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Featuring: Use of medical expulsive therapy in children
Journal of Pediatric Urology (2017) 13, 418e419
Pediatric Urology Journal Club
Featuring: Use of medical expulsive therapy in children* In June the Pediatric Urology Journal Club focused on use of medical expulsive therapy (MET) in pediatric patients by way of an article assessing recent nationwide practice patterns and outcomes [1]. Author Jonathan Ellison (@jon_ellison) led the discussion. Among the MarketScan database, Ellison and colleagues found MET utilization in children with ureteral calculi was overall low (30.4% in final year). MET was not associated with a difference in unplanned physician visits or surgical interventions. Regardless of MET utilization, appropriate follow-up imaging for children with ureteral stones was only 46%. Debate about MET in children comes after 4 large randomized control trials (RCT) showed no effect of tamsulosin on the passage of ureteral stones in adults. Some consider a yet unpublished fifth trial (“STONE”), presented as a latebreaking abstract at the American Urological Association 2017 Annual Meeting in Boston [2], to be the final nail in MET’s coffin (1).
Should adult MET data be extrapolated to children? (2) Ellison suggests the best application for adult MET evidence is pediatric patients who are post-pubertal and physiologically adults (3). Conversely, RCTs from the pediatric literature have shown a weak benefit in favor of MET (4e6). This may be because spontaneous passage rates in pediatric patients are lower overall (7). *
Among participants there was concern about using tamsulosin off-label (8), particularly in patients without close follow-up (9,10). Off-label drug usage is common in pediatrics (11,12), which may explain why more pediatric-oriented practitioners consider tamsulosin in children. Overall, off-label use of tamsulosin in the absence of strong pediatric-specific evidence (and negative effect shown in adults) may warrant parental discussion before prescription of this drug. In summary, Ellison et al.’s study presents hypothesis-generating data and calls for high-quality outcomes and follow-up data in children (13,14). A survey open to all Twitter users at the end of the discussion suggests most would still consider MET for a mid-sized, mid-ureteral stone in a young teenager (15).
Conflicts of interest All authors report no conflicts of interest.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j. jpurol.2017.09.004.
Selected tweets from the discussion are featured in parentheses according to the Supplementary Table.
http://dx.doi.org/10.1016/j.jpurol.2017.09.004 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Pediatric Urology Journal Club
References [1] Ellison JS, Merguerian PA, Fu BC, Holt SK, Lendvay TS, Gore JL, et al. Use of medical expulsive therapy in children: an assessment of nationwide practice patterns and outcomes. J Pediatr Urol 2017. http://dx.doi.org/10.1016/j.jpurol.2017.03.022. [2] Meltzer AC, Hollander JE, Wolfson AB, Kurz MC, Jackman SV, Kirkali Z, et al. PNFLBA-04 Randomized clinical trial of treatment with tamsulosin begun in the emergency department to promote passage of urinary stones. J Urol 2017;197:e604. supplement.
Christopher E. Bayne* Division of Pediatric Urology, Children’s National Health System, Washington, DC, USA
419 Diana Cardona-Grau Division of Urology, University of California at San Diego, San Diego, CA, USA Rady Children’s Hospital, San Diego, CA, USA Michael H. Hsieh Division of Pediatric Urology, Children’s National Health System, Washington, DC, USA *Correspondence to: Christopher E. Bayne, Division of Pediatric Urology, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010, USA. Tel.: þ1 202 476 5042 (office); fax: þ1 202 476 4739 E-mail address: [email protected] (C.E. Bayne) 3 July 2017
Pediatric Urology Journal Club
Featuring: Use of medical expulsive therapy in children* In June the Pediatric Urology Journal Club focused on use of medical expulsive therapy (MET) in pediatric patients by way of an article assessing recent nationwide practice patterns and outcomes [1]. Author Jonathan Ellison (@jon_ellison) led the discussion. Among the MarketScan database, Ellison and colleagues found MET utilization in children with ureteral calculi was overall low (30.4% in final year). MET was not associated with a difference in unplanned physician visits or surgical interventions. Regardless of MET utilization, appropriate follow-up imaging for children with ureteral stones was only 46%. Debate about MET in children comes after 4 large randomized control trials (RCT) showed no effect of tamsulosin on the passage of ureteral stones in adults. Some consider a yet unpublished fifth trial (“STONE”), presented as a latebreaking abstract at the American Urological Association 2017 Annual Meeting in Boston [2], to be the final nail in MET’s coffin (1).
Should adult MET data be extrapolated to children? (2) Ellison suggests the best application for adult MET evidence is pediatric patients who are post-pubertal and physiologically adults (3). Conversely, RCTs from the pediatric literature have shown a weak benefit in favor of MET (4e6). This may be because spontaneous passage rates in pediatric patients are lower overall (7). *
Among participants there was concern about using tamsulosin off-label (8), particularly in patients without close follow-up (9,10). Off-label drug usage is common in pediatrics (11,12), which may explain why more pediatric-oriented practitioners consider tamsulosin in children. Overall, off-label use of tamsulosin in the absence of strong pediatric-specific evidence (and negative effect shown in adults) may warrant parental discussion before prescription of this drug. In summary, Ellison et al.’s study presents hypothesis-generating data and calls for high-quality outcomes and follow-up data in children (13,14). A survey open to all Twitter users at the end of the discussion suggests most would still consider MET for a mid-sized, mid-ureteral stone in a young teenager (15).
Conflicts of interest All authors report no conflicts of interest.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j. jpurol.2017.09.004.
Selected tweets from the discussion are featured in parentheses according to the Supplementary Table.
http://dx.doi.org/10.1016/j.jpurol.2017.09.004 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Pediatric Urology Journal Club
References [1] Ellison JS, Merguerian PA, Fu BC, Holt SK, Lendvay TS, Gore JL, et al. Use of medical expulsive therapy in children: an assessment of nationwide practice patterns and outcomes. J Pediatr Urol 2017. http://dx.doi.org/10.1016/j.jpurol.2017.03.022. [2] Meltzer AC, Hollander JE, Wolfson AB, Kurz MC, Jackman SV, Kirkali Z, et al. PNFLBA-04 Randomized clinical trial of treatment with tamsulosin begun in the emergency department to promote passage of urinary stones. J Urol 2017;197:e604. supplement.
Christopher E. Bayne* Division of Pediatric Urology, Children’s National Health System, Washington, DC, USA
419 Diana Cardona-Grau Division of Urology, University of California at San Diego, San Diego, CA, USA Rady Children’s Hospital, San Diego, CA, USA Michael H. Hsieh Division of Pediatric Urology, Children’s National Health System, Washington, DC, USA *Correspondence to: Christopher E. Bayne, Division of Pediatric Urology, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010, USA. Tel.: þ1 202 476 5042 (office); fax: þ1 202 476 4739 E-mail address: [email protected] (C.E. Bayne) 3 July 2017