Alpha-blockers for treatment of ureteral stones
Evidence Summaries Level of Evidence = A
The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion compared with usual care.
Alpha-blockers are recommended as first-line treatment for patients presenting with urinary stones who are amenable to conservative treatment. A Cochrane review 1 included 32 studies with a total of 5864 subjects. The studied alphablockers were tamsulosin (0.4 mg), alfuzosin (10 mg), doxazosin (4 mg) and terazosin (2 or 5 mg). Most studies compared a standard therapy group to an alpha-blocker group. Standard therapy consisted of appropriate hydration and the use of various sorts and dosages of painkillers. The stone-free rates were significantly higher in the alpha-blocker group (RR 1.48, 95% CI 1.33 to 1.64) when compared to standard therapy. Stone expulsion time was 2.91 days shorter with the use of alpha-blockers (MD -2.91, 95% CI -4.00 to -1.81). Use of alpha-blockers reduced the number of pain episodes (MD -0.48, 95% CI -0.94 to -0.01), the need for analgesic medication (diclofenac) (MD -38.17 mg, 95% CI -74.93 to -1.41) and hospitalisation (RR 0.35, 95% CI 0.13 to 0.97). Patients using alpha-blockers were more likely to experience adverse effects when compared to standard therapy (RR 2.74, 95% CI 1.38 to 5.45) or placebo (RR 2.73, 95% CI 1.50 to 4.96). Most adverse effects were mild of origin and did not lead to cessation of therapy, and several studies reported no adverse events in either the treatment or control group.
A systematic review 2 included 55 randomized controlled trials. The percentage of women varied from 0% to 59.6%. There was moderate quality evidence that alpha blockers facilitate passage of ureteric stones (RR 1.49, 95% Cl 1.39 to 1.61). Based on a priori subgroup analysis, there seemed to be no benefit to treatment with alpha blocker among patients with smaller ureteric stones (1.19, 1.00 to 1.48). Patients with larger stones treated with an alpha blocker, however, had a 57% higher chance of stone passage compared with controls (1.57, 1.17 to 2.27). The effect of alpha blockers was independent of stone location (1.48 [1.05 to 2.10] for upper or middle stones; 1.49 [1.38 to 1.63] for lower stones). Compared with controls, patients who received alpha blockers had significantly shorter times to stone passage (MD -3.79 days, -4.45 to -3.14;), fewer episodes of pain (-0.74 episodes, -1.28 to -0.21), lower risks of surgical intervention (risk ratio 0.44, 0.37 to 0.52), and lower risks of admission to hospital (0.37, 0.22 to 0.64). The risk of a serious adverse event was similar between treatment and control groups (1.49, 0.24 to 9.35).
1. Campschroer T, Zhu Y, Duijvesz D et al. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev 2014;(4):CD008509. [PMID:24691989]
2. Hollingsworth JM, Canales BK, Rogers MA et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ 2016;355():i6112. [PMID:27908918]
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