Do you prescribe MET for stone patients?

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: Do you prescribe MET for stone patients?

“Yes, because anecdotally medical expulsive therapy works. Actually, some studies show it works a little bit. It’s one of those things-it can’t hurt. I’ve seen people pass stones that no human being should be able to pass. I can’t attribute it 100% to MET, it could just be their anatomy, but I’ve seen it.

If the patient has gone to the emergency room on Tuesday and shows up at your office on Thursday, you don’t know where the stone is for sure, whether it’s mid or proximal. So if I don’t have an immediate film, I give them the medication on the benefit of the doubt that the stone is hopefully distal. You may be told that it’s proximal, but 3 days later, maybe it is a distal stone.

More Speak Out: How do you approach giving bad news to patients?

The only real [alpha-blocker] side effect to worry about is orthostasis. If they’re dehydrated, they may get a little orthostatic, but generally part of the treatment to try to pass a stone is hydration, so that almost eliminates that as a problem by just making sure they’re hydrated. The other side effect is that it tends to lower blood pressure or cause retrograde ejaculation. But temporarily, who cares?”

Todd Cohen, MD

Gastonia, NC

Next: “The answer to that is yes-although I’m not particularly convinced it works that well."

“The answer to that is yes-although I’m not particularly convinced it works that well. We’re in this flux point where maybe we don’t think it works that well, but I still use it. To be honest, the most common reason I use it is because patients read about it, and if I’m treating a stone, they would have been given Flomax by the ER they went to originally. A lot of times, I’m just continuing what they’ve heard, or have had initiated by the ER, because they’re convinced by the ER that it works.

In the original literature, one study suggested that the likelihood of stone passage increased by something like 30%. It’s my impression there’s been conflicting data lately. Certainly when the one paper in the ER literature suggested it worked, using Flomax became almost standard. I think almost every ER uses it now because it’s in their literature so much.

Also read: How will the ProtecT study affect your care of PCa patients?

In our literature, it’s not so clear. That’s why sometimes I just really continue their therapy. When you’re giving patients a week or two to try to pass stones, if someone’s already convinced them that it’s the Flomax that’s going to help them pass them, they may not be convinced that it’s time to have a procedure, even if the urologist is. If you haven’t given them the Flomax or if you take them off the Flomax and the stone doesn’t pass, they’ll say’ ‘it’s because you didn’t give me the Flomax.’ A lot of times if they’re passing a stone and it looks like they might be able to pass it, we’ll give them a few weeks. You really look for it to be obvious that they passed it, or they need a procedure. If you don’t give them that, they look it up on the Internet or remember what was said in the ER, and they may not be convinced that they really need the procedure when they really do.

I know there’s conflicting data, but it’s not particularly harmful to give them the medicine. So in some ways, it’s more effort than it needs to be to convince patients they don’t need it.”

Jason Engel, MD  

Washington

Next: “In patients who are not really ill, I think it does have some efficacy"

“In patients who are not really ill, I think it does have some efficacy, which buys you more time before you can get them on surgical schedule. I also think starting a patient on Flomax, specifically, or the anti-inflammatory agents also helps to facilitate a ureteroscopy if you are going to do that first. Even if it doesn’t cause expulsion of the stone, it also helps to facilitate the ureteroscopy. Being on the two medications prior to the ureteroscopy and stents also help with stent pain. Stent pain is the real deal and most patients who are going to have a ureteroscopy for a stone which has failed expulsion therapy are going to get a stent. It doesn’t necessarily make the ureteroscopy any less challenging, but it will help post-ureteroscopy with stent pain.”

Chad Wotkowicz, MD       

Portsmouth, NH

More from Urology Times:

Medical expulsive therapy or bust?

Prior authorization: Caught in an administrative nightmare

Value-based pay in 2017: Where does urology fit?