Surgical stone removal is the preferred management for struvite stones, since eradication of urease-producing bacteria responsible for struvite stone formation is dependent on removal of bacteria-containing stones (e.g., Proteus, Klebsiella, Pseudomonas, and some Staphylococcus species). However, when complete stone removal is not possible or if struvite stones recur, AHA may be considered as an alternative or adjunctive therapy in conjunction with infection management when indicated with culture-directed antibiotics. Two RCTs (n=169) identified in our systematic review showed a reduction in stone growth at 1-2 years among participants with struvite stones at baseline who were treated with AHA compared to a control group.57, 58 In one RCT, Griffith et al. reported a lower rate of stone growth in patients with struvite stones treated with AHA compared to those receiving placebo (17% versus 46%; calculated RR: 0.38; 95% CI: 0.19 to 0.76) at a mean follow-up of 18 months.57 Another RCT by Griffith et al., in patients with struvite stones, revealed a lower rate of stone growth in the AHA group compared to the placebo control group at 1 year follow-up (33% versus 60%; calculated RR: 0.55; 95% CI: 0.34 to 0.90). However, at 2-year follow-up no statistical difference in stone growth was observed (42% versus 60%; calculated RR: 0.69; 95% CI: 0.40 to 1.20).58 Despite the potential benefit of AHA, this drug is associated with a high side effect profile that may potentially limit its use.57, 58 Griffith et al. reported 35 (78%) adverse events in the AHA group versus 24 (49%) in the placebo group (calculated RR: 1.59; 95% CI: 1.15 to 2.20).57 Likewise, another trial by Griffith et al. reported 75 possible drug-related adverse symptoms in the AHA group compared to 26 in the placebo group (p<0.001).58 The most common side effects include hemolytic anemia, headache, and GI symptoms. Basic metabolic panel (BMP), including sodium, potassium, chloride, bicarbonate, calcium, glucose, creatinine, blood urea nitrogen, and glomerular filtration rate should be obtained for dosage determination as AHA is contraindicated in patients with a creatinine >2.5 mg/dL.224 Other side effects include depression, anxiety, nervousness, and tremulousness. AHA is contraindicated during pregnancy and should be avoided in women of reproductive age without effective contraception.225 Patients should also be monitored for phlebitis and hypercoagulable effects such as blood clots.226 Drug monitoring with routine lab testing to evaluate for these adverse events is imperative (see Statement 38 for suggested laboratory monitoring).