Urinary stone disease (USD) leads to pain, diminished quality of life, missed work and
school, chronic kidney disease, and renal failure.1-5 The prevalence of kidney stone
disease in adults has risen to almost 9% as of 2010 in the United States (US). The 5-year
recurrence rate without treatment is 53%.6,7 Increasing utilization of a ureteroscopic
approach to treat urolithiasis has led to an increased proportion of stone patients
undergoing ureteral stent placement.
In the US, approximately 90% of patients receive a ureteral stent following ureteroscopy.
Some patients that undergo ureteral stent placement experience significant and
debilitating symptoms of urinary urgency, frequency, suprapubic and flank pain, and
incontinence. Treatment of these symptoms has historically relied heavily on opioid pain
medications. However, recent emphasis on risk associated with opioid medications has
reduced their use, and paved the way for alternative approaches. As such, non-steroidal
anti-inflammatory drugs (NSAIDs) have become an integral part of multimodal techniques at
mitigating post operative pain and associated ureter stent discomfort.
Ketorolac, an NSAID, can be used in the management of acute pain related to ureteral
obstruction, renal colic, and indwelling ureter stent. There are four available
formulations of ketorolac: oral, intra-muscular (IM), intra-nasal (IN), and intravenous
(IV). Non-oral formulations are known to have faster onset of action and an earlier peak
analgesic effect.8 As opposed to injectable (IM or IV) ketorolac that needs to be
administered by a clinical provider, IN ketorolac may conveniently be self-administered.9
Furthermore, the favorable pharmacokinetics of IN ketorolac allow for its significant
efficacy in providing timely pain relief without the need of opioid medications. However,
one of the significant barriers of intra-nasal ketorolac is the cost. An intra-nasal
course can cause upwards of $1500 compared to $20 of oral ketorolac.
Ketorolac prevents unplanned renal colic-related clinical encounters post stent
removal.10 Study team recently published the study team's results from a randomized trial
comparing intramuscular injection of ketorolac to placebo at the time ureteral stent
removal reduced the incidence of unplanned clinic returns or emergency room visits. While
this trial was aimed at the small number of patients that develop severe ureteral colic
following stent removal, investigators feel ketorolac's strong anti-inflammatory
properties can be leveraged to mitigate acute indwelling ureteral stent symptoms.
While it is not feasible to treat every stent patient empirically with IN ketorolac,
there may be an identifiable subset of patients that may benefit from this formulation.
Its favorable pharmacokinetics allow for its significant efficacy in providing timely
pain relief without the need of opioid medications. This makes IN ketorolac an intriguing
option that may decrease unplanned clinical encounters related to indwelling ureter stent
discomfort. Especially when the cost of a post-operative emergency room visits which can
include laboratory testing, computed tomography, IV medication and possible admission can
dwarf the cost of IN ketorolac.
Furthermore, a recent qualitative analysis published by Harper et al in the in the STudy
to Enhance uNderstanding of sTent-associated Symptoms (STENTS) study reveal a highly
variable patient experience with stents.11 For some, the negative experience of the stent
can be life altering. Therefore, there is a critical need to improve the pain and quality
of life of those requiring ureteral stenting. Ideally, this can be done in a directed way
to offer more relief to those patients most at risk for severe symptoms.