A prospective randomized clinical study evaluating the efficacy and compliance of oral sulfate solution and 2-L ascorbic acid plus polyethylene glycol

Comparison of the efficacy and safety of an oral sulfate solution and 3-L polyethylene glycol on bowel preparation before colonoscopy: a phase III multicenter randomized controlled trial

BACKGROUND AND AIMS

Adequate bowel preparation is crucial for clear mucosal visualization during colonoscopy. We aimed to comprehensively compare oral sulfate solution (OSS) and 3-L split-dose polyethylene glycol (PEG) for bowel preparation before colonoscopy.

METHODS

This randomized, active-controlled, noninferiority study was performed in 10 medical centers. Eligible subjects were enrolled to receive OSS or 3-L PEG in a split-dose regimen. The quality of bowel preparation, adverse reactions, and acceptability were evaluated. The quality of bowel preparation was evaluated using the Boston Bowel Preparation Scale. Safety was evaluated by adverse reactions. The study population was divided into the full analysis set (FAS), the safety set, the modified FAS (mFAS), and the per-protocol set (PPS).

RESULTS

Three hundred forty-eight potentially eligible subjects were enrolled. Three hundred forty-four subjects were included in the FAS and safety set, 340 subjects were included in the mFAS, and 328 subjects were included in the PPS. Adequate bowel preparation of the OSS was not inferior to 3-L PEG in the mFAS (98.22% vs 97.66%) and the PPS (98.17% vs 98.78%). There was no significant difference in acceptability between the 2 groups (94.74% vs 94.80%, P = .9798). Overall adverse reactions were similar (50.88% vs 44.51%, P = .2370) between the 2 groups.

CONCLUSIONS

The split-dose OSS regimen was not inferior to the split-dose 3-L PEG regimen for the quality of bowel preparation in a Chinese adult population. The safety and acceptability of the 2 groups were similar. (Clinical trial registration number: NCT05465889.).

The Efficacy of 480 ml Oral Sodium Sulfate for Improving Insufficient Bowel Preparation of Colonoscopy with High-Concentrated Polyethylene Glycol

Objectives

Oral sulfate solution (OSS) is used for bowel preparation (BP) during colonoscopy. The way of taking this agent can be used a same-day regimen (only on the day of colonoscopy) and split regimen (the day before and on the day of colonoscopy) for receiving it. In this study, we analyzed the efficacy of a same-day regimen of 480 ml OSS for insufficient bowel preparation (BP) with high-concentrated polyethylene glycol (H-PEG).

Materials and Methods

This multicenter retrospective study was conducted from December 2021 to December 2022 at three related institutions on patients aged ≥ 20 years with a fair or poor Aronchick score of BP with 1 l H-PEG in previous colonoscopy. All patients received a low-residual diet and 10 ml of 0.75% picosulfate sodium a day before the colonoscopy and 480 ml of OSS and ≥1 l of water 3 hours before the colonoscopy. We analyzed the rate of improvement with OSS compared to H-PEG and other efficacies, and adverse events (AE).

Results

We evaluated 125 cases (77 males) with an average age of 72.1 ± 8.8 years. The completion rate of 480 ml of OSS was 97.6% (122/125). The improvement rate of BP showing good or excellent score with OSS was 70.4% (88/125). Compared OSS with previous H-PEG, the insertion time (min) was 7.0 ± 4.8 vs. 8.1 ± 6.0 (p = 0.01), and the adenoma detection rates were 67.2% vs. 63.2% (p = 0.05). The cleansing time (min) was 131 ± 46 vs. 165 ± 53 (p < 0.01). The rate of AE with OSS was 10.4% (13/125). There were no significant differences about AE in age and gender. The tolerance of OSS compared with H-PEG (good/similar/bad) was 72.0%/24.8%/3.2% (amounts), 26.4%/39.2%/34.4% (taste), and 76.8%/10.4%/12.8% (overall preference), respectively.

Conclusions

The same-day regimen of 480 ml OSS effectively improved the insufficient BP of 1 l H-PEG.

[Hyponatremic Seizure after Ingestion of an Oral Sulfate Tablet for Bowel Preparation for Colonoscopy]

The oral sulfate tablet (OST), commercially available as Orafang^® (Pharmbio Korea Co., Seoul, Korea) in Korea, is being used increasingly because of its bowel-cleansing efficacy, safety, and tolerability in adults undergoing colonoscopy. Other bowel cleansing agents, such as polyethylene glycol and sodium picosulfate/magnesium citrate, can cause plasma volume depletion and electrolyte disturbances, such as hyponatremia. On the other hand, the OST has never been reported to cause hyponatremia in Korea. To our knowledge, the authors experienced the first case of hyponatremic seizure in an 81-year-old woman to whom an OST was administered for bowel preparation before a colonoscopy. After ingesting the OST, she presented with seizure, confusion, and dyspnea. Upon arrival, her serum sodium level was 120 mEq/L, and the urine osmolality and sodium levels were 449 mOsm/kg and 253 mOsm/kg, respectively; chest imaging suggested pulmonary edema. The associated symptoms disappeared following treatment with an intravenous injection of normal saline and 3% NaCl to normalize the sodium level. This case shows that the OST can cause hyponatremia and other severe complications related to hyponatremia.

Evaluation of the efficacy of 1 L polyethylene glycol plus ascorbic acid and an oral sodium sulfate solution: A multi-center, prospective randomized controlled trial

INTRODUCTION

Low-volume bowel preparation has been developed to increase patient compliance. We compared 1 L of polyethylene glycol/ascorbic acid (PEG/Asc) and oral sodium sulfate (OSS) with respect to bowel preparation efficacy, compliance, and safety.

METHODS

A multicenter, prospective, randomized, single-blinded, non-inferiority trial was conducted in 3 hospitals. Patients were randomized to receive a bowel-cleansing agent. Bowel-cleansing efficacy was evaluated using the Boston Bowel Preparation Scale (BBPS). Satisfaction, feeling, taste of the bowel cleanser, and adverse events after taking the bowel cleanser were investigated through a questionnaire. Additionally, blood samples were analyzed before and after bowel cleansing.

RESULTS

In total, 172 patients were analyzed (85 with 1 L PEG/Asc and 87 with OSS), and the mean BBPS scores were comparable between agents. The 1L PEG/Asc group tended to have a higher BBPS score in the right colon (2.22 vs 2.02; P = .08). The compliance of 1 L of PEG/Asc was comparable to that of OSS. Patients taking 1 L PEG/Asc reported greater thirst and dizziness (P = .04 and P = .047, respectively) than the OSS cohort. On the other hand, gastrointestinal symptoms such as vomiting and abdominal distension were more common in the OSS group, without statistical significance. In terms of laboratory adverse events, elevation of serum creatinine was found in both groups after taking the bowel cleansing agent (P < .001 for the 1L PEG/Asc group; P = .04 for the OSS group). However, most of the increased values were within the normal ranges.

DISCUSSION

The 1L PEG/Asc treatment was comparable to OSS in terms of bowel preparation efficacy, compliance, and safety.

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.

Oral sulfate solution versus low-volume polyethylene glycol for bowel preparation: Meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Oral sodium sulfate (OSS) solution and low-volume polyethylene glycol-based solutions are two of the more common low-volume purgatives used as colonoscopy preparations. Data on how these different low-volume solutions compare are mixed. Our aim was to conduct a meta-analysis of randomized controlled trials (RCTs) to compare OSS with low-volume polyethylene glycol solutions (PEG) plus ascorbic acid (PEG + Asc) solution with respect to (i) satisfactory bowel preparation, (ii) excellent bowel preparation, and (iii) tolerability.

METHODS

Studies were identified by searching 10 medical databases for reports published from 1974 until 2019. Only fully published RCTs comparing OSS and low-volume PEG-based products with regard to overall satisfactory bowel preparation were included. Pooling was conducted by both fixed-effects and random effects models; results are presented from the random effects model when heterogeneity was significant.

RESULTS

Seven studies (involving 2049 subjects) met the inclusion criteria. There was no difference between OSS and PEG + Asc with respect to adequate bowel preparation (risk ratio [RR] 1.02 [0.99-1.06]; P = 0.16). OSS did result in a higher chance of excellent bowel preparation (RR 1.18 [1.06-1.31]; P = 0.03). OSS was associated with a 30% increased risk of nausea (RR 1.35 [1.03-1.77]; P = 0.03) and more than double the risk of vomiting (RR 2.30 [1.63-2.23]; P < 0.05) compared with PEG + Asc. Begg's funnel plot indicated low probability of publication bias.

CONCLUSIONS

Individuals at low risk of inadequate bowel preparation who use OSS for bowel preparation are more likely to achieve excellent bowel preparation, but are more likely to experience nausea and vomiting than are individuals using low-volume PEG-based solutions.

Efficacy and safety of oral sulfate solution for bowel preparation in Japanese patients undergoing colonoscopy: Noninferiority-based, randomized, controlled study

OBJECTIVES

To compare the efficacy and safety of oral sulfate solution administered using the same-day dose and the split-dose regimens with those of polyethylene glycol plus ascorbate solution, used for bowel preparation in Japanese patients undergoing colonoscopy.

METHODS

This multicenter (n = 13), randomized, active-controlled, colonoscopist- and image evaluator-blinded, noninferiority study with parallel-group comparison recruited 632 patients from December 2018 to June 2019. Of these, 602 patients were divided into the oral sulfate solution same-day dose group (n = 200); oral sulfate solution split-dose group (n = 202); and polyethylene glycol plus ascorbate same-day dose group (n = 200). Differences in the efficacy rates between the polyethylene glycol plus ascorbate group and each oral sulfate solution group were calculated using the asymptotic method. The safety of the oral sulfate solution was evaluated, based on the occurrence of adverse events and reactions.

RESULTS

Both oral sulfate solution protocols were confirmed as noninferior to the polyethylene glycol plus ascorbate protocol for bowel-cleansing. The occurrence of adverse reactions was significantly lower in the oral sulfate solution same-day dose group than in the polyethylene glycol plus ascorbate group (P = 0.010). The occurrence of adverse reactions was not significantly different between the oral sulfate solution split-dose and the polyethylene glycol plus ascorbate group.

CONCLUSIONS

Oral sulfate solution is not only safe and efficacious but also not inferior to polyethylene glycol plus ascorbate solution (active control). It could be used for bowel preparation in Japanese patients scheduled for colonoscopy (Clinical trial registration number: NCT03794310).