GU/Renal & Procedures (October 2016)
Research:
AIR: Procedures
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
4 comments
Review – Did a thorough job of collecting literature studying use of tamsulosin on passage of distal ureteral stone. My own perceptions was that tamsulosin aided in the passage of smaller ureteral stones more in speed than actual passage – this is not supported by literature and in fact the opposite is suggested (>4mm). was also unaware of the duration of therapy (28 days being standard). I think it is clear from the article that the data is not there for proximal and mid ureteral stones and so I think there was some uncertainty regarding the effect of tamsulosin on these patients. Additionally, further information regarding adverse events from side effects of a-blockers should be studied.
OR article –
Strength – randomized, blinded
Limitations – did not monitor adherence to medication which in the setting of a negative outcome, could be important
Outcome – participants not needing further intervention after 4 weeks
Change practice – Yes, important to really weigh consequences of medical intervention given unclear benefits, especially in a possibly elder, comorbid population on many different medications. #shareddecisionmaking
Great point Drew!
The Lancet study is very methodologically strong. AND it included stones of all locations.
While the Wang Systematic Review and Metanalysis included the Lancet study, the 7 remaining trials in it only included distal stones. Not to mention the quality of those other studies were noted to be low or moderate. Remember that a metanalysis or systematic review of multiple inadequate studies doesn’t really make the results any stronger.
Considering we don’t really pay too much attention to exactly location of stones in the ED, I personally think the overall benefit for tamsulosin for ANY patient with kidney stone is close to 0. But can big stones > 5mm in the distal ureter benefit from Tamsulosin? Maybe.
Shared decision making is best in these cases, taking into account comorbidities, med side effects and interactions, like Drew said.
Pickard et al.
1. Crème de la crème – multi-centered, randomized, placebo-controlled, and appropriately powered. I like that they put the previous meta-analyses into context
2. Adherence to medication was not verified which could lead to bias. Incomplete collection of several secondary outcome measurements – pain control, stone passage, health status, etc.
3. Flomax and nifedipine are not effective at decreasing need for further tx to achieve stone clearance in 4 weeks for pts with ureteric colic. “No evidence that drugs reduced pain, hastened time to stone passage, or improved health state.”
4. I will listen to Ron Medzon and NOT prescribe Flomax.
Wang et al.
1. Nope – no change in practice here. I might consider Flomax in patients with LARGE stones in the DISTAL ureter as the meta-analysis suggests but on the whole, I’m still going to hold on the Flomax (are we really going to CT everyone stone to get that data point?). I will say however that I appreciate the authors applying a bit more rigor to the prior analyses (ie, Cochrane) by only including randomized, double-blinded, placebo studies. But on the whole, the Lancet study is so well done that I’m not sure how much the other 6 studies are adding to the debate.
2. Nothing debunked but there might be some evidence for Flomax in very, very specific cases.
3. See previous answer.
4. Research: Further studies looking at tx regimens. The studies included in the analysis used the same dosing and length of tx (except one which did 21 days). What if these were altered? Would they change outcomes?