What are the oral medications for nephrolithiasis (kidney stones)?

From the Guidelines

Oral medications for kidney stones should include thiazide diuretics, citrate, or allopurinol as pharmacologic monotherapy to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones. When considering treatment options, it's essential to note that moderate-quality evidence showed that thiazide diuretics, citrates, and allopurinol reduce the risk for recurrence of composite calcium stones 1. Some key points to consider when prescribing these medications include:

• Thiazide diuretics, such as hydrochlorothiazide, can reduce calcium excretion and are effective in preventing recurrence of calcium stones 1.
• Citrates, such as potassium citrate, increase urine pH and prevent crystal formation, making them a suitable option for patients with calcium stones 1.
• Allopurinol is used for uric acid stones to reduce uric acid production and is an effective option for patients with this type of stone 1. It's also important to note that combination therapy with these agents was not more beneficial than monotherapy, and the choice of treatment could be based on the type of metabolic abnormality, although evidence from randomized, controlled trials is lacking to correlate the drug of choice and stone type to the prevention of stone recurrence 1. Drinking 2-3 liters of water daily is essential with any medication regimen to increase urine volume and prevent crystal formation. The effectiveness of these medications stems from their ability to either facilitate stone passage, prevent new stone formation by altering urine composition, or address underlying metabolic issues that contribute to stone development. Treatment duration varies based on stone type and recurrence risk, typically continuing for several months after stone passage or longer for prevention. Adverse events associated with these medications should be carefully considered, and the use of lower doses of thiazides may be associated with fewer adverse effects, although their effectiveness in preventing stone recurrence compared with higher doses is not known 1.

From the Research

Oral Medication for Kidney Stones

• The primary goal of oral medication for kidney stones is to reduce the risk of stone recurrence and alleviate symptoms 2.
• Thiazide diuretics are commonly prescribed to prevent kidney stones, particularly for patients with calcium stones and idiopathic hypercalciuria 2, 3.
• The optimal dose of thiazide diuretics for preventing kidney stones is still debated, but research suggests that lower doses may be as effective as higher doses 3.
• Other oral medications that may be used to prevent kidney stones include:
  • Potassium alkali therapy for patients with hypocitraturia 2
  • Allopurinol for patients with calcium oxalate stones and hyperuricosuria 2
  • Citrates for patients with recurrent calcium stones 4
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used to manage pain associated with kidney stones, and may be preferred over opioids due to their lower risk of dependence and abuse 5, 6.
• Opioid-sparing pathways for managing pain associated with kidney stones are being developed, and may include the use of NSAIDs, acetaminophen, and other non-opioid medications 6.