A randomized clinical prospective trial comparing split-dose picosulfate/ magnesium citrate and polyethylene glycol for colonoscopy preparation

Mandatory vs. optional split-dose bowel preparation for morning colonoscopies: a pragmatic noninferiority randomized controlled trial

BACKGROUND : We compared the effectiveness of optional split-dose bowel preparation (SDBP) with mandatory SDBP for morning colonoscopies in usual clinical practice. METHODS : Adult patients undergoing outpatient early morning (8:00 AM-10:30 PM) and late morning (10:30 AM-12:00 PM) colonoscopies were included. Written bowel preparation instructions were provided based on randomization: one group were instructed to take their bowel preparation (4 L polyethylene glycol solution) as a split dose (mandatory), while the comparator group was allowed the choice of SDBP or single-dose bowel preparation administered entirely on the day before (optional). The primary end point, using noninferiority hypothesis testing with a 5 % margin, was adequate bowel cleanliness measured by the Boston Bowel Preparation Scale (BBPS) and defined by a BBPS score ≥ 6. RESULTS : Among 770 randomized patients with complete data, there were 267 mandatory SDBP and 265 optional SDBP patients for early morning colonoscopies, and 120 mandatory SDBP and 118 optional SDBP patients for late morning colonoscopies. Optional SDBP was inferior to mandatory SDBP, with a lower proportion of adequate BBPS cleanliness for early morning colonoscopies (78.9 % vs. 89.9 %; absolute risk difference [aRD] 11.0 %, 95 %CI 5.9 % to 16.1 %), but was not statistically different for late morning colonoscopies (76.3 % vs. 83.3 %; aRD 7.1 %, 95 %CI -1.5 % to 15.5 %). CONCLUSIONS : Optional SDBP is inferior to mandatory SDBP in providing adequate bowel preparation quality for early morning colonoscopies (8:00 AM-10:30 AM), and probably inferior for late morning colonoscopies (10:30 AM-12:00 PM).

The safety and effects of high- and low-volume polyethylene glycol bowel preparation methods before colonoscopy on bowel cleanliness: a systematic review and meta-analysis

Background

Although both high- and low-volume polyethylene glycol (PEG) are widely used in intestinal preparation before colonoscopy, there is still controversy over the superiority of their cleaning effects. This meta-analysis sought to explore the safety and effects of high-volume PEG solution and low-volume PEG mixed solution on intestinal cleanliness before colonoscopy.

Methods

The PubMed, EMBASE, and Cochrane Library databases were searched to retrieve relevant articles on the effects of high- and low-volume PEG mixture solutions on intestinal cleanliness from the inception of the databases to October 15, 2022. Two independent researchers screened the literature according to the predetermined inclusion and exclusion criteria, and extracted the required data separately. A bias risk assessment was conducted for each study using the relevant tools in the Cochrane Handbook. The included data were subjected to a meta-analysis using R 4.2.1 software.

Results

This article includes a total of 15 studies involving a total of 5,847 patients. There was no difference in the cleanliness score, qualified rate of intestinal cleanliness and patient compliance between the high- and low-volume group. The patients in the low-volume PEG mixed solution group had a higher repeat willingness bowel cleansing rate than those in the high-volume PEG group [risk ratio (RR) =0.71, 95% confidence interval (CI): 0.62-0.82, P<0.01]. Compared with the low-volume group, the incidence of adverse reactions such as nausea, vomiting, and abdominal pain increased in the high-volume group (RR =1.38, 95% CI: 1.22-1.56, P<0.01; RR =1.79, 95% CI: 1.41-2.27, P<0.01; RR =1.05, 95% CI: 1.01-1.08, P<0.01).

Conclusions

In the pre-colonoscopy preparation method for patients, although the high-volume PEG and low-volume PEG mixed regimen have similar effects on intestinal cleanliness, the low-volume mixed regimen has a higher willingness to repeat and a lower incidence of adverse reactions. In clinical practice, considering patient compliance and safety, a low-volume mixed regimen may be a more optimal option.

Addition of Prucalopride to Standard Bowel Preparation Does Not Improve Colonic Mucosa Visualization—A Retrospective Observational Cohort Study

Background Colonoscopy is currently gold standard for visualizing colonic mucosa. Presence of constipation is generally associated with poor bowel preparation. We compared effect on colonic cleansing when prucalopride was used as adjunct with polyethylene glycol (PEG) in patients of constipation.

Methods A retrospective study was conducted at our center. One 70 patients with constipation were enrolled in two groups of who took only PEG and other of prucalopride plus PEG+ for bowel preparation. They underwent colonoscopy by a single-blinded experienced endoscopist. Bowel preparation quality was reported by Boston bowel preparation scale prior to washing or suctioning. The groups were analyzed for bowel preparation quality and side effects in either groups based on preformed questionnaire.

Results Mean Boston Stool preparation Score (BSS) in PEG group (5.33 ± 1.43) was slightly higher than PEG+ (5.16 + 1.37) (p-value =0.44). The total number of patients with side effects was higher in PEG+ group than PEG group. (p < 0.05).

Conclusion We conclude addition of prucalopride has no additional benefit when added with standard bowel preparation in patients of constipation. It may rather lead to noncompliance and inferior bowel preparation due to increased side effects.

Evaluating patient acceptability and bowel preparation efficacy of sodium picosulfate‐magnesium citrate for colonoscopy

Objective

Methods

Results

Conclusion

Efficacy of ultra-low volume (≤1 L) bowel preparation fluids: Systematic review and meta-analysis

BACKGROUND AND AIMS

High-quality bowel preparation is paramount for the diagnostic accuracy and safety of colonoscopy; however, it is often difficult for patients to adhere to high-volume laxatives, which may contribute to poor bowel preparation. This review aims to assess the efficacy of bowel preparation fluids of 1 L or less (≤1 L).

METHODS

We performed a systematic review including all relevant randomized controlled trials on ultra-low volume (≤1 L) bowel preparation fluids for colonoscopy published since 2015. Primary endpoint was the percentage of adequately prepared patients. Secondary endpoints included adenoma detection rate (ADR) and safety.

RESULTS

Bowel preparation with sodium picosulfate/magnesium citrate (SPMC; 19 trials, n = 10,287), 1L-polyethylene glycol with ascorbate (PEGA; 10 trials, n = 1717), sodium phosphate (NaP; 2 trials, n = 621), and oral sulfate solution (OSS; 3 trials, n = 597) was adequate in 75.2%, 82.9%, 81.9%, and 92.1%, respectively, of patients; however, heterogeneity between studies was considerable (I² range: 86-98%). Pooled ADRs were 31.1% with SPMC, 32.3% with 1L-PEGA, 30.4% with NaP, and 40.9% with OSS. Temporary electrolyte changes were seen with all ultra-low volume bowel preparation fluid solutions but without sustained effects in most patients.

CONCLUSION

Ultra-low volume bowel preparation fluids do not always meet the 90% quality standard for adequate bowel preparation as defined by current guidelines. Nonetheless, they may be considered in patients intolerant for higher-volume laxatives and without risk factors for inadequate bowel preparation or dehydration-related complications.

The unmet needs for identifying the ideal bowel preparation

Colonoscopy, since it was first employed over 60 years ago, is now the gold standard method for visualizing the mucosa of the colon, but should be of good quality. Many factors affect quality, including the type of health service organization, type of facility, staff, equipment, patient characteristics, and bowel preparation (BP). The adequacy of bowel cleansing is critical, but, unfortunately, may be inadequate in up to one‐third of procedures. The current article will present and discuss the main BPs and their drawbacks, which include patient‐dependent and procedure‐dependent factors. Cleansing quality depends on the ease/complexity of solution preparation, volume, taste, and timing of consumption. Consequently, important positive factors include simple instructions, easy preparation of the solution, low volume, pleasant taste, short drinking time (e.g. <30 min), and splitting the dose between the evening before and the morning of the colonoscopy (or even better, only one dose in the early morning to avoid night‐time problems), and short onset of action. The BP solution must also be safe with negligible side effects. Furthermore, a positive experience supports patient willingness to repeat the procedure.

Split dose bowel preparation before colonoscopy of PEG (Nulytely) in comparison to routine single dose bowel preparation

BACKGROUND

The aim of this study was to compare the efficacy and tolerability of polyethylene glycol (PEG) in single- or split-dose regimens for colonoscopy bowel preparation.

METHODS

This is a prospective, randomized, endoscopist blinded, single-center study, that included adult patients who underwent colonoscopy during the period from December 2017 to October 2018. Two groups were enrolled in the same period: One group used 4 L of PEG (Nulytely) in a single-dose preparation, administered a day before the procedure, and the other group received a split-dose regimen of 2 L PEG (Nulytely), given a day before the procedure and 2 L on the day of the procedure in the early morning. The Boston Bowel Preparation Scale (BBPS) was used for bowel preparation adequacy; scales 0 and 1 were considered inadequate, and scales 2 and 3 were considered adequate preparation.

RESULTS

Two hundred and forty patients were enrolled, 120 (50%) using the split-dose regimen and 120 (50%) using the single-dose regimen, for bowel preparation. Males constituted 51.6% of the study cohort. In the single-dose group, 62.5% achieved adequate bowel preparation compared to 89.2% in the split-dose group (p< 0.001). In addition, polyp detection in the split-dose group was 23.3% in comparison to 10.8% in the single-dose group (P = 0.016). We also found hypertension and diabetes as significant predictors of bowel preparation inadequacy, while sex and age were not related to bowel preparation adequacy.

CONCLUSIONS

Split-dose bowel preparation for colonoscopy with PEG (Nulytely) is better than routine single-dose, in terms of adequate bowel preparation and polyp detection.

Efficacy and Patient Tolerability of Split-Dose Sodium Picosulfate/Magnesium Citrate (SPMC) Oral Solution Compared to the Polyethylene Glycol (PEG) Solution for Bowel Preparation in Outpatient Colonoscopy: An Evidence-Based Review

Background

Colonoscopy is the gold standard exam for evaluation of colonic abnormalities and for screening and surveillance for colorectal cancer. However, the efficacy of colonoscopy is dependent on the quality of the pre-colonoscopy bowel preparation. Polyethylene glycol (PEG) and sodium picosulfate/magnesium citrate (SPMC) have emerged as two of the most commonly used bowel preparation agents. We conducted an evidence-based review of current evidence to further investigate the efficacy and patient tolerability of split-dose SPMC oral solution compared to PEG solution for colonoscopy bowel preparation.

Methods

A systematic search was performed using Pubmed (MEDLINE), Web of Science, EMBASE, and Cochran Central Register of Controlled Trials databases. All studies on split-dose bowel preparation with SPMC and PEG were reviewed. Relevant studies regarding colonoscopy and bowel preparations were also included. Randomized controlled trials were prioritized due to the high quality of evidence.

Results

Eight randomized controlled trials were included. Split-dose SPMC and PEG were associated with similar results for adequacy of bowel preparation. Split-dose SPMC was associated with increased patient tolerability and compliance.

Conclusion

Split-dose SPMC and PEG are both adequate and safe for bowel preparation for outpatient colonoscopy, with split-dose SPMC being more tolerable for patients. Additional RCTs comparing these and other bowel preparation solutions are necessary to further investigate quality of bowel preparation, patient preference, and cost-effectiveness of the various options.

Bowel Preparation for Colonoscopy in 2020: A Look at the Past, Present, and Future

PURPOSE OF THIS REVIEW

Colorectal cancer is the third most common cancer in the USA. Colonoscopy is considered the gold standard for colorectal cancer screening and can offer both diagnosis and therapy. The bowel preparation remains a significant barrier for patients who need to undergo colonoscopy and is often cited as the most dreaded aspect of the colonoscopy process. Inadequate bowel preparations still occur in 10-25% of colonoscopies, and this in turn can lead to increased procedural times, lower cecal intubation rates, and shorter interval between colonoscopies. From a quality standpoint, it is imperative that we do what we can to decrease the rate of inadequate bowel preparations. This review will focus on recent data regarding bowel preparation and offers a glimpse into what may be coming in the future.

RECENT FINDINGS

Recent advances in the field have been made to improve tolerability of bowel preparations and allow for more adequate colonoscopies. Newer, lower volume, flavored preparations, the use of adjuncts, and using split-dose preparations all can help with tolerability, compliance, and, in turn, preparation quality. Edible bowel preparations may become available in the near future. Early data on the use of artificial intelligence for assessment of preparation quality has been promising. Additionally, utilization of smartphone technology for education prior to the bowel preparation has also been shown to improve the adequacy of bowel preparations.

CONCLUSIONS

Ongoing efforts to improve the tolerability and palatability of colonoscopy bowel preparations are important from a quality improvement standpoint to ensure the adequacy of colonoscopy. Incorporating patient-specific factors and comorbidities is also an essential aspect of improving the quality of bowel preparation. Leveraging technology to better communicate with and educate patients on the bowel preparation process is likely to play a larger role in the coming years.