Table 2.
Pharmacologic treatments by stone type.
| Medication | Rationale | Dose | Specifics/side effects | Monitoring |
|---|---|---|---|---|
| Calcium oxalate stones | ||||
| Thiazide | Hypercalciuria | Hydrochlorothiazide 25–50 mg BID, chlorthalidone 25–50 mg/day, indapamide 1.25–5 mg/day | Hypokalemia, hyperlipidemia, hyperuricemia, hyperglycemia, hypocitraturia, hyperuricosuria, fatigue, erectile dysfunction | BMP, uric acid, lipid profile |
| Potassium citrate (oral) | Hypocitraturia, low urine pH | 10–30 mEq BID | GI side effects | Serum creatinine & potassium |
| Potassium citrate (liquid) | Enteric hyperoxaluria, chronic diarrhea | 15–30 mEq TID–QID (titrate to reduce oxalate) | GI side effects, take with two largest meals | Serum creatinine & potassium |
| Allopurinol | Hyperuricosuria | 100–300 mg/day | Hypertransaminasemia, Stevens–Johnson syndrome | Liver enzymes |
| Uric acid stones | ||||
| Potassium citrate (oral)a | Alkalinization | 10–30 mEq BID (titrate dose to pH 6–6.5) | GI side effects | Serum creatinine & potassium |
| Sodium bicarbonate | Alkalinization | 650 mg BID–QID | Increased sodium load may increase risk of calcium stones | BMP |
| Allopurinol | Hyperuricosuria 2nd line therapy when alkalinization not successful | 100–300 mg/day | Hypertransaminasemia, Stevens–Johnson syndrome | Liver enzymes |
| Cystine stones | ||||
| Tiopronin (α-MPG) | Increase cystine solubility | Initial 400 mg/day titrate to effect | Hematologic effects, tachyphylaxis, proteinuria, nausea, diarrhea, vitamin B6 deficiency (long-term use) | CBC, BMP, urine protein |
| Potassium citrate (oral) | Alkalinization | 10–30 mEq BID (titrate dose to pH 7–7.5) | GI side effects | Serum creatinine & potassium |
| Struvite stones | ||||
| Acetohydroxamic acid | Urease-inhibitor | 250 mg BID–TID | Headache, anemia, thrombophlebitis, rash, tremulousness | CBC |
BMP, basic metabolic profile; CBC, complete blood count; GI, gastrointestinal; MPG, mercaptopropionyl glycine.
a
First-line therapy.