Pharmacological management of renal colic in the older patient

Renal colic affects up to 12% of the population. Initial management of most patients is expectant. Acute symptom management of renal colic is best accomplished with a combination of parenteral opioids and NSAIDs. The elderly patient with a kidney stone should be screened for contraindications to NSAID therapy, such as renal failure or previous peptic ulcer disease. Use of parenteral opioids is often necessary during the acute setting, and downward-adjusted doses and monitoring are necessary to prevent associated confusion and respiratory depression. Novel therapy with desmopressin may also be effective for symptom control at the initial presentation, without the adverse effects of opioids or NSAIDs. However, use of desmopressin in the elderly must be undertaken cautiously, given the potential adverse effects of this agent. Many small, distal ureteral stones are treated initially with watchful waiting for the first 2-4 weeks after presentation. The patient should have effective, non-parenteral analgesics for use at home. Included in these agents are oral or suppository NSAIDs and oral opioids. Medical expulsion therapy with alpha-adrenoceptor antagonists or calcium channel antagonists is efficacious. alpha-Adrenoceptor antagonists such as the alpha(1A/)(1)(D)-selective tamsulosin are well tolerated in the elderly and increase the rate of spontaneous stone passage by approximately 50% for small distal stones. These agents also appear to decrease the severity of renal colic. Corticosteroids and calcium channel antagonists are also effective but their use in the elderly is not recommended as first-line therapy.