Skip to main content
Log in

Sodium Picosulfate/Magnesium Citrate

A Review of its Use as a Colorectal Cleanser

  • Adis Drug Evaluation
  • Published:
Drugs Aims and scope Submit manuscript

Summary

Abstract

Oral sodium picosulfate/magnesium citrate (CitraFleet®; Picolax®), consisting of sodium picosulfate (a stimulant laxative) and magnesium citrate (an osmotic laxative), is approved for use in adults (CitraFleet®; Picolax®) and/or adolescents and children (Picolax®) as a colorectal cleansing agent prior to any diagnostic procedure (e.g. colonoscopy or x-ray examination) requiring a clean bowel and/or surgery. It is dispensed in powder form (sodium picosulfate 0.01 g, magnesium oxide 3.5 g, citric acid 12.0 g per sachet), with the magnesium oxide and citric acid components forming magnesium citrate when the powder is dissolved in water.

In adult patients, two sachets of sodium picosulfate/magnesium citrate was at least as effective and well tolerated as oral magnesium citrate 17.7 or 35.4 g, or oral polyethylene glycol 236 g in adult patients undergoing a double-contrast barium enema procedure in three large, randomized, comparative clinical studies. In contrast, sodium picosulfate/magnesium citrate was less effective than a sodium phosphate enema preparation in two studies in patients undergoing flexible sigmoidoscopy. A similar number of patients receiving two sachets of sodium picosulfate/magnesium citrate or two 45 mL doses of oral sodium phosphate the day before a double-contrast barium enema procedure achieved satisfactory barium coating and none/minimal faecal residue in one study. However, the data from three of these studies should be interpreted with caution because the administrative regimens used differed from that recommended. Sodium picosulfate/ magnesium citrate is also an effective and generally well tolerated colorectal cleansing agent in children and adolescents; the preparation was more effective than oral bisacodyl 0.01 or 0.02 g plus a sodium phosphate enema preparation in this population. Further research is thus required to accurately position sodium picosulfate/magnesium citrate and fully establish its efficacy and tolerability prior to various exploratory or surgical procedures. Nevertheless, oral sodium picosulfate/magnesium citrate provides a useful option in the preparation of the colon and rectum in adults, adolescents and children undergoing any diagnostic procedure (e.g. colonoscopy or x-ray examination) requiring a clean bowel and/or surgery.

Pharmacological Properties

Oral sodium picosulfate/magnesium citrate acts locally in the colon as both a stimulant laxative, by increasing the frequency and the force of peristalsis (sodium picosulfate component), and an osmotic laxative, by retaining fluids in the colon (magnesium citrate component), to clear the colon and rectum of faecal contents. It is not absorbed in any detectable quantities. Sodium picosulfate is a prodrug: it is hydrolyzed by bacteria in the colon to the active metabolite 4,4′-dihydroxydiphenyl-(2-pyridyl)methane.

Sodium picosulfate/magnesium citrate may be associated with a dehydrating effect, as evidenced by a reduction in bodyweight and increased haemoglobin levels; some at-risk patients may experience postural hypotension and older patients may require additional electrolytes.

Clinical Efficacy

In three large (n > 100), randomized, single-blind clinical studies, two sachets of oral sodium picosulfate/magnesium citrate was at least as effective as oral magnesium citrate 17.7 or 35.4 g, or oral polyethylene glycol 236 g as a colorectal cleansing agent in adult patients undergoing a double-contrast barium enema procedure. In contrast, sodium picosulfate/magnesium citrate was less effective than a sodium phosphate enema preparation in two studies in patients undergoing flexible sigmoidoscopy. A similar number of patients receiving two sachets of sodium picosulfate/magnesium citrate or two 45 mL doses of oral sodium phosphate the day before a double-contrast barium enema procedure achieved satisfactory barium coating and none/minimal faecal residue in one study. However, the data from three of these studies should be interpreted with caution because the administrative regimens used differed from that recommended.

In children and adolescents, sodium picosulfate/magnesium citrate was significantly more effective as a colorectal cleansing agent than oral bisacodyl 0.01 or 0.02 g plus a sodium phosphate enema preparation in a randomized, single-blind study; dosages were adjusted for age in this study.

Tolerability

Oral sodium picosulfate/magnesium citrate is generally well tolerated in adult patients undergoing various investigational colorectal procedures. Adverse events were generally mild to moderate in intensity and mainly gastrointestinal in nature (e.g. abdominal cramps/pain, nausea); other common treatment-emergent adverse events included disturbance of daily activity, headache and sleep disturbance. This combination is at least as well tolerated as oral sodium phosphate or oral polyethylene glycol, with moderate/severe nausea and vomiting occurring less frequently in sodium picosulfate/magnesium citrate recipients than in those receiving oral sodium phosphate, and abdominal bloating/pain and nausea developing less often with sodium picosulfate/magnesium citrate than polyethylene glycol therapy.

The incidence of abdominal pain and sleep disturbance in sodium picosulfate/ magnesium citrate versus oral magnesium citrate recipients was similar in one study, but significantly lower with sodium picosulfate/magnesium citrate in another. While the incidence of most adverse events was similar in recipients of sodium picosulfate/magnesium citrate and a sodium phosphate enema preparation, more patients receiving sodium picosulfate/magnesium citrate reported moderate/severe flatulence, incontinence and sleep disturbance, and more patients receiving the enema preparation reported rectal soreness. The tolerability profile of sodium picosulfate/magnesium citrate in patients aged >70 years is reportedly similar to that in patients aged <70 years.

Abdominal pain also occurred less frequently with sodium picosulfate/ magnesium citrate than with oral bisacodyl plus a sodium phosphate enema preparation in children and adolescents.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Curran MP, Plosker GL. Oral sodium phosphate solution: a review of its use as a colorectal cleanser. Drugs 2004; 64(15): 1697–714

    Article  CAS  PubMed  Google Scholar 

  2. Toledo TK, DiPalma JA. Review article: colon cleansing for gastrointestinal procedures. Aliment Pharmacol Ther 2001 May; 15(5): 605–11

    Article  CAS  PubMed  Google Scholar 

  3. Tooson JD, Gates Jr LK. Bowel preparation before colonoscopy: choosing the best lavage regimen. Postgrad Med 1996 Aug; 100(2): 203–4, 207–12, 214

    Article  CAS  PubMed  Google Scholar 

  4. Zmora O, Pikarsky AJ, Wexner SD. Bowel preparation for colorectal surgery. Dis Colon Rectum 2001 Oct; 44(10): 1537–49

    Article  CAS  PubMed  Google Scholar 

  5. Wexner SD, Beck DE, Baron TH, et al. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Dis Colon Rectum 2006 May; 49(6): 792–809

    Article  PubMed  Google Scholar 

  6. EC De Witt & Company Limited. CitraFleet powder for oral solution: summary of product characteristics [online]. Available from URL: http://emc.medicines.org.uk [Accessed 2008 Dec 1]

  7. EC De Witt & Company Limited. CitraFleet powder for oral solution in sachet: mutual recognition procedure public assessment report [online]. Available from URL: http://www.mhra.gov.uk/home/groups/l-unit1/documents/websiteresources/con2033180.pdf [Accessed 2008 Dec 1]

  8. Ferring Pharmaceuticals. Picolax: summary of product characteristics [online]. Available from URL: http://emc.medicines.org.uk/ [Accessed 2008 Dec 1]

  9. Ferring Pharmaceuticals. Picolax patient information [online]. Available from URL: http://emc.medicines.org.uk [Accessed 2006 Sep 4]

  10. Sarre R. Bowel preparation. Aust Prescr 2005; 28(1): 16–7

    Article  Google Scholar 

  11. Barker P, Trotter T, Hanning C. A study of the effect of Picolax on body weight, cardiovascular variables and haemoglobin concentration. Ann R Coll Surg Engl 1992 Sep; 74(5): 318–9

    PubMed Central  CAS  PubMed  Google Scholar 

  12. Sanders G, Mercer SJ, Saeb-Parsey K, et al. Randomized clinical trial of intravenous fluid replacement during bowel preparation for surgery. Br J Surg 2001 Oct; 88(10): 1363–5

    Article  CAS  PubMed  Google Scholar 

  13. German K, Chandiramani VJ, Stephenson TP. A study of the effects of Picolax on body weight, cardiovascular variables and haemoglobin concentration [letter]. Ann R Coll Surg Engl 1993 Jan; 75(1): 70

    PubMed Central  CAS  PubMed  Google Scholar 

  14. Kutt E, Hall MJ, Booth A, et al. Barium enemas are a headache. Clin Radiol 1988 Jan; 39(1): 9–10

    Article  CAS  PubMed  Google Scholar 

  15. Takada H, Ambrose NS, Galbraith K, et al. Quantitative appraisal of Picolax (sodium picosulfate/magnesium citrate) in the preparation of the large bowel for elective surgery. Dis Colon Rectum 1990 Aug; 33(8): 679–83

    Article  CAS  PubMed  Google Scholar 

  16. Ryan F, Anobile T, Scutt D, et al. Effects of oral sodium picosulphate Picolax on urea and electrolytes. Nurs Stand 2005 Jul; 19(45): 41–5

    Article  PubMed  Google Scholar 

  17. Evans M, Barton K, Pritchard G, et al. Plasma magnesium should be monitored perioperatively in patients undergoing colorectal resection. Colorectal Dis. Epub 2008 Jul 9

  18. Kim DH, Hyun SH, Shim SB, et al. The role of intestinal bacteria in the transformation of sodium picosulfate. Jpn J Pharmacol 1992 May; 59(1): 1–5

    Article  CAS  PubMed  Google Scholar 

  19. Atkin WS, Hart A, Edwards R, et al. Single blind, randomised trial of efficacy and acceptability of oral Picolax versus self administered phosphate enema in bowel preparation for flexible sigmoidoscopy screening. BMJ 2000 Jun; 320(7248): 1504–8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Drew PJ, Hughes M, Hodson R, et al. The optimum bowel preparation for flexible sigmoidoscopy. Eur J Surg Oncol 1997 Aug; 23(4): 315–6

    Article  CAS  PubMed  Google Scholar 

  21. Swarbrick MJ, Collins MC, Moore DJ, et al. A comparative trial of magnesium citrate (Citramag) and Picolax for barium enema bowel preparation. Clin Radiol 1994 Jun; 49(6): 379–81

    Article  CAS  PubMed  Google Scholar 

  22. Macleod AJ, Duncan KA, Pearson RH, et al. A comparison of Fleet Phospho-soda with Picolax in the preparation of the colon for double contrast barium enema. Clin Radiol 1998 Aug; 53(8): 612–4

    Article  CAS  PubMed  Google Scholar 

  23. Chakraverty S, Hughes T, Keir MJ, et al. Preparation of the colon for double-contrast barium enema: comparison of Picolax, Picolax with cleansing enema and Citramag (2 sachets): a randomized prospective trial. Clin Radiol 1994 Aug; 49(8): 566–9

    Article  CAS  PubMed  Google Scholar 

  24. Hawkins S, Bezuidenhout P, Shorvon P, et al. Barium enema preparation: a study of low-residue diet, ‘Picolax’ and ‘Kleen-Prep’. Australas Radiol 1996 Aug; 40(3): 235–9

    Article  CAS  PubMed  Google Scholar 

  25. Pinfield A, Stringer MD. Randomised trial of two pharmacological methods of bowel preparation for day case colonoscopy. Arch Dis Child 1999 Feb; 80(2): 181–3

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Sweetman SC, editor. Martindale: the complete drug reference. 35th ed. London: Pharmaceutical Press, 2007

    Google Scholar 

  27. Heymann TD, Chopra K, Nunn E, et al. Bowel preparation at home: prospective study of adverse effects in elderly people. BMJ 1996 Sep 21; 313(7059): 727–8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. ADRAC. Electrolyte disturbances with sodium picosulfate bowel cleansing products. Aust Adv Drug React Bull 2002 Feb; 21: 2

    Google Scholar 

  29. Barkun AN, Chiba N, Enns R, et al. Commonly used preparations for colonoscopy: efficacy, tolerability, and safety: a Canadian Association of Gastroenterology position paper. Can J Gastroenterol 2006 Nov; 20(11): 699–710

    Article  PubMed  PubMed Central  Google Scholar 

  30. Nelson DB, Barkun AN, Block KP, et al. Technology status evaluation report: colonoscopy preparations. May 2001. Gastrointest Endosc 2001 Dec; 54(6): 829–32

    CAS  PubMed  Google Scholar 

  31. Keeffe EB. Colonoscopy preps: what’s best? Gastrointes Endosc 1996 May; 43(5): 524–8

    Article  CAS  Google Scholar 

  32. Lai AK, Kwok PC, Man SW, et al. A blinded clinical trial comparing conventional cleansing enema, Pico-salax and Golytely for barium enema bowel preparation. Clin Radiol 1996 Aug; 51(8): 566–9

    Article  CAS  PubMed  Google Scholar 

  33. Regev A, Fraser G, Delpre G, et al. Comparison of two bowel preparations for colonoscopy: sodium picosulphate with magnesium citrate versus sulphate-free polyethylene glycol lavage solution. Am J Gastroenterol 1998 Sep; 93(9): 1478–82

    Article  CAS  PubMed  Google Scholar 

  34. Lawrance JA, Massoud TF, Creasy TS, et al. Colonic preparation with Picolax: patient tolerance and approaches to fluid replacement. Clin Radiol 1994 Jan; 49(1): 35–7

    Article  CAS  PubMed  Google Scholar 

  35. Schmidt LM, Williams P, King D, et al. Picoprep-3 is a superior colonoscopy preparation to Fleet: a randomized, controlled trial comparing the two bowel preparations. Dis Colon Rectum 2004 Feb; 47(2): 238–42

    Article  PubMed  Google Scholar 

  36. Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Aliment Pharmacol Ther 2007 Feb; 25(4): 373–84

    Article  CAS  PubMed  Google Scholar 

  37. Navarro A, Hession PT. Sodium picosulfate/magnesium citrate is highly efficacious as a bowel cleansing agent: results from a meta-analysis [abstract no. 187 plus poster]. 16th United European Gastroenterology Week; 2008 Oct 18–22; Vienna

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sheridan M. Hoy.

Additional information

Various sections of the manuscript reviewed by: S.M. Chamberlain, Section of Gastroenterology, Medical College of Georgia, Augusta, Georgia, USA; J.M. Henderson, Gastroenterology Associates Inc., Indianapolis, Indiana, USA; L.C. Hookey, Division of Gastroenterology, Hotel Dieu Hospital, Queen’s University, Kingston, Ontario, Canada; E.M.H. Mathus-Vliegen, Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands; A. Parra-Blanco, Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain; P.S. Phull, Gastrointestinal and Liver Service, Aberdeen Royal Infirmary, Aberdeen, Scotland.

Data Selection

Sources: Medical literature published in any language since 1967 on ‘sodium picosulfate’, identified using MEDLINE and EMBASE, supplemented by AdisBase (a proprietary database of Wolters Kluwer Health | Adis). Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from the company developing the drug.

Search strategy: MEDLINE search terms were ‘sodium picosulfate’ or ‘sodium picosulphate’ or ‘DA-1773’; EMBASE and AdisBase search terms were ‘sodium picosulfate’ or ‘sodium picosulphate’. Searches were last updated 6 January 2009.

Selection: Studies in patients undergoing endoscopy, surgery or x-ray examination and requiring colorectal cleansing. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well controlled trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic and pharmacokinetic data are also included.

Index terms: Sodium picosulfate, sodium picosulphate, DA-1773, pharmacodynamics, pharmacokinetics, therapeutic use, tolerability.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hoy, S.M., Scott, L.J. & Wagstaff, A.J. Sodium Picosulfate/Magnesium Citrate. Drugs 69, 123–136 (2009). https://doi.org/10.2165/00003495-200969010-00009

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00003495-200969010-00009

Keywords

Navigation