Issues for surgery
Risk of constipation if omitted, particularly in patients with chronic laxative use, which may further be exacerbated by medication administered perioperatively, e.g. opioids.
For bowel cleansing - increased risk of infection if clinically indicated and not given pre-operatively.
Risk of fluid imbalance and hypokalaemia with chronic or excessive use, which may further be exacerbated if continued during prolonged periods of fasting.
For bowel cleansing - 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.
Advice in the perioperative period
Elective surgery
Continue, if required.
EXCEPT:
- for patients having bowel cleansing preparations prior to surgery – stop when bowel preparation starts.
Check electrolytes pre-operatively in patients with chronic or suspected excessive stimulant laxative use.
Pre-operative use of sodium picosulfate (CitraFleet®, Picolax®) for bowel cleansing
Bowel cleansing preparations 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 preparations 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 preparation.
Patients with diabetes mellitus
Patients who take medication for diabetes mellitus and require bowel cleansing preparations will require alterations to their medication whilst they have an altered diet or are fasting. NHS Trusts or Health Boards should have agreed guidance for patients undergoing any procedure that requires the use of bowel cleansing preparations.
Patients taking laxatives
Patients who take regular laxatives should be advised to stop taking these while they are taking bowel cleansing preparations.
Patients taking non-steroidal anti-inflammatory drugs (NSAIDs)
Where possible NSAIDs should be discontinued on the day of administration of any oral bowel cleansing preparation and withheld until 72 hours after the procedure – see Interactions with other common medicines in the perioperative period.
Emergency surgery
Continue, if required.
EXCEPT:
- for patients with suspected bowel obstruction or perforation
- for patients with severe painful and/or feverish acute abdominal conditions, e.g. appendicitis.
Check electrolytes in patients with chronic or suspected excessive stimulant laxative use.
Pre-operative use of sodium picosulfate (CitraFleet®, Picolax®) for bowel cleansing
If there is time, and it is safe for the patient to use bowel cleansing preparations prior to emergency surgery, follow the advice as for elective surgery.
Post-operative advice
Resume post-operatively, if needed, once enteral intake resumed.
If concomitant use of opioids or other medication that may cause constipation, or antibiotics that may cause diarrhoea, monitor response to treatment and adjust dose accordingly.
Review if patient develops reduced gastrointestinal motility (e.g. ileus) post-operatively.
Patients undergoing colorectal surgery
Review the need for stimulant laxatives post-operatively.
Post-operatively following use of sodium picosulfate (CitraFleet®, Picolax®) for bowel cleansing
Check renal function and electrolytes post-operatively.
Interactions with common anaesthetic agents
Hypokalaemia
Sodium picosulfate may cause hypokalaemia (mainly in cases of misuse or overdose). Concomitant use with medications that prolong the QT-interval, e.g. desflurane, isoflurane, sevoflurane and possibly thiopental, increases the risk of torsades de pointes. Monitor serum potassium and QT-interval with concomitant treatment.
Interactions with other common medicines used in the perioperative period
Hypokalaemia
Sodium picosulfate may cause hypokalaemia (mainly in 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 loperamide. Monitor serum potassium and QT-interval with concomitant treatment.
Hyponatraemia
Concomitant use of the following medicines with sodium picosulfate can increase the risk of hyponatraemia:
- cyclo-oxygenase-2 (COX-2) inhibitors
- gabapentin
- non-steroidal anti-inflammatory drugs (NSAIDs)
- trimethoprim
Whilst single doses should not pose a problem, sodium levels should be monitored with continued post-operative treatment of concomitant medication.
Antimicrobials
Concurrent administration of antibiotics may reduce the laxative action of sodium picosulfate.
Bowel cleansing indication
Bowel cleansing preparations increase gastrointestinal transit rate and as a result absorption of oral medication may be reduced if taken alongside bowel preparation products. Oral medication should be avoided at least one hour before and after administration of bowel cleansing preparations. See also Antimicrobials.
Antimicrobials
Oral tetracycline (e.g. doxycycline) and fluoroquinolone (e.g. ciprofloxacin) 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 magnesium.
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 preparations. Where possible, NSAIDs should be discontinued on the day of administration of any oral bowel cleansing preparation and withheld until 72 hours after the procedure. 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 imbalance.
Further information
Safe prescribing of bowel cleansing preparations
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 preparations prior to surgery and/or investigative procedures. Frail and debilitated elderly patients and those with contraindications (e.g. renal impairment) are particularly at risk.
NHS Trusts or 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 preparation 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 patient.
References
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed 26 March 2024]
Connor A, Tolan D, Hughes S et al. Consensus guidelines for the safe prescription and administration of oral bowel-cleansing agents. Gut. 2012,61:1525-1532 DOI:10.1136/gutjnl-2011-300861
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press http://www.medicinescomplete.com [Accessed on 26 March 2024]
National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE Guideline 125. Published 19 August 2020. [Accessed 25 March 2024]
National Patient Safety Agency (NPSA). Rapid Response Report (NPSA/2009/RRR012). Reducing risk of harm from oral bowel cleansing solutions. 19 February 2009. Accessed 25 March 2024 via nationalarchives.gov.uk
Summary of Product Characteristics – CitraFleet®, Powder for oral solution in sachet. Casen Recordati S.L. Accessed 25 March 2024 via www.medicines.org.uk [date of revision of the text January 2024]
Summary of Product Characteristics – Dulcolax® (sodium picosulfate monohydrate) Adult Pico Liquid, 5mg / 5ml, oral solution. SANOFI. Accessed on 25 March 2024 via www.medicines.org.uk [date of revision of the text November 2021]
Summary of Product Characteristics – Picolax®. Ferring Pharmaceuticals Ltd. Accessed 26 March 2024 via www.medicines.org.uk [date of revision of the text February 2021]