[Management of recurrent urolithiasis: indications for therapy escalation and discontinuation]

Urolithiasis is a common condition characterized by a high recurrence rate and substantial clinical and economic impact. Stone formers are stratified into low- and high-risk groups based on stone analysis and basic diagnostic evaluation. Following a stone event (spontaneous passage or interventional treatment), all patients should receive general preventive measures, including increased fluid intake, dietary modification, and lifestyle changes. High-risk patients should additionally undergo extended metabolic evaluation (24 h urine analysis) and, if indicated, targeted pharmacological therapy. Therapeutic escalation is warranted in cases of recurrent stone formation, persistent metabolic abnormalities in 24 h urine, or high-risk stone types (e.g., brushite, cystine). The primary aim is correction of pathological urinary parameters by reducing lithogenic factors (calcium, oxalate, uric acid) and increasing inhibitors of stone formation (citrate, magnesium). Pharmacological treatment mainly includes alkaline citrates, thiazides, and xanthine oxidase inhibitors, initiated at low doses and adjusted according to urinary and, if necessary, serum parameters. Therapy de-escalation or discontinuation may be considered in patients with sustained stone-free status and stable metabolic findings, considering age, recurrence dynamics, and comorbidities (particularly hypertension, diabetes, and obesity). Individualized management in interdisciplinary collaboration with nephrology, primary care, and nutritional medicine is essential, as urolithiasis should be regarded as a complex metabolic disorder. Patient adherence remains a key determinant of long-term therapeutic success.