title: Medical Expulsive Therapy is Underused for the Management of Renal Colic in the Emergency Setting.
abstract: OBJECTIVE
  Although the 2007 AUA (American Urological Association) guidelines established it as first line therapy for ureteral stones less than 10 mm, widespread adoption of medical expulsive therapy has been low. We determined the current penetrance of medical expulsive therapy guideline recommendations and the efficacy of medical expulsive therapy in reducing the requirement for urological procedures after emergency department visits for ureteral stones.
  
  
  METHODS
  In a retrospective analysis of patients seen in the emergency department we included 2,105 emergency department visits associated with an ICD-9 diagnosis of urolithiasis in which computerized tomography abdomen/pelvis scan was performed. Outcomes were reviewed for spontaneous passage or required urological procedure.
  
  
  RESULTS
  Ureteral stones were found in 48.8% of patients, including 50.0% in whom medical expulsive therapy was prescribed. There was no significant difference between patients who did and did not receive medical expulsive therapy. Within 12 weeks of the initial emergency department visit there was no difference in the rate of urological procedures performed in those who received medical expulsive therapy or in the rate of return to the emergency department. Patients treated with medical expulsive therapy experienced a shorter time to spontaneous expulsion (7.1 vs 12.8 days, p = 0.048).
  
  
  CONCLUSIONS
  Medical expulsive therapy for renal colic in the emergency setting remains underused. Half of the patients who met criteria for medical expulsive therapy in this study did not receive the standard of care. Patients treated with medical expulsive therapy achieved spontaneous passage more quickly but there was no difference in the requirement for a urological procedure. These results highlight the need for personnel at emergency departments to better standardize care for patients with ureteral stones.
authors.affiliation: Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio. Electronic address: oftusc@ccf.org.
authors.forename: Christopher
authors.initials: C
authors.lastname: Loftus
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Yaw
authors.initials: Y
authors.lastname: Nyame
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bryan
authors.initials: B
authors.lastname: Hinck
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Daniel
authors.initials: D
authors.lastname: Greene
authors.affiliation: Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Hemant
authors.initials: H
authors.lastname: Chaparala
authors.affiliation: Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Kareem
authors.initials: K
authors.lastname: Alazem
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Manoj
authors.initials: M
authors.lastname: Monga
mesh_terms: D004638:Emergency Treatment; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D056844:Renal Colic / Q000209:etiology / Q000628:therapy*; D012189:Retrospective Studies; D014514:Ureteral Calculi / Q000150:complications / Q000628:therapy*
keywords: emergency service, hospital; kidney; standard of care; ureter; urolithiasis