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Tamsulosin not effective in promoting stone expulsion in symptomatic patients
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: Does tamsulosin provide benefit in ureteral stone expulsion for patients who present with a symptomatic stone less than 9 mm?
Background: Treatment of urinary stone disease often includes the use of alpha-blockers such as tamsulosin to promote stone passage, and between 15% and 55% of patients presenting to EDs for renal colic are prescribed alpha-blockers. Current treatment guidelines support the use of tamsulosin, with recent evidence suggesting that this treatment is more effective for larger stones (5-10 mm). However, other prospective trials have called these guidelines into question.
Study design: Double-blind, placebo-controlled study.
Setting: Six emergency departments at U.S. tertiary-care hospitals.
Synopsis: 512 participants with symptomatic ureteral stones were randomized to either tamsulosin or placebo. At the end of a 28-day treatment period, the rate of urinary stone passage was 49.6% in the tamsulosin group vs. 47.3% in the placebo group (95.8% confidence interval, 0.87-1.27; P = .60). The time to stone passage also was not different between treatment groups (P = .92). A second phase of the trial also evaluated stone passage by CT scan at 28 days, with stone passage rates of 83.6% in the tamsulosin group and 77.6% in the placebo group (95% CI, 0.95-1.22; P = .24). This study is the largest of its kind in the United States, with findings similar to those of two recent international multisite trials, increasing the evidence that tamsulosin is not beneficial for larger stone passage.
Bottom line: For patients presenting to the ED for renal colic from ureteral stones smaller than 9 mm, tamsulosin does not appear to promote stone passage.
Citation: Meltzer AC et al. Effect of tamsulosin on passage of symptomatic ureteral stones: A randomized clinical trial. JAMA Intern Med. 2018;178(8):1051-7. Published online June 18, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Mortality risk remains high for survivors of opioid overdose
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.
Clinical question: What are the causes and risks of mortality in the first year after nonfatal opioid overdose?
Background: The current opioid epidemic has led to increasing hospitalizations and ED presentations for nonfatal opioid overdose. Despite this, little is known about the subsequent causes of mortality in these patients. Additional information could suggest potential interventions to decrease subsequent risk of death.
Study design: Retrospective cohort study.
Setting: U.S. national cohort of Medicaid beneficiaries, aged 18-64 years, during 2001-2007.
Synopsis: This cohort included 76,325 adults with nonfatal opioid overdose with 66,736 person-years of follow-up. In the first year after overdose, there were 5,194 deaths, and the crude death rate was 778.3 per 10,000 person-years. Compared with a demographically matched general population, the standardized mortality rate ratios (SMRs) for this cohort were 24.2 times higher for all-cause mortality and 132.1 times higher for drug use–associated disease. The SMRs also were elevated for conditions including HIV (45.9), chronic respiratory disease (41.1), viral hepatitis (30.6), and suicide (25.9). Though limited to billing data from Medicaid beneficiaries during 2001-2007, this study is important in identifying a relatively young population at high risk of preventable death and suggests that additional resources and interventions may be important in this population.
Bottom line: Adults surviving opioid overdose remain at high risk of death over the following year and may benefit from multidisciplinary interventions targeted at coordinating medical care and treatment of mental health and substance use disorders following hospitalization and emergency department presentations.
Citation: Olfson M et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-7. Published online June 20, 2018.
Dr. Breviu is assistant professor of medicine and an academic hospitalist, University of Utah, Salt Lake City.