This is a new guideline from NICE on managing renal and ureteric stones, published in Jan 19.
I’ll give a summary of what is new, then do a more detailed summary below.
What is new in this guideline?
- Investigations should be done within 24 hrs of presentation… (I’ll just stop for a little laugh here…). Apparently the cost savings of this come from a reduction in complications down the line.
- NSAIDs should be first-line analgesia, with iv paracetamol coming in at second. Opiates are third line.
- Avoid antispasmodics – they have no benefit over NSAIDs and only iv antispasmodics have been used in the trials. They also have more side-effects.
- Medical expulsive therapy (eg alpha-blockers – tamsulosin). These can be considered for people with distal ureteric stones of less than 10mm. So basically they’ll be used after imaging.
- Surgical treatment (including lithotripsy) should be offered within 48 hrs of diagnosis or readmission if pain is ongoing and not tolerated or if the stone is unlikely to pass by itself.
- Lifestyle advice. There is fairly limited evidence on what lifestyle measures are beneficial, but NICE does advice a few measures.
What imaging should be done?
- CT imaging is first-line. This should be done in adults (other than pregnant ladies).
- USS – for children and pregnant ladies. Consider a CT for young people and children if there is still uncertainty after the USS.
Both of these should be done within 24 hrs of presentation.
What other investigations should be done?
- Consider stone testing in adults.
- Measure calcium levels in adults.
- Consider referring children and young people to a specialist for further assessment and metabolic investigations.
What analgesia should be given?
- NSAIDs are first-line. Any route can be used. Most of the evidence is for iv and im, but it is felt that oral or PR is likely to be as effective. They are as effective as other analgesia andthey reduce the need for other analgesia.
- Paracetamol iv is second line. There haven’t been any studies done on oral paracetamol and it is thought to be less effective than iv.
- Opioids should only be used third line because they are no more effective than NSAIDs or paracetamol.
- Don’t use antispasmodics – they have lots of side-effects and are no more effective than NSAIDs. They have also been used in the iv form in trials.
- Combinations of NSAIDs and oral paracetamol. There wasn’t felt to be enough evidence to recommend this. There is some evidence of benefit, though of limited quality.