Cost-analysis model of colonoscopy preparation using split-dose reduced-volume oral sulfate solution (OSS) and polyethylene glycol with electrolytes solution (PEG-ELS)

Navigating Bowel Preparation for Colonoscopy: A Comprehensive Overview

Colorectal cancer (CRC) is the third most common cancer in the United States. Early detection through colonoscopy significantly improves survival rates. Detecting colon polyps depends on the quality of bowel preparation. However, inadequate bowel preparation remains a significant issue in clinical practice. Efforts to address this challenge have led to the development of bowel preparation regimens emphasizing efficacy, tolerability, and safety. Bowel preparation options can be categorized by their osmotic and volume properties. Isosmotic solutions based on polyethylene glycol-electrolyte lavage solutions (PEG-ELS) are available in both low-volume PEG-ELS with ascorbic acid (PEG-Asc) (e.g., MoviPrep, PLENVU) and high-volume formulations (e.g., GoLYTELY, CoLyte), as well as sulfate-free high-volume PEG-ELS formulations (SF-PEG-ELS). Hyperosmotic solutions include oral sulfate solution (OSS) (e.g., SUPREP), sodium phosphate tablets (NaP) (e.g., OsmoPrep), oral sulfate tablets (OST) (e.g., SUTAB), flavored PEG with sulfate salts (FPSS) (e.g., SUFLAVE), and magnesium citrate. Hypoosmotic solutions consist of PEG-sports drink (PEG-SD). In addition, combination solutions are available, such as sodium picosulfate with magnesium citrate (SPMC) with laxatives (e.g., CLENPIQ), and OSS with SF-PEG-ELS (Suclear). Each regimen differs in terms of cost, volume, taste, contraindications, and potential adverse effects. Therefore, clinicians must carefully evaluate each patient to determine the most suitable regimen for their patients.

Efficacy and safety of oral sulfate solution versus polyethylene glycol for colonoscopy: A systematic review and meta-analysis of randomized controlled trials

Background

Colonoscopy is the gold standard for early detection and monitoring of colorectal cancer. Procedural effectiveness is dependent on optimal bowel preparation. Traditional polyethylene glycol (PEG) solutions are difficult to tolerate, whereas newer low-volume alternatives, including PEG with ascorbic acid and oral sulfate solutions (OSS), offer improved efficacy and tolerability. The meta-analysis was performed to evaluate the efficacy and safety of OSS compared to PEG for bowel preparation in colonoscopy.

Methods

Studies were identified by searching PubMed, Embase, Cochrane CENTRAL, and clinicaltrials.gov from inception until June 2024. Only randomized controlled trials comparing OSS with PEG were included. Data was analyzed using R version 4.4.0 using a random effects model to calculate risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results

Twenty-one studies with 6346 participants met the inclusion criteria. OSS significantly improved adenoma detection (RR, 1.13; 95% CI, 1.04-1.22; p-value <0.01; I2 = 0%) and polyp detection rates (RR, 1.16; 95% CI, 1.06-1.26; p-value <0.01; I2 = 0%), and had a higher Boston Bowel Preparation Scale (BBPS) score (MD, 0.31; 95% CI, 0.13-0.50; p-value <0.01; I2 = 81%). PEG was associated with more sleep disturbances (RR, 0.45; 95% CI, 0.25-0.82; p-value = 0.03; I2 = 0%). However, other adverse effects were similar between both solutions.

Conclusion

OSS demonstrated superior adenoma and polyp detection rates. When compared to PEG, patients utilizing OSS achieved higher BBPS scores. Data gleaned support enhanced cleansing efficacy and safety of OSS as a bowel preparation regimen.

Oral sulfate solution benefits polyp and adenoma detection during colonoscopy: Meta-analysis of randomized controlled trials

OBJECTIVES

Although oral sulfate solution (OSS) has been revealed to be not only safe and efficacious but also noninferior to polyethylene glycol with ascorbic acid (PEG + ASC), it is unclear whether OSS can ultimately increase the polyp detection rate (PDR) and adenoma detection rate (ADR). We performed this meta-analysis to estimate the effect of OSS on PDR and ADR during colonoscopy.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library to identify relevant randomized controlled trials (RCTs) investigating the comparative effect of OSS versus PEG + ASC on the PDR and ADR during colonoscopy. Cecal intubation time (CIT), cecal intubation rate (CIR), and bowel preparation score were also evaluated. Review Manager (RevMan) version 5.3.0 was used to perform statistical analysis.

RESULTS

Eight RCTs involving 2059 patients fulfilled the selection criteria. Meta-analysis suggested that OSS significantly increased the PDR (47.34% vs. 40.14%, risk ratio [RR] 1.13, 95% confidence interval [CI] 1.03-1.24, P = 0.01) and ADR (44.60% vs. 38.14%, RR 1.17, 95% CI 1.03-1.33, P = 0.01) during colonoscopy. Subgroup analysis showed that the beneficial effects of OSS on PDR and ADR were consistent among patients with mean age >55 years and with body mass index <25 kg/m² receiving outpatient colonoscopy, morning colonoscopy, and the 2-L bowel preparation protocol. Meanwhile, patients receiving OSS had a beneficial bowel preparation score.

CONCLUSION

Compared with polyethylene glycol-based regimens, the OSS bowel preparation regimen significantly increased the PDR and ADR in patients undergoing colonoscopy.

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy

AIM

To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy.

METHODS

Retrospective review of the University of Michigan and Veteran’s Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation.

RESULTS

Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality.

CONCLUSION

Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.