Help Desk Answers
Alpha Blockers for Nephrolithiasis
Am Fam Physician. 2019 Dec 1;100(11):710-712.
How effectively do alpha blockers increase ureteral stone passage?
The alpha blocker tamsulosin (Flomax) can be used to improve clearance of stones larger than 5 mm, shorten expulsion times, and reduce hospitalization. (Strength of Recommendation: B, based on meta-analyses of moderate-quality randomized controlled trials.) Alfuzosin (Uroxatral), doxazosin (Cardura), and silodosin (Rapaflo) are also effective but have significantly more adverse effects.
A 2018 Cochrane review compared alpha blockers with placebo or standard therapy for urinary stone expulsion.1 The five highest-quality placebo-controlled studies with the lowest risk of bias found a benefit. A subgroup analysis of 15 moderate-quality randomized controlled trials identified significant differences based on stone size. When all of the alpha blocker vs. placebo studies were included (seven studies; N = 3,240), there were fewer days to stone clearance when alpha blockers were used (mean difference [MD] = −1.98 days; 95% CI, −3.71 to −0.24). When individual studies reported results for stones 6 to 10 mm, the decreased time to clearance was even better (four studies; n = 1,884; MD = −5.99 days; 95% CI, −7.16 to −4.82). Improvement in time to stone clearance was not statistically significant when the three highest-quality studies (n = 2,891) were included (MD = −1.72; 95% CI, −5.13 to 1.68). Moderate-quality evidence showed fewer hospitalizations in patients who were treated with alpha blockers (13 studies; n = 1,876; relative risk [RR] = 0.51; 95% CI, 0.34 to 0.77). However, there was some risk of bias, and limiting the analysis to the highest-quality studies found no statistical difference (one study; n = 403; RR = 0.87; 95% CI, 0.49 to 1.52). There was no subgroup analysis of hospitalization rate based on stone size.
The studies that evaluated tamsulosin did not find any increase in adverse effects (13 studies; n = 2,062; RR = 1.24; 95% CI, 0.62 to 2.47). Three other alpha
1. Campschroer T, Zhu X, Vernooij RW, et al. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev. 2018;(4):CD008509.
2. Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of tamsulosin on passage of symptomatic ureteral stones: a randomized clinical trial. JAMA Intern Med. 2018;178(8):1051–1057.
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