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Bowel preparation before
colonoscopy: get it right
first time
Content supplied by the authors
and the publication funded by
Ferring Pharmaceuticals
This is an Affinity
publishing service provided by BMJ Group
Dec 2012
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BOWEL PREPARATION
BEFORE COLONOSCOPY:
GET IT RIGHT FIRST TIME
Ferring Pharmaceuticals was involved in the
outline development and medicolegal approval
of this supplement and provided financial
support for its publication. The views expressed
in this publication are not those of the publisher
or Ferring Pharmaceuticals. Full editorial control
of the article rested with the authors. Full
prescribing information is available on page 8.
Paper
Bowel preparation before colonoscopy:
get it right first time
P Bhandari, A Agrawal, C Lim,
S Manjunath, S Murphy,
B Rembacken, J Robb
1
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J460Sat21
Dec 2012
Bowel preparation before colonoscopy
Bowel preparation before colonoscopy:
get it right first time
Pradeep Bhandari,1 Anurag Agrawal,2 Chee Lim,3
Srikantaiah Manjunath,4 Seamus Murphy,5 Bjorn Rembacken,6
Jane Robb7
ABSTRACT
Detection of anomalies during colonoscopy is
contingent on an effective prior bowel cleanse. Indeed,
inadequate bowel cleansing can result in missed
lesions, thereby hampering the identification of colon
cancer, or the need for a repeat procedure which is
both costly and inconvenient. Despite its importance,
the quality of bowel preparation in clinical practice is
suboptimal. Understanding the rationale for the
bowel cleanse and the implications of a poor
preparation will help motivate patients to comply with
the cleansing requirements. Furthermore, patients
should undergo a thorough clinical pre-assessment
before the bowel preparation is prescribed and
physicians should select the bowel preparation
according to the specific needs of each patient rather
than follow a ‘one prep for all’ policy.
Introduction
The use of diagnostic and therapeutic colonic investigation
procedures has increased significantly over the past decade
and several advances in techniques and equipment have also
been made.1 Colonoscopy now plays a central role in the
investigation and surveillance of several bowel conditions,
such as inflammatory bowel disease and colonic polyps, and
is fundamental to national bowel cancer screening
1
Queen Alexandra Hospital, Portsmouth, UK
Doncaster Royal Infirmary, Doncaster, UK
3
Good Hope Hospital, Birmingham, UK
4
Manor Hospital, Walsall, West Midlands, UK
5
Southern Trust, Northern Ireland, Ireland
6
Leeds Teaching Hospitals Trust, Leeds, UK
7
Newham University Hospital, London, UK
2
Correspondence to
Professor P Bhandari, Solent Centre for Digestive Diseases,
Queen Alexandra Hospital, Portsmouth PO63LY, UK;
[email protected]
Prescribing information can be found at the end of this
Satellite
programmes. Colonoscopy has the potential to prevent future
colon cancers by detecting and eradicating dysplastic colonic
lesions, such as adenomas. Technological advances, including
magnifying endoscopes, electronic imaging and confocal
imaging, can identify subtle precancerous lesions but this
requires a meticulously clean mucosa devoid of faecal residue
(figure 1).2 3 Effective bowel preparation may be particularly
important for right-sided cancers, which can be challenging to
detect, and for flat colonic lesions, where the features may be
subtle and easily missed.4–7
Inadequate prior cleansing can result in a colonoscopy
being aborted or pathological lesions being missed.1–3
Repeating a colonoscopy generates unnecessary additional
workload and cost. Furthermore, repeating the investigation—
and therefore the bowel preparation—puts patients at
unnecessary risk. The uncertainty and delay in diagnosis can
also be extremely stressful for patients.
Despite its importance, the quality of bowel preparation
prior to colonoscopy is currently suboptimal. In a recent analysis of 12 787 colonoscopies at a hospital-based endoscopy
unit, bowel preparation was inadequate in 24% of cases.8
Remarkably, only 17% of patients with an inadequate preparation underwent repeat endoscopy within the following
3 years. Of the 198 adenomas identified during this study,
42% were found only on repeat colonoscopy, 27% of which
were advanced. It was, however, unclear whether radiological
alternatives were considered in patients where colonoscopy
was suboptimal. The retrospective nature of this study associated with the possibility of selection bias would suggest
that this study was susceptible to a type II error. Regardless,
these data add to the growing body of evidence suggesting
that poor bowel preparation is common and leads to missed
pathology, and this situation clearly needs to be redressed.
The objectives of this report are to raise awareness of the
importance of good bowel preparation before colonoscopy, and
identify strategies to improve the standard of bowel cleansing
practices.
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
1
Bowel preparation before colonoscopy
Figure 1
Adequate bowel preparation is essential before colonoscopy. The preparation is excellent in the top two images,
allowing optimal visualization of a polyp in the top right image (arrow). In contrast, the bottom two images show inadequate bowel
preparation, with semisolid or solid debris that obscures the complete view of the mucosa in spite of extensive flushing and
suction. Reproduced with permission from CCMJ. Atreja A, Nepal S, Lashner BA. Making the most of currently available bowel
preparations for colonoscopy. Cleve Clin J Med 2010;77:317–326. Reprinted with permission. Copyright © 2010 Cleveland Clinic
Foundation. All rights reserved.
Issues and challenges in ensuring a good
bowel preparation
When considering how to improve the quality of bowel preparation before colonoscopy, it is prudent first to review the
current clinical situation and potential reasons for inadequate
bowel preparation.
Understanding and adherence
Patients do not always adhere fully to the bowel preparation
requirements, typically due to tolerability issues with the product
and/or the regimen. In general, there may be insufficient appreciation among patients, but also among physicians, of the importance of an effective bowel preparation and of the implications of
a poor preparation. The information and support provided to
patients may not be sufficient, and there may not be any
follow-up from clinicians or nurses to check that a patient has
complied with the preparation instructions. Inpatients may be
particularly vulnerable to poor bowel cleansing as they are often
sedentary and can have other medical conditions that may have
an impact on the success of bowel preparation.1 There may also
2
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
be unintentional alterations in the timing of bowel preparation
administration with difficult access to toilet facilities and
adequate fluid intake due to the busy nature of the inpatient
wards, which can affect the outcome of the bowel preparation.
Pre-assessment and prescribing
Clinicians want a choice of which bowel cleansing agent to
use, and desire a product that provides a clean mucosa with
no residue, is well tolerated and requires no monitoring or
screening. Conversely, the focus of patients is on tolerability.
They want a palatable product with good taste and few side
effects (eg, pain, cramps, nausea). They want the regimen to
have a manageable fluid intake, allowing a choice of fluids,
tolerable dietary restriction, with limited impact on their activities of daily living and productivity.
The available agents differ in their mechanism of action,
and therefore in their administration and effect (table 1). No
single agent is ideal in all clinical scenarios.9 10 However,
there are notable differences among the products in tolerability and patient acceptability.12
Bowel preparation before colonoscopy
Table 1
Bowel preparation products available in the UK, by active ingredient(s)9–11
Active ingredient(s)
Products
Mechanism of action
Comments
Polyethylene glycol
(PEGs)/macrogols
• Klean-Prep
• Moviprep
Non-absorbable isosmotic solutions that
Diluted in large volumes of water (up
pass through the bowel without absorption to 4 l), unpalatable taste; leaves
leading to reduced fluid and electrolyte
increased watery residue10
flux
Phosphate
• Fleet
phospho-soda
Hyperosmotic and draws large volumes of
water into the colon
Diluted in approx 250 ml water; use
has decreased due to issues with
renal insufficiency9
Sodium picosulfate
with magnesium
citrate
• CitraFleet
• Picolax*
Two ingredients have synergistic effects.
Picosulfate stimulates peristalsis;
magnesium citrate has an osmotic effect
Requires 300 ml water for dilution;
leaves the least amount of watery
residue9 10; patients can drink fluid of
their choice
Klean Prep® and Moviprep® are registered trademarks of the Norgine® group of companies.
CitraFleet® and Fleet Phospho-soda® are registered trademarks of Laboratorios Casen-Fleet SLU.
*Brand name Picoprep is used in some countries outside the UK.
Pre-assessment of patients may not be as rigorous as it
should be and bowel preparation regimens are sometimes provided to patients without the correct prescribing and dispensing policies being followed. Furthermore, despite there being a
selection from which to choose, hospitals may blanket prescribe one product for all patients. There may be several barriers to overcome when trying to use a product that is not
included in the hospital bowel preparation protocol.
Guidance on the use of bowel preparation
products
In 2009, the National Patient Safety Agency (NPSA) issued an
alert in response to reported safety incidents following the
use of oral bowel cleansing preparations.13 The alert called for
a clinical risk assessment to be made for all patients prior to
bowel cleansing. It also stated that bowel preparation should
be authorised at the same time as the procedure, that an
explanation on the safe use of the product be provided to the
patient/carer and that an authorised clinical professional
should supply the medicine and written information to each
patient. The NPSA alert triggered many changes in bowel
preparation practices. Clinics stopped posting bowel preparations directly to patients and instigated new departmental
guidelines and organisational changes to ensure patients were
pre-assessed in the clinic before undergoing bowel cleansing.
A greater emphasis was placed on the use of blood tests to
assess estimated glomerular filtration rate and baseline
sodium and potassium levels, and some local protocols
restricted the choice of bowel cleansing products in an
attempt to simplify the pre-assessment process.
The British Society of Gastroenterology working party guidelines were subsequently developed to provide greater detail on
how to assess risk in patients prior to bowel preparation.9 10 The
guidelines were developed by a multidisciplinary team representing key medical societies, including the Renal Association, the
British Society of Gastroenterology, the Royal College of
Radiologists and the Royal College of Surgeons. Contrary to the
NPSA, the consensus guidelines do not demand that all patients
are pre-assessed in clinic, but agree that screening for risk
factors is important. The guidelines list absolute and relative contraindications to the use of oral bowel cleansing agents and
recommendations on the choice and administration of agents
(table 2). They also provide a useful checklist for pre-assessing
patients, which can be adapted at a local level (figure 2).
Evidence to guide the paediatric use of bowel cleansing
products is scant. A Cochrane review by Gordon et al found
only seven randomised controlled trials in this population.12
Of these, four used sodium phosphate, which is no longer considered suitable for use in children, and two evaluated Picolax
versus polyethylene glycol (PEG) or bisacodyl.14 15 In this population, Picolax was as effective as PEG but had better tolerability and patient acceptance. For example, a nasogastric
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
3
Bowel preparation before colonoscopy
Table 2 Key recommendations from the consensus guideline on the prescription and administration of bowel
cleansing products9 10
Absolute contraindications to the use of
bowel cleansing agents
• GI obstruction or perforation, ileus or gastric
retention
• Severe acute inflammatory bowel disease or
toxic megacolon
• Reduced levels of consciousness
• Hypersensitivity to any product ingredients
• Inability to swallow without aspiration
(nasogastric tube may be used)
• Ileostomy
Relative contraindications to the use of bowel cleansing agents
• CKD
• Haemodialysis patients
• Peritoneal dialysis patients
• Renal transplant patients
• Congestive cardiac failure
• Liver cirrhosis and/or ascites
• Patients taking renin–angiotensin blockers, diuretics, NSAIDs or medications
known to induce the syndrome of inappropriate ADH secretion
Choice of oral bowel cleansing product
• Magnesium salt preparations are relatively contraindicated in patients with stages 4 and 5 CKD.
• Sodium picosulfate preparations should be used with caution in patients at risk or, or suffering from, hypovolaemia, including
those patients taking high-dose diuretics, those with congestive cardiac failure and advanced cirrhosis, and those with CKD.
• The use of sodium phosphate preparations is strongly discouraged in patients with CKD, pre-existing electrolyte disturbances,
congestive cardiac failure, cirrhosis or with a history of hypertension.
• The use of oral sodium phosphate preparations in otherwise healthy patients is currently acceptable in cases where sodium
picosulfate, magnesium salts and polyethylene glycols are contraindicated or have proven ineffective or intolerable.
Administration of oral bowel cleansing agents
• The appropriate doses of oral bowel cleansing preparations should not be exceeded.
• The period of bowel cleansing should not normally exceed 24 h.
• Hypovolaemia must be corrected prior to administration of oral bowel cleansing preparations.
• Hypovolaemia must be prevented during administration of oral bowel cleansing preparations.
• If no recent measurement of kidney function is available (within 3 months), renal function should be measured (using an eGFR
from serum creatinine concentration) for certain patients.
• Regular medications:
W Regular oral medications should not be taken 1 h before or after administration of bowel cleansing preparations.
W Patients taking the oral contraceptive pill should take alternative precautions during the week following taking the bowel
preparation.
W Patients in whom reduced absorption of regular medications may prove catastrophic (eg, patients taking
immunosuppressives post-transplant) may require hospital admission to allow intravenous administration.
W Patients with diabetes mellitus receiving treatment with insulin will require specific advice and guidance for management
of diabetes while on reduced oral intake.
ADH, antidiuretic hormone; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GI, gastrointestinal; NSAIDs, non-steroidal
anti-inflammatory drugs.
tube was needed in 75% of children given PEG but in only
2.5% of children given Picolax.15
Research into maximising the success of bowel preparation
continues. For example, recent studies have explored differences
in the success of bowel preparation before morning and afternoon procedures, and the impact of the time delay between the
last dose of the bowel cleanse product and colonoscopy.16–20
4
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
Studies have also investigated patient treatment preference and
determinants of compliance with bowel cleansing.20–22
Recommendations to improve the standard
of bowel cleansing
Several steps can be taken to ensure good quality bowel
preparation prior to colonoscopy.
Bowel preparation before colonoscopy
Figure 2 Oral bowel cleansing agent prescription checklist, according to the Consensus guidelines for the safe prescription and
adminstration of oral bowel clensing agents. See reference 10, appendix 5. Supplementary data published online.
Improve the level of patient education
It is imperative to explain to patients the importance of a
good bowel preparation and to motivate them to adhere to the
process. They should be made aware that following the bowel
cleanse instructions precisely is fundamental to the success of
the colonoscopy. Furthermore, if the bowel preparation is not
carried out correctly, the investigator may miss lesions, which
could have a significant negative impact on their future health,
and patients are likely to have to undergo the bowel cleanse
and the colonoscopy for a second time. This education should
be extended to ward staff to help improve the quality of
bowel cleansing for inpatients.
Patients should be given comprehensive, highly illustrated,
written information about the bowel cleanse.3 This should
be provided at the pre-procedure clinic appointment. The
educational material must describe clearly how and when to
take the doses of the laxatives, how patients can determine
whether the bowel preparation is complete, the foods and
drinks to avoid and the fluids to take. It should also
detail the need to maintain adequate hydration when taking
the preparation. Finally, it is also important to emphasise
that following the instructions ‘to the letter’ reduces but
does not completely eliminate the possibility of an unclean
bowel.
Further study data are needed to define the dietary recommendations that should be given to patients. Clinical experience shows that following a low residue diet for 1–2 days
prior to the colonoscopy is useful. However, controversy
remains over whether patients need to restrict their intake to
only clear fluids for 24 h before the procedure.
Enhance pre-assessment
Clinics should develop a written protocol for pre-assessment of
patients undergoing bowel cleansing. The likely effect of the
bowel preparation and the required fluid intake on concomitant
medications and on pre-existing conditions should be evaluated
carefully. In addition to screening for safety reasons, physicians
should also enquire about a patient’s bowel habits. Chronic
constipation has been associated with poor bowel preparation2
and is best identified before a bowel preparation is selected.
In patients who have previously undergone colonoscopy,
enquiring about past experiences of bowel preparations can
prove useful for identifying the most appropriate product to
prescribe and, if necessary, a different bowel cleaning agent
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
5
Bowel preparation before colonoscopy
may be more appropriate for the subsequent procedure.
For example, a patient may report previous tolerability issues
with a product that may affect the likelihood of their adherence to a repeat use of that medication.
Select the most appropriate bowel
cleansing product for the individual
The choice of bowel cleansing product should be based on the
needs of the individual patient, and should take into consideration the varying mechanisms of action of the products, precautions for use and tolerability profiles. Physicians should not
simply use one product for all patients. The ideal would be to
identify which products are best for each patient subtype
(eg, the immobile, children, inpatients, patients with learning
difficulties, patients with chronic constipation, patients with a
previous failed preparation). However, there is insufficient evidence to guide this differentiation presently. Until further clinical trial data answer this question, hospitals should develop a
local protocol based on the advice given in the consensus
guidelines (see table 2 and figure 2).
While the use of bowel preparations requires caution in
patients with severe chronic kidney disease, congestive heart
disease and other medical conditions, blanket prescribing of
one product for all patients should not be accepted. The
patients at risk are small in number and are easily identified,
particularly with the improved pre-assessment process.
Re-evaluate the approach in repeat
colonoscopy
In patients with failed colonoscopies, it is important to check
normal bowel habits to identify chronic constipation. It is also
useful to review any issues the patient had with the bowel
cleansing product or process.
In patients who have followed all of the bowel cleansing
guidelines but the effect was unsatisfactory, a different
approach may be needed—for example, in terms of the products used, the timing of the procedure or perhaps involving
supervision of compliance in a hospital setting.
Conclusions
Colonoscopy is a powerful tool in the fight against colorectal
cancer but relies heavily on effective prior cleansing of the
bowel. The implications of poor bowel preparation practices
are serious, with high miss rates of early and advanced
lesions. Repeating colonoscopy generates significant additional
workload and cost to healthcare services, and unnecessary
stress, risk and inconvenience to the patient.
6
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
Bowel preparation is a demanding process. Patients have
to follow a restricted diet and take a laxative that produces
large volume diarrhoea, often with associated nausea and
bloating. In some cases, the laxative may taste unpleasant
and there may be significant amounts of fluid to consume.
The process is disruptive to their normal routines and
requires time off from work in addition to the inconvenience
of the colonoscopy itself.3 It is not surprising that patients
do not always follow the bowel preparation instructions fully.
To motivate patients to comply with the directions, physicians should help patients to understand the rationale for the
bowel cleansing process and the likely outcome if the preparation is poor.
Prescription of bowel preparations should be individualised,
rather than follow a ‘one prep for all’ policy, and should
follow a thorough clinical pre-assessment. Although none of
the available products shows a significantly superiority in
terms of efficacy, differences exist in tolerability and patient
acceptance, and these may be key to ensuring patient compliance. When considering the issues of cost, it should be
remembered that the cost of repeat colonoscopy is a far
greater issue than that of the bowel preparation product.
In summary, much can be done to improve the quality of
bowel preparation practices; to get it right first time. Indeed,
achieving a high quality bowel preparation is in the best interests of both the hospital and the patient as neither wishes to
repeat a colonoscopy unnecessarily. Effective oral bowel
cleansing products are available, and guidance exists to direct
the safe and effective use of these products. What is now
needed is to improve awareness of the importance of optimal
bowel cleansing to maximise the protective capabilities of
colonoscopy.
Key points
▪ Effective bowel cleansing prior to colonoscopy is
essential.
▪ Poor cleansing can result in pathological lesions being
missed, or the colonoscopy may need to be repeated.
▪ The standard of bowel cleansing practices in the UK
should be improved.
▪ Recommended steps to improve bowel cleansing
include:
– Improving the level of education given to patients
– Enhancing pre-assessment
– Selecting the most appropriate bowel cleansing
product for the individual patient.
Bowel preparation before colonoscopy
Competing interests All authors received an honorarium
related to attending the advisory board meeting and development
of this paper. Dr Chee Lim has declared associations with the
following companies/organisations: Ferring Pharamceuticals Ltd.
Full details of the relationship are held with the publisher.
Funding This satellite was sponsored by Ferring
Pharmaceuticals and is based on discussions at a Ferring
sponsored advisory board meeting held on 1 June 2012. Writing
support was provided by Lyndsey Wood, Freelance Medical
Writer. All costs related to development of the Satellite were
provided by Ferring Pharmaceuticals.
Ferring Pharmaceuticals was involved in the outline development
and medicolegal approval of this supplement and provided financial
support for its publication. The views expressed in this publication
are not those of the publisher or Ferring Pharmaceuticals.
For further details on the discussion at this advisory board meeting,
please contact Medical Information, Ferring Pharmaceuticals Ltd.
Tel: 0208 5804100. Email: [email protected]
8.
Lebwohl B, Kastrinos F, Glick M, et al. The impact of suboptimal
preparation on adenoma miss rates and the factors associated with
9.
early repeat colonoscopy. Gastrointest Endosc 2011;73:1207–14.
Connor A, Tolan D, Hughes S, et al. Consensus guideline for the
prescription and administration of oral bowel cleansing agents. 2009.
http://www.rcr.ac.uk (accessed 28 Jun 2012).
10. Connor A, Tolan D, Hughes S, et al. Consensus guidelines for the
safe prescription and administration of oral bowel cleansing agents.
Gut 2012;61:1525–32.
11. British National Formulary. London: BMJ Publishing Group Ltd,
RCPCH Publications Ltd and the Royal Pharmaceutical Society of Great
Britain, No 63, March 2012.
12. Gordon M, Harper V, Thomas A, et al. Bowel preparation for paediatric
colonoscopy: a systematic review. Abstract Presented at the British
Society of Paediatric Gastroenterology Hepatology and Nutrition
(BSPGHAN) Annual Meeting; Nottingham, January 2012. www.bspghan.
org.uk (accessed 28 Jun 2012).
13. National Patient Safety Agency. Rapid Response Alert. Reducing risk
of harm from oral bowel cleansing solutions. http://www.npsa.nhs.uk/
nrls/alerts-and-directives/rapidrr/reducing-risk-of-harm-from-oral-bowelcleansing-solutions (accessed 25 Jun 2012).
14. Gremse DA, Sacks AI, Raines S. Comparison of oral sodium phosphate
to polyethylene glycol-based solution for bowel preparation for
colonoscopy in children. J Pediatric Gastroenterol Nutrition
1996;23:586–90.
References
1.
Hendry PO, Jenkins JT, Diament RH. The impact of poor bowel
preparation on colonoscopy: a prospective single centre study of 10571
colonoscopies. Colorectal Dis 2007;9:745–8.
2.
Froehlich F, Wietlisbach V, Gonvers JJ, et al. Impact of colonic
cleansing on quality and diagnostic yield of colonoscopy: the European
Panel of Appropriateness of Gastrointestinal Endoscopy European
multicenter study. Gastrointest Endosc 2005;61:378–84.
3.
Spiegel BMR, Talley J, Shekelle P, et al. Development and validation
of a novel patient educational booklet to enhance colonoscopy
preparation. Am J Gastroenterol 2011;106:875–83.
4.
Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of
serrated polyps in an average risk colorectal cancer screening cohort.
Am J Gastroenterol 2010;105:2656–64.
5.
Kahi CJ, Hewett DG, Norton DL, et al. Prevalence and variable
detection of proximal colon serrated polyps during screening
colonoscopy. Clin Gastroenterol Hepatol 2011;9:42–6.
6.
Brenner H, Chang-Claude J, Seiler CM, et al. Interval cancers after
negative colonoscopy: population-based case-control study. Gut
2012;61:1576–82.
7.
Singh H, Nugent A, Demers AA, et al. The reduction in colorectal
cancer mortality after colonoscopy varies by site of the cancer.
Gastroenterology 2010;139:1128–37.
15. Turner D, Benchimol EI, Dunn H, et al. Pico-Salax versus polyethylene
glycol for bowel cleanout before colonoscopy in children: a randomized
controlled trial. Endoscopy 2009;41:1038–45.
16. Siddiqui AA, Yang K, Spechler SJ, et al. Duration of the interval
between the completion of bowel preparation and the start of
colonoscopy predicts bowel-preparation quality. Gastrointest Endoscopy
2009;69:700–6.
17. Cohen LB. Split dosing of bowel preparations for colonoscopy: an analysis
of its efficacy, safety and tolerability. Gastrointest Endosc 2010;72:406–12.
18. Unger RZ, Amstutz SP, Seo DH, et al. Willingness to undergo split-dose
bowel preparation for colonoscopy and compliance with split-dose
instructions. Dig Dis Sci 2010;55:2030–4.
19. Seo EH, Kim TO, Park MJ, et al. Optimal preparation-to-colonoscopy
interval in split-dose PEG bowel preparation determines satisfactory
bowel preparation quality: an observational prospective study.
Gastrointest Endoscopy 2012;75:583–90.
20. Van Dongen M. Enhancing bowel preparation for colonoscopy: an
integrative review. Gastroenterol Nursing 2012;35:36–44.
21. Lebwohl B, Wang TC, Neugut AI. Socioeconomic and other predictors
of colonoscopy preparation quality. Dig Dis Sci 2010;55:2014–20.
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Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
7
Bowel preparation before colonoscopy
Prescribing information: Picolax
Please consult the full summary of product characteristics before prescribing
Name of product: Picolax. Composition: Active ingredients: sodium picosulfate and magnesium citrate. Each sachet
contains 10 mg sodium picosulfate, 3.5 mg light magnesium
oxide and 12 g anhydrous citric acid. Indication: To clean the
bowel prior to x-ray examination, endoscopy or surgery.
Dosage: To be reconstituted in water. Please consult the full
summary of product characteristics for information about reconstitution and fluid intake. Adults (including the elderly): First
sachet to be taken at 8 am on the day before the procedure,
second sachet 6–8 h later. Children: 1–2 years: ¼ sachet
morning and afternoon. 2–4 years: ½ sachet morning and
afternoon. 4–9 years: 1 sachet morning, ½ sachet afternoon.
9 years and above: adult dose. Contraindications:
Hypersensitivity to any of the ingredients, congestive cardiac
failure, gastric retention, gastrointestinal ulceration, toxic
colitis, toxic megacolon, ileus, nausea and vomiting, acute surgical abdominal conditions such as acute appendicitis and
gastrointestinal obstruction or perforation. In patients with
severely reduced renal function, accumulation of magnesium in
plasma may occur; another preparation should be used in such
cases. Special warnings and precautions: Take care in
patients with recent gastrointestinal surgery, renal impairment,
heart disease and inflammatory bowel disease. Use with
caution in patients on drugs that might affect water and/or
electrolyte balance. Picolax may modify the absorption of regularly prescribed oral medication. An inadequate oral intake of
8
Bhandari P, Agrawal A, Lim C, et al. Satellites 2012;21:1–8
water and electrolytes could create clinically significant deficiencies, particularly in less fit patients; the elderly, debilitated
individuals and patients at risk of hypokalaemia may need
particular attention. Prompt corrective action should be taken
to restore fluid/electrolyte balance in patients with signs or
symptoms of hyponatraemia. The period of bowel cleansing
should not exceed 24 h because longer preparation may
increase the risk of water and electrolyte imbalance.
Side effects: Please consult the full summary of product
characteristics for further information about side effects. Very
rare: anaphylactoid reaction; hypersensitivity; hyponatraemia;
epilepsy; grand mal convulsion; convulsions; confusion; headache; vomiting; diarrhoea; abdominal pain; nausea; proctalgia;
rash; urticaria; pruritis; purpura; drug interaction. Nature and
contents of container: Carton containing two sachets.
Marketing authorisation number: 03194/0014. Marketing
authorisation holder: Ferring Pharmaceuticals Ltd, Drayton
Hall, Church Road, West Drayton, UB7 7PS, UK. Legal
category: P. Basic NHS price: £33.90 for 10×2 sachets.
Date of preparation of prescribing information: August
2012. Picolax is a registered trademark.
Adverse events should be reported. Reporting forms and
information can be found at http://www.mhra.gov.uk/
yellowcard. Adverse events should also be reported to
Ferring Pharmaceuticals.
A patient information leaflet on Picolax is available from
Ferring—which can be adapted, for example, to add hospital
information or local branding.
BMJ Group
BMA House, Tavistock Square, London WC1H 9JR. Tel. +44 (0)20 7383 6055. Fax. +44 (0)20 7383 6668
© 2012 All rights of reproduction of this material are reserved in all countries in the world.
Published by the BMJ Publishing Group Ltd, typeset by Techset and printed in UK.
affinity.bmj.com
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