Bowel Preparations: A Review for Community Pharmacists

Diana Chang, PharmD; Kevin Van, PharmD; Janette D. Lie, PharmD, BCACP; Jason P. Smith, PharmD; Kristie N. Tu, PharmD, BCPS, CGP


US Pharmacist. 2013;38(12):30-34. 

In This Article

Newer Bowel Preparations

Over the last several years, three new products have been FDA-approved for use in colonoscopy preparation. These agents were developed to better address the challenge of improving tolerability while maintaining efficacy. Caution should be exercised in patients with a history of arrhythmias, seizures, renal impairment, significant gastrointestinal (GI) disease, impaired gag reflex, regurgitation or aspiration, and fluid or electrolyte imbalances.[27–29]

Oral Sulfate Solution (SUPREP)

SUPREP is a low-volume osmotic laxative containing a combination of poorly absorbed sulfate salts (sodium sulfate, potassium sulfate, magnesium sulfate). These salts draw water into the lumen of the GI tract to promote cathartic effects.[27]

To decrease GI AEs, including vomiting, the manufacturer recommends administering SUPREP as a split-dose regimen. On the evening before the procedure, the first 16-oz bottle should be consumed, followed by 32 oz of water, over 1 hour. On the morning of the procedure, at least 2 hours prior to the procedure, the regimen is repeated with the second 16-oz bottle.[11,27]

Clinical trials evaluating both one-dose and split-dose regimens have demonstrated similar efficacy and safety compared with PEG preparations. SUPREP, therefore, may be an alternative, particularly in patients unable to tolerate PEG.[30]

Sodium Picosulfate Preparation (Prepopik)

Prepopik (sodium picosulfate, magnesium hydroxide, anhydrous citric acid) is a 10-oz preparation that combines a stimulant laxative with an osmotic laxative, making it the lowest-volume preparation currently available in the U.S. Sodium picosulfate is a prodrug that is hydrolyzed and activated by colonic bacteria to produce peristalsis. Magnesium hydroxide and anhydrous citric acid react with water to form magnesium citrate, further promoting a laxative effect.[8,28]

Prepopik is contraindicated in patients with severely reduced renal function. Prior or current use of antibiotics may decrease the preparation's efficacy because of the conversion of sodium picosulfate to its active metabolite by colonic bacteria, so evaluation is necessary in this case.[28]

When one-dose regimens of low-volume PEG-3350 plus bisacodyl tablets were compared with Prepopik, both preparations were equally effective for bowel cleansing. In a comparison of split-dose regimens, Prepopik had slightly superior efficacy. Tolerability was also improved with Prepopik. Bowel preparations containing this combination have been studied and used extensively outside the U.S. and have achieved similar results, further supporting this preparation's role as an alternative.[24,28,30,31]

Combination Osmotic Laxative (Suclear)

Suclear (sodium sulfate, potassium sulfate, and magnesium sulfate; PEG-3350, sodium chloride, sodium bicarbonate, potassium chloride), the latest bowel preparation approved by the FDA (January 2013), combines the osmotic effects of oral sulfates and PEG to induce cathartic effects in the GI tract.[29]

Split-dose administration of Suclear is preferred. On the evening before the procedure, the 6-oz bottle of oral sulfate solution should be diluted and consumed, followed by 32 oz of water, over 2 hours. On the morning of the procedure, the 2-L jug of PEG should be reconstituted and consumed at a rate of 16 oz every 20 minutes, to be completed 2 hours before procedure.[29]

In two different studies comparing one-dose regimens and split-dose regimens of low-volume PEG-3350, with or without bisacodyl tablets, the proportion of successful colon cleansing was similar between groups. Suclear may be considered an alternative bowel preparation.[29]