Dosing & Uses
Dosage Forms & Strengths
sodium picosulfate/magnesium oxide/anhydrous citric acid
powder for oral solution
- Each of the 2 packets contains: 10mg/3.5g/12g per 16.1 g of powder
- Flavors: Orange, cranberry
Indicated for colon cleansing as a preparation for colonoscopy in adults
- Preferred dosing method
- First dose: Take during the evening before the colonoscopy (eg, 5:00 to 9:00 PM) followed by five 8-ounce drinks (upper line on the dosing cup) of clear liquids before bed; consume clear liquids within 5 hr
- Second dose: Take the next day ~5 hr before the colonoscopy followed by at least three 8-ounce drinks of clear liquids before the colonoscopy; consume clear liquids within 5 hr up until 2 hr before the time of the colonoscopy
Day before dose
- Alternate method
- First dose: Take in the afternoon or early evening (eg, 4:00 to 6:00 PM) before the colonoscopy followed by five 8-ounce drinks (upper line on the dosing cup) of clear liquids before the next dose; consume clear liquids within 5 hr
- Second dose: Take ~6 hr later in the late evening (eg, 10:00 PM to 12:00 AM), the night before the colonoscopy followed by three 8-ounce drinks of clear liquids before bed; consume clear liquids within 5 hr
Do not prepare solution in advance
Reconstitute powder with cold water immediately before each dose
Fill the supplied dosing cup with cold water up to the lower (5-ounce) line on the cup and pour in the contents of 1 packet of Prepopik powder
Stir solution for 2-3 minutes; reconstituted solution may become slightly warm as the powder dissolves
Take with additional clear liquids according to either split-dose or day-before dose directions
Safety and efficacy not established
Serious - Use Alternative
Significant - Monitor Closely
Decreased eGFR (10-13.1%)
Increased magnesium (8.7-11.6%)
Increased serum creatinine (1.9-4.5%)
Decreased potassium (4.7-7.3%)
Decreased sodium (1-3.7%)
Decreased chloride (1-3.7%)
Allergic reactions including rash, urticaria, and purpura
Electrolyte abnormalities including hypokalemia, hyponatremia, and hypermagnesemia
Gastrointestinal reactions including abdominal pain, diarrhea, fecal incontinence, and proctalgia; also isolated reports of aphthoid ileal ulcers and ischemic colitis (causal relationship not established)
Neurologic effects including generalized tonic-clonic seizures associated with and without hyponatremia in epileptic patients
Severe renal impairment (ie, CrCl <30 mL/minute)
GI obstruction or ileus
Toxic colitis or toxic megacolon
Adequate hydration essential before, during, and after the use
Caution with congestive heart failure when replacing fluids
If significant vomiting or signs of dehydration including signs of orthostatic hypotension develop after use, consider performing post-colonoscopy lab tests (electrolytes, creatinine, and BUN) and treat accordingly
Fluid and electrolyte disturbances can lead to serious adverse events including cardiac arrhythmias or seizures and renal impairment
Reports of generalized tonic-clonic seizures with the use of bowel preparation products in patients with no prior history of seizures; these cases were associated with electrolyte abnormalities
Orthostatic changes occurred in ~20% of patients in clinical trials on the day of colonoscopy and were documented out to 7 days post colonoscopy
Uncorrected magnesium concentration reached a maximum of ~1.9 mEq/L, which occurred at 10 hr post initial packet administration; this represents an ~20% increase from baseline
Increased magnesium plasma levels may occur with severe renal impairment (ie, CrCl <30 mL/min)
Renal impairment or coadministration with medications that may affect renal function (eg, diuretics, ACE inhibitors, ARBs, NSAIDs) may increase risk for renal injury; adequate hydration before during and after the use is particularly important in these patients; consider performing baseline and post-colonoscopy laboratory tests (electrolytes, creatinine, and BUN)
Caution with severe active ulcerative colitis; osmotic laxatives may cause colonic mucosal aphthous ulcerations and there have been reports of more serious cases of ischemic colitis requiring hospitalization
Rule out significant GI disease before use (eg, obstruction, perforation) (see Contraindications)
Caution with impaired gag reflex or patients prone to aspiration; these patients should be observed during administration
Must reconstitute powder into solution, direct ingestion of powder may result in nausea, vomiting, dehydration, and electrolyte disturbances
Oral medications taken within 1 hour of each dosing may be flushed from GI tract and not properly absorbed
Administer drugs prone to chelation with magnesium (eg, tetracycline, iron, digoxin) at least 2 hr before or at least 6 hr after administration
Prior or concomitant antibiotics may reduce efficacy by decreasing colonic bacteria-mediated conversion of sodium picosulfate to the active metabolite (BHPM)
Pregnancy & Lactation
Pregnancy Category: B
Lactation: Unknown whether distributed in breast milk
A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA:Information not available.
Mechanism of Action
The stimulant laxative activity of sodium picosulfate together with the osmotic laxative activity of magnesium citrate produces a purgative effect which, when ingested with additional fluids, produces watery diarrhea
Sodium picosulfate: Hydrolyzed by colonic bacteria to form an active metabolite, bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM); BHPM acts directly on the colonic mucosa to stimulate colonic peristalsis
Magnesium oxide and anhydrous citric acid: These 2 ingredients react to create magnesium citrate in solution, an osmotic agent that causes water to be retained within the GI tract
Peak Plasma Time: 7 hr (sodium picosulfate, 2 packets)
Peak Plasma Concentration: 3.2 ng/mL (sodium picosulfate after 2 doses); active metabolite BHPM below level of quantification
Sodium picosulfate, a prodrug, is converted to its active metabolite, bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM), by colonic bacteria
Magnesium oxide and citric acid react in water to create magnesium citrate
Half-life: 7.4 hr (sodium picosulfate)
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