Practice Change: I will no longer prescribe Flomax for kidney stones. Medically expulsive therapy of stones appears ineffective. Our urologists seem to like these medications, and I think we should have a discussion with them about their use.
Tamsulosin (Flomax) and Nifedipine have had two metaanalyses which have showed mild benefit, but there has been a LOT of criticism of the articles that they chose to include for likely bias, small sample size, lack of blinding, etc. Both analyses ended with the typical “further research is needed…” Well, here it is…
Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial
— Lancet in May 2015
Design: Double Blind Randomized Placebo Controlled Trial done in UK
Patients: 1163 pts in UK with CT proven kidney stones
Randomized to Tamsulosin 0.4mg/day (T), Nifedipine 30mg/day (N), or Placebo (P)
Randomized based on: size of stone (<5mm or >/=5mm), Position (Upper, Mid, Lower) Ureter
Primary Outcome: Did patients require a urologic procedure within 28 days?
Secondary Outcome: Differences in time to stone passage, days of pain?
|Required Urologic Procedure?||20%||19%||20%|
|Days of Pain Medication?||10.5 d||11.6 d||10.7 d|
|Days to Stone Passage?||15.9 d||16.5 d||16.2 d|
#In an extensive subgroup analysis there was a slight TREND towards benefit in passage in distal ureter stones for Tamsulosin, but conversely it made passage WORSE in mid and proximal ureteral stones. All of the CIs crossed 1, so there were no significant differences.#
Conclusion: Medically expulsive therapy of stones does not decrease the need for urologic intervention, the amount of pain patients experience, or the time to stone passage. Subgroup analysis DID show that there is possibly a place for Flomax in very specific stones, but as this was a secondary subgroup non-significant TREND, — it would have to be shown in another trial before use could become recommended.