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Bowel Cleansing Agents

 

Bisacodyl, CitraFleet®, Citramag®, Docusate Sodium, Kleanprep®, Moviprep®, Picolax®(sodium picosulfate), Plenvu®

[For bisacodyl for treatment of constipation see Stimulant Laxative monograph and for docusate sodium for the treatment of constipation see Softening Laxatives monograph]

 Issues for Surgery


Dehydration may occur in patients with reduced fluid intake or those at risk of electrolyte imbalance complications (i.e. frail, elderly, renally impaired) when given pre-operatively – see Further Information.

Increased risk of infection if clinically indicated and not given pre-operatively1.

  Advice in the Perioperative period


Elective Surgery
Bowel cleansing agents are used to prepare the bowel for endoscopy, radiological procedures, or surgery that requires a clean bowel.

Patients should be assessed for the suitability of bowel cleansing agents and be fully counselled on the correct procedure to follow for the bowel preparation that they have been given – see Further Information.

Check renal function and electrolytes prior to commencing bowel preparation2.

For Patients with Diabetes Mellitus
Patients who take medication for diabetes mellitus and require bowel cleansing agents will require alterations to their medication whilst they have an altered diet / are fasting. NHS Trusts / Health Boards should have agreed guidance for patients undergoing any procedure that requires the use of bowel cleansing agents.

For Patients taking Laxatives
Patients who take regular laxatives should be advised to stop taking these while they are taking bowel cleansing agents.

For Patients taking Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Where possible NSAIDs should be discontinued on the day of administration of any oral bowel cleansing agent and withheld until 72 hours after the procedure2, 3.

Emergency Surgery
If there is time, and it is safe for the patient to use bowel cleansing agents prior to emergency surgery, follow the advice as for elective surgery.

Post-operative Advice
Check renal function and electrolytes post-operatively.

  Interaction(s) with Common Anaesthetic Agents


Hypokalaemia
Bisacodyl, Citrafleet® and sodium picosulfate can cause hypokalaemia (mainly in the cases of misuse or overdose). Hypokalaemia increases the risk of torsades de pointes, which might be additive with the effects of desflurane, isoflurane, sevoflurane and thiopental4.

  Interaction(s) with other Common Medicines used in the Perioperative Period


Bowel cleansing agents increase gastrointestinal transit rate and as a result absorption of oral medication may be reduced if taken alongside bowel prep products5, 6, 7, 8. Oral medication should be avoided at least one hour before and after administration of bowel cleansing agents2, 3, 9, 10. See also under Antimicrobials.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs reduce renal perfusion and therefore limit the kidney’s capacity to compensate for reduced renal perfusion through potential volume depletion that may occur with bowel cleansing agents. Where possible, NSAIDs should be discontinued on the day of administration of any oral bowel cleansing agent and withheld until 72 hours after the procedure2, 3; however, a single intra-operative dose may be given at discretion of anaesthetist as part of multi-modal analgesia approach (providing patient is adequately hydrated and no significant comorbidities e.g. frailty, renal impairment).

Caution is advised when CitraFleet® or Picolax® are used concomitantly with NSAIDs due to the increased risk of water retention and / or electrolyte imbalance5, 6.

Hypokalaemia
Bisacodyl, Citrafleet® and sodium picosulfate can cause hypokalaemia (mainly in the cases of misuse or overdose). Hypokalaemia increases the risk of torsades de pointes with medicines which prolong the QT-interval e.g. antiemetics (haloperidol, ondansetron), antimicrobials (ciprofloxacin, clarithromycin, erythromycin), corticosteroids and loperamide4, 5, 6.

Monitor potassium closely.

Antimicrobials
Tetracycline and fluoroquinolone antibiotics should be taken at least 2 hours before and not less than 6 hours after administration of CitraFleet® or Picolax® to avoid chelation with magnesium5, 6.

  Further Information


Safe Prescribing
In 2009 the NPSA issued a Rapid Response Report on the potential risk of harm associated with use of oral bowel cleansing preparations. Death and harm from electrolyte abnormalities, dehydration and serious gastrointestinal problems have been associated with the use of bowel cleansing agents prior to surgery and / or investigative procedures. Frail and debilitated elderly patients and those with contraindications (e.g. renal impairment) are particularly at risk3, 8, 11.

NHS Trusts / Health Boards should have safeguards in place to reduce the risk, ensuring that a clinical assessment of each patient for contraindications and risk takes place, that the use of a bowel cleansing agent is authorised by a clinician, that an explanation on the safe use of the preparation is provided to the patient, and that a safe system exists for the supply of preparation to each patient3.

  References


  1. National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE Guideline 125. Accessed via https://www.nice.org.uk/guidance/ng125 27/02/22. Published 19th  August 2020
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 9th October 2021]
  3. Connor A, Tolan D, Hughes S et al. Consensus guidelines for the safe prescription and administration of oral bowel-cleansing agents. Gut (2012). Accessed via www.rcr.ac.uk 9th October 2021 Doi:10.1136/gutjnl-2011-300861
  4. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 9th October 2021]
  5. Summary of Product Characteristics – CitraFleet® Powder for oral solution in sachet. Casen Recordati S.L. Accessed via www.medicines.org.uk 18/10/2021 [date of revision of the text February 2020]
  6. Summary of Product Characteristics – Picolax®. Ferring Pharmaceuticals Limited. Accessed via www.medicines.org.uk 18/10/2021 [date of revision of the text May 2021]
  7. Summary of Product Characteristics – Plenvu® powder for oral solution. Norgine Limited. Accessed via www.medicines.org.uk on 18/10/2021 [date of revision of the text October 2020]
  8. Sodium Picosulfate. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed on 9th October 2021]
  9. Summary of Product Characteristics – MOVIPREP®, powder for oral solution. Norgine Limited. Accessed via www.medicines.org.uk 18/10/2021 [date of revision of the text November 2020]
  10. Summary of Product Characteristics – KLEAN PREP® 69g, sachet powder for oral solution. Norgine Limited. Accessed via www.medicines.org.uk 18/10/2021 [date of revision of the text September 2020]
  11. National Patient Safety Agency (NPSA). Rapid Response Report (NPSA/2009/RRR012). Reducing the risk of harm from oral bowel cleansing solutions. 19th February 2009. Accessed via https://webarchive.nationalarchives.gov.uk/ukgwa/20171030124607/http://www.nrls.npsa.nhs.uk/resources/type/alerts/?p=2 27th February 2022
Bisacodyl CitraFleet Citrameg Docusate Sodium Kleanprep Moviprep Picolax Sodium Picosulfate Plenvu