Bowel cleansing

Other drugs used for Bowel cleansingBisacodyl, p.61

.

Docusate sodium, p.61

.

Magnesium sulfate, p.1051

LAXATIVES

›

OSMOTIC LAXATIVES

Citric acid with magnesium carbonate

09-Jul-2018

(Formulated as a bowel cleansing preparation)

lINDICATIONS AND DOSE

Bowel evacuation for surgery, colonoscopy or radiological examination

▶BY MOUTH

▶Child 5–9 years:One-third of a sachet to be given at 8a.m. the day before the procedure and, one-third of a sachet to be given between2^and4p.m. the day before the procedure

▶Child 10–17 years:0^.5–1sachet, given at8a.m. the day before the procedure and0^.5–1sachet, given between 2^and4p.m. the day before the procedure

▶Adult:1sachet, given8a.m. the day before the procedure and1sachet, given between2^and4^{p.m. the} day before the procedure, use half the dose in frail elderly patients

lCONTRA-INDICATIONSAcute severe colitis

.

gastric retention

.

gastro-intestinal obstruction

.

gastro-intestinal perforation

.

toxic megacolon

lCAUTIONSChildren

.

colitis (avoid if acute severe colitis)

.

debilitated

.

elderly

.

hypovolaemia (should be corrected before administration of bowel cleansing preparations)

.

impaired gag reflex or possibility of regurgitation or aspiration

.

patients withfluid and electrolyte disturbances CAUTIONS, FURTHER INFORMATIONAdequate hydration should be maintained during treatment.

lINTERACTIONS→Appendix1: bowel cleansing preparations

lSIDE-EFFECTS

▶Common or very commonGastrointestinal discomfort

.

nausea

.

vomiting

▶UncommonDehydration

.

dizziness

.

electrolyte imbalance

.

headache

SIDE-EFFECTS, FURTHER INFORMATIONAbdominal pain is usually transient and can be reduced by taking preparation more slowly.

lPREGNANCYUse with caution.

lBREAST FEEDINGUse with caution.

lRENAL IMPAIRMENT

▶In adultsAvoid if eGFR less than30^mL/minute/1^.73^m2— risk of hypermagnesaemia.

▶In childrenAvoid if estimated glomerularfiltration rate less than30^mL/minute/1^.73^m2—risk of hypermagnesaemia.

50 Constipation and bowel cleansing

BNF78

Gastro-intestinalsystem

1

lMONITORING REQUIREMENTSRenal function should be measured before starting treatment in patients at risk of fluid and electrolyte disturbances.

lDIRECTIONS FOR ADMINISTRATIONOne sachet should be reconstituted with200mL of hot water; the solution should be allowed to cool for approx.30minutes before drinking.

lPRESCRIBING AND DISPENSING INFORMATION Reconstitution of one sachet containing11^.57^g magnesium carbonate and17^.79g anhydrous citric acid produces a solution containing magnesium citrate with 118^{mmol Mg2+.}

Flavours of oral powders may include lemon and lime.

lPATIENT AND CARER ADVICELow residue orfluid only diet (e.g. water, fruit squash, clear soup, black tea or coffee) recommended before procedure (according to prescriber’s advice) and copious intake of clearfluids recommended until procedure. Patient or carers should be given advice on how to administer oral powder.

lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.

Effervescent powder

CAUTIONARY AND ADVISORY LABELS13, 10 ELECTROLYTES:May contain Magnesium

▶Citramag(Sanochemia Diagnostics UK Ltd)

Magnesium carbonate heavy 11.57 gram, Citric acid anhydrous 17.79 gramCitramag effervescent powder sachets sugar-free| 10sachet^p £20.50

Macrogol 3350 with anhydrous sodium sulfate, ascorbic acid,

potassium chloride, sodium ascorbate and sodium chloride

01-Mar-2018

(Polyethylene glycols)

lINDICATIONS AND DOSE MOVIPREP^®

Bowel cleansing [before any procedure requiring a clean bowel]

▶BY MOUTH

▶Adult:1litre daily for2^doses;first dose of reconstituted solution taken on the evening before procedure and the second dose on the morning of procedure, alternatively2litres daily for1^dose;

reconstituted solution to be taken on the evening before the procedure, or on the morning of the procedure, treatment should be completed at least 1hour before clinical procedures conducted without general anaesthesia, and at least2hours before clinical procedures conducted under general anaesthesia PLENVU^®

Bowel cleansing [before any procedure requiring a clean bowel]

▶BY MOUTH

▶Adult:500mL daily for2^doses;first dose of reconstituted solution taken on the evening before procedure and the second dose on the morning of procedure, alternatively1litre daily in2divided doses, reconstituted solution to be taken either on the evening before the procedure, or in the morning of the procedure—separate doses by at least1^hour, treatment should be completed at least1hour before clinical procedures conducted without general anaesthesia, and at least2hours before clinical procedures conducted under general anaesthesia

lCONTRA-INDICATIONSDisorders of gastric emptying

.

G6PD deficiency

.

gastro-intestinal obstruction

.

gastro-intestinal perforation

.

ileus

.

toxic megacolon lCAUTIONSDebilitated patients

.

dehydration (correct

before administration)

.

impaired consciousness

.

impaired gag reflex or possibility of regurgitation or aspiration

.

moderate-to-severe cardiac impairment

.

patients at risk of arrhythmia (including those with thyroid disease or electrolyte imbalance)

.

severe acute inflammatory bowel disease

lINTERACTIONS→Appendix1: bowel cleansing preparations

lSIDE-EFFECTS

▶Common or very commonChills

.

dehydration

.

dizziness

.

fever

.

gastrointestinal discomfort

.

headaches

.

hunger

.

malaise

.

nausea

.

sleep disorder

.

thirst

.

vomiting

▶UncommonArrhythmias

.

asthenia

.

drowsiness

.

dry mouth

.

dry throat

.

dysphagia

.

electrolyte imbalance

.

hot flush

.

pain

.

palpitations

.

temperature sensation altered

▶Frequency not knownFlatulence

.

hyponatraemic seizure SIDE-EFFECTS, FURTHER INFORMATIONAbdominal pain is usually transient and can be reduced by taking preparation more slowly.

lPREGNANCYManufacturer advises use only if essential— no or limited information available.

lBREAST FEEDINGManufacturer advises use only if essential—no information available.

lRENAL IMPAIRMENTManufacturer advises caution if eGFR less than30^mL/minute/1^.73^m2.

lMONITORING REQUIREMENTSManufacturer advises consider monitoring baseline and post-treatment electrolytes, renal function and ECG as appropriate, in debilitated patients, those with significant renal impairment, arrhythmia, or at risk of electrolyte imbalance.

lDIRECTIONS FOR ADMINISTRATION

PLENVU^®Manufacturer advises the contents of the single sachet for Dose1should be made up to500mL with water and taken over30minutes; the contents of the2^sachets (A and B) for Dose2should be made up to500^{mL with} water and taken over30minutes. Each dose should be followed by500mL of clearfluid taken over30^minutes.

MOVIPREP^® Manufacturer advises one pair of sachets (A and B) should be made up to1litre with water and taken over1–2^hours;1litre of other clearfluid should also be taken during treatment.

lPRESCRIBING AND DISPENSING INFORMATION

PLENVU^®Dose1(single sachet) when reconstituted up to 500mL with water provides Na⁺160^.9^{mmol, K+}13^.3^mmol, Cl^-47^.6^{mmol; Dose}2(sachets A and B) when

reconstituted up to500mL with water provides Na⁺ 297^.6^{mmol, K+}16^.1^{mmol, Cl-}70^.9^mmol.

MOVIPREP^® 1pair of sachets (A+B) when reconstituted up to1litre with water provides Na⁺181^.6^{mmol (Na+} 56^.2mmol absorbable), K⁺14^.2^{mmol, Cl–}59^.8^mmol.

lPATIENT AND CARER ADVICEManufacturer advises solid food should not be taken during treatment until procedure completed.

lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.

Oral powder

CAUTIONARY AND ADVISORY LABELS10, 13 EXCIPIENTS:May contain Aspartame

ELECTROLYTES:May contain Chloride, potassium, sodium

▶Moviprep(Forum Health Products Ltd)

Moviprep oral powder sachets sugar-free|4sachet^p£10.36

▶Plenvu(Forum Health Products Ltd)

Plenvu oral powder sachets sugar-free|3sachet^p£12.43

BNF78

Bowel cleansing 51

Gastro-intestinalsystem

1

Macrogol 3350 with anhydrous sodium sulfate, potassium chloride, sodium bicarbonate and sodium chloride

(Formulated as a bowel cleansing preparation)

lINDICATIONS AND DOSE

Bowel cleansing before radiological examination, colonoscopy, or surgery

▶INITIALLY BY MOUTH

▶Adult:Initially2litres daily for2^doses:first dose of reconstituted solution taken on the evening before procedure and the second dose on the morning of procedure, alternatively (by mouth) initially250^mL every10–15minutes, reconstituted solution to be administered, alternatively (by nasogastric tube) initially20–30mL/minute, starting on the day before procedure until4litres have been consumed lCONTRA-INDICATIONSAcute severe colitis

.

gastric

retention

.

gastro-intestinal obstruction

.

gastro-intestinal perforation

.

toxic megacolon

lCAUTIONSColitis (avoid if acute severe colitis)

.

debilitated patients

.

elderly

.

fluid and electrolyte disturbances

.

heart failure

.

hypovolaemia (should be corrected before administration of bowel cleansing preparations)

.

impaired gag reflex or possibility of regurgitation or aspiration lINTERACTIONS→Appendix1: bowel cleansing

preparations

lSIDE-EFFECTSAngioedema

.

arrhythmia

.

chills

.

confusion

.

dehydration

.

dizziness

.

dyspnoea

.

electrolyte imbalance

.

fever

.

flatulence

.

gastrointestinal discomfort

.

headache

.

malaise

.

nausea

.

palpitations

.

seizure

.

skin reactions

.

thirst

.

vomiting

SIDE-EFFECTS, FURTHER INFORMATIONAbdominal pain is usually transient and can be reduced by taking preparation more slowly.

lPREGNANCYManufacturers advise use only if essential— no information available.

lBREAST FEEDINGManufacturers advise use only if essential—no information available.

lMONITORING REQUIREMENTSRenal function should be measured before starting treatment in patients at risk of fluid and electrolyte disturbances.

lDIRECTIONS FOR ADMINISTRATION1sachet should be reconstituted with1litre of water. Flavouring such as clear fruit cordials may be added if required. After

reconstitution the solution should be kept in a refrigerator and discarded if unused after24^hours.

lPRESCRIBING AND DISPENSING INFORMATIONEach Klean-Prep^®sachet provides Na⁺125^{mmol, K+}10^{mmol, Cl} -35mmol and HCO^3-20mmol when reconstituted with 1litre of water.

lPATIENT AND CARER ADVICESolid food should not be taken for2hours before starting treatment. Adequate hydration should be maintained during treatment.

Treatment can be stopped if bowel motions become watery and clear.

lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.

Powder

CAUTIONARY AND ADVISORY LABELS10, 13 EXCIPIENTS:May contain Aspartame

ELECTROLYTES:May contain Bicarbonate, chloride, potassium, sodium

▶Klean-Prep(Forum Health Products Ltd)

Potassium chloride 742.5 mg, Sodium chloride 1.465 gram, Sodium bicarbonate 1.685 gram, Sodium sulfate anhydrous

5.685 gram, Polyethylene glycol 3350 59 gramKlean-Prep oral powder69g sachets sugar-free|4sachet^p £10.48 LAXATIVES

›

STIMULANT LAXATIVES

Magnesium citrate with sodium picosulfate

(Formulated as a bowel cleansing preparation)

lINDICATIONS AND DOSE CITRAFLEET^®SACHETS

Bowel evacuation on day before radiological examination, endoscopy, or surgery

▶BY MOUTH

▶Adult:1sachet taken before8^{a.m, then}1sachet after 6–8^hours

PHARMACOKINETICS

▶ForCitraFleet^®: Acts within3^{hours of}first dose.

PICOLAX^®SACHETS

Bowel evacuation on day before radiological procedure, endoscopy, or surgery

▶BY MOUTH

▶Child 1 year:0^.25sachet taken before8^{a.m, then} 0^.25sachet after6–8^hours

▶Child 2–3 years: 0^.5sachet taken before8^{a.m, then} 0^.5sachet after6–8^hours

▶Child 4–8 years:1sachet taken before8^{a.m, then} 0^.5sachet after6–8^hours

▶Child 9–17 years:1sachet taken before8^{a.m, then} 1sachet after6–8^hours

▶Adult:1sachet taken before8^{a.m, then}1sachet after 6–8^hours

PHARMACOKINETICS

▶ForPicolax^®: Acts within3^{hours of}first dose.

lCONTRA-INDICATIONSAcute severe colitis

.

ascites

.

congestive cardiac failure

.

gastric retention

.

gastro-intestinal obstruction

.

gastro-intestinal perforation

.

gastro-intestinal ulceration

.

toxic megacolon lCAUTIONSCardiac disease (avoid in congestive cardiac

failure)

.

children

.

colitis (avoid if acute severe colitis)

.

debilitated patients

.

elderly

.

fluid and electrolyte disturbances

.

hypovolaemia (should be corrected before administration)

.

impaired gag reflex or possibility of regurgitation or aspiration

.

recent gastro-intestinal surgery

lSIDE-EFFECTS

▶Common or very commonGastrointestinal discomfort

.

headache

.

nausea

▶UncommonConfusion

.

electrolyte imbalance

.

gastrointestinal disorders

.

seizures

.

skin reactions

.

vomiting

lPREGNANCYCaution.

lBREAST FEEDINGCaution.

lHEPATIC IMPAIRMENTAvoid in hepatic coma if risk of renal failure.

lRENAL IMPAIRMENT

▶In adultsAvoid if eGFR less than30^mL/minute/1^.73^m2— risk of hypermagnesaemia.

▶In childrenAvoid if estimated glomerularfiltration rate less than30^mL/minute/1^.73^m2—risk of hypermagnesaemia.

lDIRECTIONS FOR ADMINISTRATIONOne sachet of sodium picosulfate with magnesium citrate powder should be reconstituted with150mL (approx. half a glass) of cold water; patients should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.

52 Constipation and bowel cleansing

BNF78

Gastro-intestinalsystem

1

PICOLAX^®SACHETS, CITRAFLEET^®SACHETSOne sachet should be reconstituted with150mL (approx. half a glass) of cold water.

lPRESCRIBING AND DISPENSING INFORMATIONFlavours of oral powder formulations may include lemon.

PICOLAX^®SACHETSOne reconstituted sachet contains K⁺ 5mmol and Mg²⁺87^mmol.

CITRAFLEET^®SACHETSOne reconstituted sachet contains K⁺5mmol and Mg²⁺86^mmol.

lPATIENT AND CARER ADVICELow residue diet recommended on the day before procedure and copious intake of water or other clearfluids recommended during treatment. Patients and carers should be given advice on how to administer oral powder; they should be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.

lMEDICINAL FORMSThere can be variation in the licensing of different medicines containing the same drug.

Powder

CAUTIONARY AND ADVISORY LABELS10, 13 ELECTROLYTES:May contain Magnesium, potassium

▶CitraFleet(Casen Recordati S.L.)

Sodium picosulfate 10 mg, Magnesium oxide light 3.5 gram, Citric acid anhydrous 10.97 gramCitraFleet oral powder15.08g sachets sugar-free|2sachet^p£3.25

▶Picolax(Ferring Pharmaceuticals Ltd)

Sodium picosulfate 10 mg, Magnesium oxide 3.5 gram, Citric acid anhydrous 12 gramPicolax oral powder16.1g sachets sugar-free| 2sachet^p£3.39

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