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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
[Ureteral Calculi/ or renal colic.mp or Kidney Calculi] AND [calcium channel blockers.mp. or Calcium Channel Blockers]
Limit to human and English

Search Outcome

12 papers were found of which 5 were relevant
Search of references revealed another 2 papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Singh, Harrison, Littlepage 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
Hollingsworth, Rogers 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
Davenport, Timoney 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?
Dellabella, Milanese 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
Porpiglia, Destefanis, Fiori 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
Cooper, Stack, Cooper 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
Porpiglia, Ghignone, Fiori, Fontana, Scarpa 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

Comment(s)

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.

Clinical Bottom Line

Calcium channel blockers enhance stone passage over days rather than hours, therefore are not a definitive Emergency Department treatment

References

1. Singh A. Alter HJ. Littlepage A A systematic review of medical therapy to facilitate passage of ureteral calculi Annals of Emergency Medicine 50(5):552-63, 2007 Nov
2. Hollingsworth JM, Rogers MAM, Kaufman SR Medical therapy to facilitate urinary stone passage: a meta-analysis Lancet 368: 1171-79
3. 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 BJU International 98(3):651-5, 2006 Sep
4. Dellabella M. Milanese G. Randomised trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi Journal of Urology 174(1):167-72, 2005 Jul
5. Porpiglia F. Destefanis P. Fiori C. Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones Urology 56(4):579-82, 2000 Oct 1
6. Cooper JT. Stack GM. Cooper TP Intensive medical management of ureteral calculi Urology 56(4):575-8, 2000 Oct 1
7. Porpiglia F. Ghignone G. Fiori C. Nifedipine versus tamsulosin for the management of lower ureteral stones Journal of Urology Vol. 172, 568-571, Aug 2004