The treatment of nephrolithiasis involves different measures e.g non pharmacological measures consisting of increased fluid intake, straining an dietary restrictions. Pharmacological measures include pain relief using NSAIDs and opioids., helping passage of stone spontaneously with drugs like tamsulosin and nifedipine. The treatment of underlying cause and being specific to type of stones is very important.It involves treating primary hyperparathyroidism and Renal tubular acidosis. For those having high urinary calcium, Hydrochlorothiazide or Chlorthalidone are used. For recurrent stones and high urine uric acid, Allopurinol is used. For recurrent stones and hypocitraturia, Potassium citrate is sued to alkalinize the urine. For uric acid stones, alkalinizing urine with potassium citrate/potassium bicarbonate is done and if needed Allopurinol is also used. For struvite stones, medical therapy is not of much help, although urease inhibitors such as acetohydroxamic acid can be given in urease +ve etiology. For cysteine stones, again alkalinizing urine helps along with Tiopronin. The Urological consult is needed when stone >10 mm in diameter, uncontrolled pain, Anuria, or there is Acute kidney injury.

• Increased fluid intake
• Straining
  • Stone ≤5 mm can pass spontaneously.
  • Passage of stone also depends on the site of stone^[1]
• Evaluating diet as per the composition of stones, for example:
  • Diet containing excess proteins can precipitate uric acid stones
  • Diet containing excess phosphorus can cause struvite stone

• Both NSAIDS and opiods are seen efficacious for the pain relief related to nephrolithiasis.^[2]
• The combination works in effective pain relief.^[3]
• NSAIDS should be stopped before undergoing Extracorporeal shockwave lithotripsy to reduce the risk of bleeding.

• Parenteral regimen
  • Preferred regimen (1): Ketorolac 60 mg as a single dose or 30 mg IM q6h
  • Alternative regimen (1): Ketorolac 10 to 30 mg (as single dose) IM and then q4-6 h as needed (maximum: 120 mg/day)
  • Alternative regimen (2): Ketorolac 30 mg as a single dose or 30 mg IV q6h (maximum: 120 mg/day)
• Oral regimen
  • Preferred regimen (1): Ketorolac 20 mg, followed by 10 mg q4-6 h as needed; maximum: 40 mg/day; follows the parenteral dose (contraindicated in patients with renal failure)
  • Alternative regimen (1):Indomethacin 20 mg PO q8h
  • Alternative regimen (2):Indomethacin 40 mg PO q8-12h

Opioids

• Parenteral regimen
  • Preferred regimen (1): Morphine 5 mg IV q4h as needed

• The passage of stones depend on the size and location of the stone.^[4][5][6]
• Stones ≤5 mm in diameter pass spontaneously.
• It decrease as the size grows and not likely for sizes ≥10 mm in diameter.
• Stones which are proximal are less likely to pass spontaneously.
• Oral regimen
  • Preferred regimen (1):Tamsulosin 0.4 mg PO q24h until stone passage occurs or for up to 30 days^[7]
  • Preferred regimen (2):Used as adjuvant in Extracorporeal shockwave lithotripsy; Tamsulosin 0.4 mg PO q24h for 14 days to 3 months^[8]
  • Preferred regimen (3): Nifedipine 10-30 mg PO q8h for up to 4 weeks or until expulsion of lower stones^[9]

Treating the underlying cause is very important.

• Calcium stones
  • Treating primary hyperparathyroidism
  • Treating Renal tubular acidosis
  • For those having high urinary calcium:
    • Preferred regimen (1): Hydrochlorothiazide 50 mg PO q24h^[10]
    • Alternative regimen (1): Chlorthalidone 25 mg PO q24h^[10]
  • For recurrent stones and high urine uric acid:
    • Preferred regimen (1): Allopurinol 200-300 mg PO in single or divided doses
  • For recurrent stones and hypocitraturia:^[11]
    • Preferred regimen (1): Potassium citrate 15 mEq extended release q12h in mild-to-moderate hypocitraturia (>150 mg urinary citrate); maximum dose: 100 mEq/day
    • Alternative regimen (1): Potassium citrate 10 mEq extended release q8h
    • Preferred regimen (2): Potassium citrate 30 mEq extended release q12h in severe hypocitraturia (<150 mg/day urinary citrate); maximum dose: 100 mEq/day
    • Alternative regimen (2): Potassium citrate 20 mEq extended release q8h
• Uric acid stones
  • Alkalinizing urine with potassium citrate^[11]/potassium bicarbonate^[12] as above^[13]
  • Preferred regimen (1): Allopurinol 200-300 mg PO in single or divided doses^[13]
• Struvite stones
  • Medical therapy is not of much help, although urease inhibitors can be given in urease +ve etiology
    • Preferred regimen (1): Acetohydroxamic Acid 250 mg PO q6-8h for a total daily dose of 10 to 15 mg/kg/day; maximum dose: 1500 mg daily^[14]
• Cysteine stones
  • Alkalinizing urine
  • Preferred regimen (1):Tiopronin 800 mg/day PO in 3 divided doses; average dose: 1000 mg q24h^[10]

• The Urological consult is needed in the following:^[15][16]
  • Stone >10 mm in diameter
  • Uncontrolled pain
  • Anuria
  • Acute kidney injury
  • Acute abdomen features like nausea and vomiting
  • Signs of sepsis