Efficacy of oral sulfate tablets for bowel preparation and adenoma detection rate

Optimal bowel preparation for colonoscopy

There is robust evidence to indicate a strong correlation between the bowel preparation status and adenoma detection rate (ADR), which directly impacts the incidence and mortality rate of postcolonoscopy colorectal cancer. Therefore, improving bowel preparation has been of increasing interest. In Japan, commercially available bowel preparation agents include polyethylene glycol, oral sodium sulfate, sodium picosulfate-magnesium citrate, magnesium citrate, and oral sodium phosphate; each has its own strengths and limitations. The timing of administration can also influence the efficacy of bowel preparation and patient tolerability. Furthermore, meta-analyses have suggested predictive factors for inadequate bowel preparation. A detailed understanding of these factors could contribute to reducing the need for repeat colonoscopy within 1 year, as recommended for patients with inadequate bowel preparation. Recent advancements, such as oral sulfate tablets, present promising alternatives with higher patient satisfaction and ADRs than traditional methods. Achieving optimal bowel preparation requires enhanced instructions, individualized regimens, and a comprehensive understanding of patient backgrounds and the characteristics of various bowel preparation agents. This article provides a concise overview of the current status and advancements in bowel preparation for enhancing the quality and safety of colonoscopy.

Efficacy of Oral Sulfate Tablet and 2 L-Polyethylene Glycol With Ascorbic Acid for Bowel Preparation: A Prospective Randomized KASID Multicenter Trial

BACKGROUND

Oral sulfate tablets (OSTs) are bowel preparation agents that combine oral sulfate solution and simethicone. This study compared the efficacy, tolerability, and safety of OST compared to 2 L-polyethylene glycol plus ascorbic acid (2 L-PEG/ASC).

METHODS

This prospective, randomized, controlled, single-blinded, multicenter, noninferiority trial enrolled 211 healthy adults who underwent colonoscopy between May 2020 and September 2022 at 13 university hospitals. The bowel cleansing rate was assessed using the Boston Bowel Preparation Scale (BBPS) and Harefield Cleansing Scale (HCS), and the preparation agents were administered in split regimens.

RESULTS

The total BBPS score (8.2 ± 1.5 vs. 7.8 ± 1.4, p = 0.040) and the high-quality bowel cleansing rates in the right colon (73.2% vs. 50.5), transverse colon (80.6% vs. 68.0%), and left colon (81.5% vs. 67.0%) on the BBPS were significantly higher in the OST group than in the 2 L-PEG/ASC group. However, the rates of successful cleansing according to BBPS (90.7% vs. 91.2%) and HCS (96.3% vs. 94.2%) did not significantly differ between the two groups. The taste, ease, and amount of consumption of the preparation agent; and willingness to repeat colonoscopy with the same agent (89.8% vs. 78.6%, P = 0.026) were significantly better in the OST group compared to the 2 L-PEG/ASC group. Adverse events and clinically significant laboratory changes were not significantly different between the two groups.

CONCLUSION

The OST was not inferior to 2 L-PEG/ASC in terms of bowel cleansing efficacy and showed better tolerability when used for bowel preparation for colonoscopy.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0005017.

Colonoscopy Remains an Important Option for Primary Screening for Colorectal Cancer

Colonoscopy remains the most commonly used colorectal cancer screening test in the United States. A substantial portion of the screening population value the high sensitivity of colonoscopy for precancerous colorectal lesions of all sizes, which allows it to be performed at 10 year intervals in average-risk persons with negative examinations. Emerging evidence supports the eventual endorsement of 15 year intervals for patients with normal examinations. Considerable evidence supports an impact of colonoscopy on colorectal cancer incidence and mortality, including a randomized controlled trial of colonoscopy vs. no screening, numerous case-control and cohort studies, an impact of fecal blood testing on cancer incidence, and the impact of one randomized controlled trial of flexible sigmoidoscopy on proximal colon cancer incidence. Colonoscopy is the gold standard for detection of colorectal precancerous lesions, and continues to evolve with regard to sensitivity for precancerous lesions and the effectiveness and safety of precancerous lesion resection. Gains in detection of precancerous lesions have followed from a robust movement to improve colonoscopy quality, and development of non-device techniques such as patient rotation during withdrawal, water exchange colonoscopy, and double examination of one or more colonic segments. Further, development of devices to improve mucosal exposure during withdrawal (e.g. Endocuff Vision, distal cap attachment, and Computer-Aided Quality), and devices that highlight flat lesions (e.g. chromoendoscopy, electronic chromoendoscopy, and Computer-Aided Detection) have created opportunities to achieve very high levels of detection and thereby increase the protective benefits of colonoscopy. Further, colonoscopy resection safety has improved via the widespread use of cold resection for lesions < 10 mm in size, as well as sessile serrated lesions of all sizes. Colonoscopy can be offered to patients as one of multiple options for screening, or as the test of choice for patients with the highest pre-screening probability of cancer and precancerous lesions, or as the first test offered followed by offers of other screening tests if colonoscopy is declined (sequential offers of screening). Sequential offers of screening result in overall adherence to screening similar to offering multiple options, but with a higher fraction of patients undergoing colonoscopy. Given the long-lasting protective effects of colonoscopy and its improving effectiveness and safety, colonoscopy remains a useful option for primary average-risk colorectal cancer screening.

Acute Gastropathy Associated with Bowel Preparation According to Age: Oral Sulfate Tablets versus 1-L Polyethylene Glycol with Ascorbic Acid

Background/Aims

The use of 1-L polyethylene glycol with ascorbate (PEG/Asc) and oral sulfate tablets (OST) as low-volume bowel preparation agents has gradually increased. However, these agents may induce acute gastropathy during bowel preparation, particularly in elderly populations. This study aimed to compare the incidence of acute gastropathy of 1-L PEG/Asc and OST according to age, as well as efficacy and safety.

Methods

This retrospective study included patients who underwent esophagogastroduodenoscopy (EGD) and colonoscopy for screening on the same day and underwent bowel preparation using OST or 1-L PEG/Asc. We collected EGD findings related to acute gastropathy, bowel-cleansing score using the Boston Bowel Preparation Scale (BBPS), polyp or adenoma detection rate (ADR), and laboratory parameters.

Results

Of 4,711 patients, 1,758, 2,241, and 712 were in the younger (18-49 years), middle-aged (50-64 years), and older (≥65 years) groups, respectively. In all age groups, the OST group had higher rates of acute gastropathy than the 1-L PEG/Asc group. The younger-, middle-, and older-aged groups had OST and 1-L PEG/Asc usage rates of 42.9% and 11.6%, 41.2% and 16.0%, and 41.5% and 16.4%, respectively. Notably, in the younger group, the total BBPS and ADR scores were significantly higher in the OST group than in the 1-L PEG/Asc group; however, these did not differ in the other age groups.

Conclusions

Acute gastropathy was more strongly associated with OST than with 1-L PEG/Asc in all age groups. Therefore, physicians should consider acute gastropathy associated with low-volume agents in all age groups when performing bowel preparation.

Efficacy, tolerability, and safety of oral sulfate tablet versus 2 L-polyethylene glycol/ascorbate for bowel preparation in older patients: prospective, multicenter, investigator single-blinded, randomized study

BACKGROUND

We compared the efficacy, tolerability, and safety of oral sulfate tablets (OST, which contains simethicone) and 2 L-polyethylene glycol/ascorbate (2 L-PEG/Asc) with a split-dosing regimen in older individuals aged ≥ 70 years who underwent scheduled colonoscopy.

METHODS

This prospective, randomized, investigator-blinded, multicenter study was conducted between June 2022 and October 2023. Participants aged ≥ 70 years were randomized at a ratio of 1:1 to the OST or 2 L-PEG/Asc groups.

RESULTS

In total, 254 patients were evaluated using a modified full analysis set. Successful overall bowel preparation was excellent and similar between the OST and 2 L-PEG/Asc groups for the Boston Bowel Preparation Scale (BBPS) (96.5% vs. 96.6%) and Harefield Cleansing Scale (HCS) (96.5% vs. 97.4%). The overall high-quality preparation rate was higher in the OST group than in the 2 L-PEG/Asc group (BBPS: 55.7% vs. 28.4%, P < 0.001; HCS: 66.1% vs. 38.8%, P < 0.001). The overall adenoma detection rate (54.8% vs. 35.3, P = 0.003) was superior in the OST group compared to the 2 L-PEG/Asc group. Tolerability scores, including overall satisfaction, were generally higher in the OST group than in the 2 L-PEG/Asc group. The incidence of major solicited adverse events was comparable between the two groups (55.7% vs. 68.1, P = 0.051), and there were no clinically significant changes in the serum laboratory profiles on the day of or 7 days after colonoscopy.

CONCLUSIONS

OST is an effective and safe low-volume agent for colonoscopy, with better tolerance than 2 L-PEG/Asc, in older individuals aged ≥ 70 years.

Comparison of a novel mini-oral sulfate tablet and the conventional oral sulfate tablet in bowel preparation for colonoscopy: a prospective, randomized, investigator-blinded, multicenter, non-inferior, phase 3 trial

BACKGROUND AND AIMS

The use of conventional oral sulfate tablets (OSTs) has gained popularity; nonetheless, they may be not only inconvenient to swallow but also difficult to dissolve. A novel mini-OST has recently been developed to enhance compliance with conventional OST use. This study aimed to compare the efficacy, tolerability, and safety between mini-OST and conventional OST.

METHODS

This was a prospective, randomized, investigator-blinded, multicenter, and non-inferior phase 3 trial conducted between September 2022 and December 2022. The efficacy, safety, and tolerability were compared between mini-OST and conventional OST.

RESULTS

Exactly 83 patients were evaluated based on a full analysis set (FAS), whereas 82 patients were evaluated as a per-protocol set (PPS). With respect to the efficacy of preparation, successful and high-quality preparation was excellent in the mini-OST and conventional OST groups on both FAS and PPS analyses, without significant differences between the two groups. On the FAS analysis, the satisfaction and tolerability scores were high in both groups, without significant differences. The first bowel movement after taking the investigational product occurred 30 min earlier in the mini-OST group than in the OST group. Mild, moderate, and severe adverse events (AEs) were comparable between the two groups; however, any AEs were more common in the mini-OST group than in the conventional OST group overall.

CONCLUSIONS

Compared with conventional OST, the novel mini-OST preparation showed similar efficacy, tolerability, and safety, including mild eight solicited AEs and moderate-to-severe AEs. Clinical trial registration NCT05670470.