Efficacy and Tolerability of High- vs Low-Volume Split-Dose Bowel Cleansing Regimens for Colonoscopy: A Systematic Review and Meta-analysis

Marco Spadaccini; Leonardo Frazzoni; Giuseppe Vanella; James East; Franco Radaelli; Cristiano Spada; Lorenzo Fuccio; Robert Benamouzig; Raf Bisschops; Michael Bretthauer; Evelien Dekker; Mario Dinis-Ribeiro; Monika Ferlitsch; Ian Gralnek; Rodrigo Jover; Michal F Kaminski; Maria Pellisé; Konstantinos Triantafyllou; Jeanin E Van Hooft; Jean-Marc Dumonceau; Clelia Marmo; Sergio Alfieri; Viveksandeep Thoguluva Chandrasekar; Prateek Sharma; Doug K Rex; Alessandro Repici; Cesare Hassan

doi:10.1016/j.cgh.2019.10.044

Efficacy and Tolerability of High- vs Low-Volume Split-Dose Bowel Cleansing Regimens for Colonoscopy: A Systematic Review and Meta-analysis

Clin Gastroenterol Hepatol. 2020 Jun;18(7):1454-1465.e14. doi: 10.1016/j.cgh.2019.10.044. Epub 2019 Nov 1.

Authors

Marco Spadaccini¹, Leonardo Frazzoni², Giuseppe Vanella³, James East⁴, Franco Radaelli⁵, Cristiano Spada⁶, Lorenzo Fuccio², Robert Benamouzig⁷, Raf Bisschops⁸, Michael Bretthauer⁹, Evelien Dekker¹⁰, Mario Dinis-Ribeiro¹¹, Monika Ferlitsch¹², Ian Gralnek¹³, Rodrigo Jover¹⁴, Michal F Kaminski¹⁵, Maria Pellisé¹⁶, Konstantinos Triantafyllou¹⁷, Jeanin E Van Hooft¹⁰, Jean-Marc Dumonceau¹⁸, Clelia Marmo¹⁹, Sergio Alfieri²⁰, Viveksandeep Thoguluva Chandrasekar²¹, Prateek Sharma²¹, Doug K Rex²², Alessandro Repici²³, Cesare Hassan²⁴

Affiliations

¹ Endoscopy Department, Humanitas University, Milan, Italy. Electronic address: marco.spadaccini@humanitas.it.
² Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
³ Endoscopy Unit, Sant'Andrea University Hospital, "Sapienza" University of Rome, Rome, Italy.
⁴ Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom.
⁵ Valduce Hospital, Como, Italy.
⁶ Digestive Endoscopy Unit, Fondazione Poliambulanza, Brescia, Italy.
⁷ Gastroenterology Unit, Bobigny, France.
⁸ Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
⁹ Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Institute of Health and Society, University of Oslo Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.
¹⁰ Department of Gastroenterology and Hepatology Amsterdam University Medical Centers, Amsterdam, the Netherlands.
¹¹ CIDES/CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal.
¹² Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Austria.
¹³ Institute of Gastroenterology and Hepatology Emek Medical Center, Afula, Israel.
¹⁴ Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain.
¹⁵ Department of Gastroenterology, Hepatology and Oncology, Center of Postgraduate Medical Education, Warsaw, Poland.
¹⁶ Gastroenterology Department, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
¹⁷ Ηepatogastroenterology Unit, Second Department of Internal Medicine and Research Institute, Athens University, Athens, Greece.
¹⁸ Gedyt Endoscopy Center, Buenos Aires, Argentina.
¹⁹ Division of Surgical Digestive System, University Hospital Second University of Naples, Naples, Italy.
²⁰ Fondazione Policlinico A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
²¹ Kansas City Veterans Affairs Hospital, Kansas City, Missouri.
²² Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
²³ Endoscopy Department, Humanitas University, Milan, Italy.
²⁴ Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy.

PMID: 31683057
DOI: 10.1016/j.cgh.2019.10.044

Abstract

Background & aims: Efficacy of bowel preparation is an important determinant of outcomes of colonoscopy. It is not clear whether approved low-volume polyethylene glycol (PEG) and non-PEG regimens are as effective as high-volume PEG regimens when taken in a split dose.

Methods: In a systematic review of multiple electronic databases through January 31, 2019 with a registered protocol (PROSPERO: CRD42019128067), we identified randomized controlled trials that compared low- vs high-volume bowel cleansing regimens, administered in a split dose, for colonoscopy. The primary efficacy outcome was rate of adequate bowel cleansing, and the secondary efficacy outcome was adenoma detection rate. Primary tolerability outcomes were compliance, tolerability, and willingness to repeat. We calculated relative risk (RR) and 95% CI values and assessed heterogeneity among studies by using the I² statistic. The overall quality of evidence was assessed using the GRADE framework.

Results: In an analysis of data from 17 randomized controlled trials, comprising 7528 patients, we found no significant differences in adequacy of bowel cleansing between the low- vs high-volume split-dose regimens (86.1% vs 87.4%; RR, 1.00; 95% CI, 0.98-1.02) and there was minimal heterogeneity (I² = 17%). There was no significant difference in adenoma detection rate (RR, 0.96; 95% CI, 0.87-1.08) among 4 randomized controlled trials. Compared with high-volume, split-dose regimens, low-volume split-dose regimens had higher odds for compliance or completion (RR, 1.06; 95% CI, 1.02-1.10), tolerability (RR, 1.39; 95% CI, 1.12-1.74), and willingness to repeat bowel preparation (RR, 1.41; 95% CI, 1.20-1.66). The overall quality of evidence was moderate.

Conclusions: Based on a systematic review of 17 randomized controlled trials, low-volume, split-dose regimens appear to be as effective as high-volume, split-dose regimens in bowel cleansing and are better tolerated, with superior compliance.

Keywords: Adherence; Comparative; Endoscopy; Screening.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

MeSH terms

Adenoma* / diagnosis
Cathartics* / adverse effects
Colon
Colonoscopy
Humans
Polyethylene Glycols / adverse effects

Substances

Cathartics
Polyethylene Glycols