Bowel cleansing before colonoscopy: Balancing efficacy, safety, cost and patient tolerance

Table 1 Relative effectiveness and cost of available bowel preparations

Prep		% Adequate	Lesion detection rate	Cost1
4 L PEG	Single	51%-88%[16,64]	PDR 50.5%-51%[26,51]	PEG 3350 with electrolytes 4 L
	Split	71.3%-92.1%[23,51]	ADR 27.8-34.3%[51,70]	$26.59
2 L PEG	Single	83.5%-91%[45,64]	ADR 18.8%[70]	Moviprep 100 g/1 kit
	Split	74.4%-93.5%[45,48]		$91.55
MiraLAX	Single	67.8%-81.8%[29,31]	PDR 47%[26]	MiraLAX 8.3oz/238 g
	Split			$13.99
Sodium Phosphate		84.3%-90%[35,37]	Not Available	OsmoPrep 32 tabs
				$163.05
Sodium Picosulfate	Single	61.5%-82.6%[49,51]	PDR 38.5%-42.9%[51,53]	Prepopik, 2 pkts
	Split	81.6%-87.9%[49,50]	ADR 23.8%-31.3%[51,53]	$121.31
Oral Sulfate Solution	SuPrep	94.7%-98.4%[44,53]	PDR 50.9%[53]	SuPrep 1 kit
				$49.09
	Suclear	93.5%[45]	ADR 26%[53]	Suclear
				$76.38

¹Prices from RxPriceQuotes.com as listed for CVS w/exception of MiraLAX which was priced at local CVS. PEG: Polyethylene glycol; PDR: Polyp detection rate; ADR: Adenoma detection rate.

Table 2 Advantages and disadvantages of available bowel preparations

Prep	Advantages	Disadvantages
4 L PEG	Effective	Poor taste
	Safe in most populations	Very high volumes
		Poorly tolerated by patients
2 L PEG	Effective	Poor taste
	Safe in most populations	High volumes
		High cost
MiraLAX	Well tolerated by patients	Not as effective as prescription PEG preparations
	Available over the counter	Rare reports of hyponatremia
	Existing studies indicate it is safe
Sodium phosphate	Available as oral tab	Inappropriate for use in patients with renal disease, volume depletion, heart or liver failure, or who are taking ACEi or NSAIDs
	Well tolerated by patients	Risk of acute phosphate nephropathy and subsequent chronic kidney disease
Sodium picosulfate		Cost
	Well tolerated by patients	Not as effective as PEG or OSS
OSS	Small volumes to be ingested	Inappropriate for patients with heart failure, renal insufficiency, end stage liver disease, or baseline electrolyte abnormalities
	Pleasant taste	High cost
	Well tolerated by patients	High cost
	Highly effective	Not as well studied
	Available as oral tab

PEG: Preparation of polyethylene glycol; ACEi: Angiotensin converting enzyme inhibitors; NSAIDs: Nonsteroidal anti-inflammatory drugs; OSS: Oral sulfate solution.