Comparison of Empiric Preventative Pharmacologic Therapies on Stone Recurrence Among Patients with Kidney Stone Disease

To compare the frequency of stone-related events among patients receiving thiazides, alkali citrate, and allopurinol without prior 24 h urine testing. It is unknown whether 1 preventative pharmacological therapy (PPT) medication class is more beneficial for reducing kidney stone recurrence when prescribed empirically.Using medical claims data from working-age adults with kidney stone disease diagnoses (2008-2018), we identified those prescribed thiazides, alkali citrate, or allopurinol. We excluded those who received 24 h urine testing prior to initiating PPT and those with less than 3 years of follow-up. We fit multivariable regression models to estimate the association between the occurrence of a stone-related event (emergency department visit, hospitalization, or surgery for stones) and PPT medication class.Our cohort consisted of 1834 (60%), 654 (21%), and 558 (18%) patients empirically prescribed thiazides, alkali citrate, or allopurinol, respectively. After controlling for patient factors including medication adherence and concomitant conditions that increase recurrence risk, the adjusted rate of any stone event was lowest for the thiazide group (14.8%) compared to alkali citrate (20.4%) or allopurinol (20.4%) (each P.001). Thiazides, compared to allopurinol, were associated with 32% lower odds of a subsequent stone event by 3 years (OR 0.68, 95% CI 0.53-0.88). No such association was observed when comparing alkali citrate to allopurinol (OR 1.00, 95% CI 0.75-1.34).Empiric PPT with thiazides is associated with significantly lower odds of subsequent stone-related events. When 24 h urine testing is unavailable, thiazides may be preferred over alkali citrate or allopurinol for empiric PPT.