Urology

Bladder Pain Protocol

Erectile Dysfunction Guidelines for Adults

Lower Urinary Tract Symptoms (LUTS) Pathway

Overactive Bladder (OAB) Treatment Management

Summary

  • This guidance the use of potassium citrate oral mixture and Effercitrate® effervescent tablets (potassium citrate/citric acid) in patients with renal stone diseases.
  • Potassium citrate oral mixture and Effercitrate® tablets are licenced for the symptomatic relief of dysuria associated with mild urinary tract infections, especially cystitis over short term use. In renal stone disease, potassium citrate is used off-label to restore normal urinary citrate levels, alkalinise the urinary pH, and in certain types of stone formers to act as a crystal inhibitor.
  • Patients who are high risk stone formers are usually advised to continue potassium citrate long term.

Recommendations

  • Patients are reviewed in the Metabolic Kidney Stone Prevention or Urology Clinic in one of the hospitals within SWL. A management plan is formulated by the specialist based on history and investigations.
    • First line: Potassium citrate oral mixture to be initiated first-line by the specialist following discussion and agreement with the patient (Amber 2 on NHS SWL Formulary).
    • The patient will remain under the specialist for a minimum of 8 weeks until they are on a tolerated dose and their kidney function has been re-checked.
    • If intolerant to potassium citrate mixture, Effercitrate® effervescent tablets may be initiated by the specialist following discussion and agreement with the patient (Amber 2 on NHS SWL Formulary). Effervescent tablets should be continued only if there is an improvement in tolerability.
  • Prescribing of potassium citrate will then transfer to primary care.
  • Transfer of prescribing responsibility is to be communicated to primary care via clinic letter including an individual management plan.
  • Patients discharged on potassium citrate should have their renal function checked at least annually.

Roles and responsibility

Metabolic Kidney Stone and Urology specialist team responsibility

  • Following a shared decision by a specialist Chemical Pathologist, Urologist or Clinical Nurse Specialist (CNS) with the patient, considering the off-label use, benefits and risks, sick day rules, contra-indications and side effects (see Summary of Product Characteristics [SmPC]), initiate potassium citrate oral mixture or Effercitrate® effervescent tablets to reduce the risk of kidney stones.
  • Review the patient in the Metabolic clinic in 8 weeks’ time, following a blood test, to check kidney function, tolerance to the medication and to discuss and agree an individual management plan, prior to transfer of prescribing to primary care.
  • Complete a clinic letter requesting transfer of prescribing responsibility, which should include:
    • Indication for therapy and dose
    • Individual management plan
    • Confirmation that the patient has been informed of off-label use of potassium citrate and has agreed to treatment
    • Assessment results upon stabilisation on maintenance dose including renal function
    • Details of Metabolic Kidney Stone or Urology specialist team for advice or support
  • Supply at least 4 weeks of potassium citrate oral mixture or Effercitrate® effervescent tablets at transfer of prescribing.

Primary care responsibility

  • Continue prescribing potassium citrate oral mixture or Effercitrate® effervescent tablets at the recommended dose in the communication from the Metabolic Kidney Stone/Urology Specialist team as above (Amber 2 on SWL formulary – transfer of care via clinic letter, to include individual management plan).
  • Add medication to repeat prescriptions ensuring that any concurrent potassium containing medications, potassium sparing diuretics or other drugs that increase potassium levels (e.g. ACE inhibitors, ciclosporin, aliskiren) have been taken into consideration by the specialist and noted in the communication received.
  • Ensure process in place to check patient’s renal function annually.
  • Review medication and seek specialist advice if concerned about:
    • any renal or cardiac dysfunction
    • patient is elderly (caution advised)
    • patient continuing to form kidney stones after stopping the medication.
  • Discontinue treatment if there is hyperkalaemia or if eGFR is below 30ml/min/1.73m2 or ventricular arrhythmia. Exercise caution if eGFR is less than 40 mL/min by more frequent monitoring (6 monthly) and seek specialist advice if patient continues to be a stone former.
  • Advise patient on sick day rules in the event of acute intercurrent illness.

Prescribing and monitoring guidance

  • The prescribing of potassium citrate is Amber 2 for alkalinisation of urine. The patient will remain under the specialist for a minimum of 8 weeks until they are on a tolerated dose and their kidney function has been re-checked.
    • First line: Potassium citrate oral mixture, 10mls twice daily orally OR
    • Effercitrate® effervescent tablets, 2 tablets twice daily orally, if patient is intolerant to potassium citrate mixture .
  • Dose can be reduced or increased depending on the clinical response, investigations and patient’s tolerance. This will be communicated in the clinic letter.
  • A blood test review is organised, by the specialist, 8 weeks after initiating treatment.
  • Blood test is organised in 8 weeks’ time to check kidney functions which is reviewed by the specialist team; if stable, an annual blood test is needed to check kidney function.
  • Side effects- Mild nausea and occasionally vomiting may occur due to gastric irritation. Other side effects are those due to hyperkalaemia (if this occurs), therefore requires a blood test to check U&E.
  • Discontinue treatment if there is hyperkalaemia or if eGFR is below 30ml/min/1.73m2 or ventricular arrhythmia.
  • Exercise caution if eGFR is less than 40 mL/min by more frequent monitoring (6 monthly).
  • Sick day rules: In the event of acute intercurrent illness e.g. gastroenteritis, potassium citrate oral mixture and Effercitrate® effervescent tablets should be stopped. They should be re-started 24 to 48 hours after symptoms have resolved and the person is eating and drinking normally.

For clinical queries, please contact:

  • Epsom and St Helier Hospital via Advice &Guidance to Chemical Pathology
  • St Georges’s Hospital via an email to [email protected]
  • Kingston Hospital and Croydon Hospital: contact the specialist team who initiated the treatment.

References/resources

V1.0 Approved by Integrated Medicines Optimisation Committee (IMOC) December 2025