Established and recent developments in the pharmacological management of urolithiasis: an overview of the current treatment armamentarium

ABSTRACT

Introduction: Urolithiasis is a common, highly recurrent disease with increasing prevalence worldwide. There are many dietary and pharmacological measures to prevent kidney stones.

Areas covered: Herein, the authors explore medical expulsive therapy as well as pharmacological therapies to prevent/treat urolithiasis.

Expert opinion: All stone formers should be advised to increase their fluid intake sufficiently to achieve a urine volume of at least 2.5 L/day. In the case of hypercalciuria, a thiazide diuretic should be prescribed while in cases of hypocitraturia, potassium citrate should be given. In the case of hyperoxaluria, the treatment depends on the type of hyperoxaluria. Pyridoxine or calcium supplements with a meal can be offered. For uric acid stone formers, alkali therapy is the standard of care whereas allopurinol can be beneficial in hyperuricosuric stone formers. For cystine stone formers, increased fluid intake, restriction of sodium and animal protein ingestion, and urinary alkalinization are the standard therapies used. Cystine binding thiol drugs such as tiopronin and D-penicillamine are reserved for patients where a conservative approach fails. For struvite stone formers, optimal management is the complete stone removal. Acetohydroxamic acid may be offered only after surgical options have been exhausted, for patients with residual stones but it has many side effects.

KEYWORDS:

• Stone
• prevention
• urolithiasis
• cystine
• calcium
• uric acid
• struvite
• calculus
• kidney
• renal

Article Highlights

• The prevalence of urolithiasis has been increasing for the past few decades in industrialized nations causing significant morbidity.

• Medical expulsion therapy with alpha-blockers increased stone expulsion rates in distal ureteral stones > 5 mm.

• Thiazide-type diuretics reduce urinary calcium excretion and calcium stone formation.

• Pyridoxine should be used for the treatment of primary hyperoxaluria.

• Allopurinol should be used in hyperuricosuric urate stone formers.

• Removing the stone material as completely as possible with surgery is important in struvite stone management. Acetohydroxamic acid has a limited role in its prevention.

• Patients knowing to have cystine stone should be advised to increase their fluid intake to reach a 24-hour urine volume of 3 L. Potassium citrate can be used to achieve urine pH > 7.5. When all measures are insufficient, Tiopronine may be used.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.