II. Mechanism
- Poorly absorbed, they act as hyperosmolar agents
- Stimulate colonic activity (via cholecystokinin)
III. Complications
- Hypermagnesemia (in patients with Renal Failure)
- Hypocalcemia (phosphate Overdose)
IV. Contraindications
- Renal Failure (except Lactulose and Sorbitol)
V. Preparations: Poorly-absorbed sugars (may be used in Renal Failure)
-
Lactulose (Chronulac)
- Easier to administer to young children
- May cause abdominal cramping and Flatus
- More expensive then Sorbitol ($10-30 per 480 ml)
- Onset of action within 24-48 hours
- Dose
- Adults: 15-60 ml PO daily
- Child (10 mg/15 ml): 1-3 cc/kg/day divided qd-bid
- Lactitol
- As effective as Lactulose with less pain and Flatus
- Pitzalis (1995) Pediatr Med Chir 17(3):223-6 [PubMed]
- Sorbitol 70%
- Less expensive than Lactulose ($7 per 480 ml)
- Sweet taste
- Dosing
- Adult: 15-60 ml PO daily
- Child: 1-3 ml/kg/day divided twice daily
VI. Preparations: Magnesium salt Osmotic Laxatives
- Rapid onset (within 3 hours)
- Avoid longterm use due to electrolyte loss risk
- Milk of Magnesia (Magnesium Hydroxide)
- Cost: $3 per 360 ml
- Concentration: 400 mg/5 ml
- Adults: 15-60 ml PO qd prn
- Children: 1-3 cc/kg/day divided bid prn
- Concentration 800 mg/5 ml
- Children: 0.5 cc/kg/day divided bid prn
- Adverse effects
- May cause abdominal cramping in higher doses
- Magnesium Citrate (Citroma)
- Cost: $1.50 per 300 ml
- Dose
- Adult: 8 ounces PO daily prn
- Child: 4 ml/kg up to 200 ml PO daily prn
VII. Preparations: Mineral Oil
- Child: 1-3 cc/kg/day divided daily to twice daily
- Contraindicated if aspiration risk
- Not recommended under age 18 months
- Give chilled in juice to maximize tolerability
- Coadminister Multivitamin daily if used chronically
VIII. Preparations: Sodium salt Osmotic Laxatives
- Phopho-Soda (Osmoprep, Visicol) 2 tablespoons in 4 ounces water orally
- Fleets Enema (Sodium phosphate) 120 ml enema
- Pink Lady Enema (1/2 Fleet Enema, 100 ml Docusate, 60 ml Mineral Oil, 60 ml Magnesium Citrate)
- Alternative agent: Tap Water Enema
- Precaution: Acute phosphate nephropathy (FDA Black Box Warning)
- Risk of permanent impact on Renal Function following use
- Risk Factors
- Diabetes Mellitus
- Age over 65 years
- Dehydration
- Concurrent NSAID, ACE Inhibitor, ARB or Diuretic
- Prevention of Renal Function impact
- Consider alternative Bowel Preparation if risk factors above
- Maintain clear fluid intake to replace fluid losses from Diarrhea
IX. Preparations: Polyethylene glycol 3350 (PEG, Miralax)
- Similar to bowel prep solution (GoLytely, Colyte)
- Onset of action with 24-48 hours
- No salty taste
- More expensive then Sorbitol: $2/day
- Preparation
- Use PEG powder 17 grams (one capful)
- Dissolve in 240 ml (8 ounces) water or juice
- May chill PEG solution or mix with flavoring (e.g. Crystal Light) to improve taste
- If for Colonoscopy prep, avoid colored flavoring that might interfere with visibility
- Dose:
- Adult: 17 grams (1 capful) daily
- Child
- Start 0.8-1 g/kg/day (15 ml/kg/day) divided bid
- Adjust dose for two soft painless stools per day
- Taper dose over time
- Efficacy
- Safe, well tolerated and effective
- More effective and better tolerated than Lactulose
- Safety
- Appears safe in children and adults
- In 2017, studies initiated to determine if young children absorb Ethylene Glycol with neurotoxicity based on case reports
- No evidence at this point that this is a significant concern
- (2017) Presc Lett 24(4): 23
- References
X. Preparations: Not recommended
-
Castor oil or Ricinoleic Acid (Purge)
- Avoid due to electrolyte disturbance
- Adult: 15-30 ml PO qhs
- Child: 5-15 ml PO qhs
-
Soapsuds Enemas (never use)
- Risk of irritation or hemorrhagic colitis
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| milk of magnesia (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| MILK OF MAGNESIA SUSPENSION | Generic OTC | $0.01 per ml |
| magnesium citrate (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| MAGNESIUM CITRATE SOLUTION | Generic OTC | $0.00 per ml |
| polyethylene glycol (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| POLYETHYLENE GLYCOL 3350 POWD | Generic | $0.03 per gram |
| peg (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| PEG 3350 ELECTROLYTE SOLN | Generic | $0.00 per ml |
| PEG 3350-ELECTROLYTE SOLUTION | Generic | $0.00 per ml |
| PEG-3350 AND ELECTROLYTES SOLN | Generic | $0.00 per ml |
| PEG3350 POWDER | Generic OTC | $0.02 per gram |
| fleet enema (on 4/19/2017 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| FLEET ENEMA | Generic OTC | $0.01 per ml |
Ontology: Magnesium Hydroxide (C0024476)
| Definition (NCI) | A solution of magnesium hydroxide with antacid and laxative properties. Milk of magnesium exerts its antacid activity in low doses such that all hydroxide ions that enter the stomach are used to neutralize stomach acid. This agent exerts its laxative effect in higher doses so that hydroxide ions are able to move from the stomach to the intestines where they attract and retain water, thereby increasing intestinal movement (peristalsis) and inducing the urge to defecate. |
| Definition (MSH) | An inorganic compound that occurs in nature as the mineral brucite. It acts as an antacid with cathartic effects. |
| Concepts | Pharmacologic Substance (T121) , Inorganic Chemical (T197) |
| MSH | D008276 |
| SnomedCT | 387337001, 317584009, 25550008, 60468008 |
| English | Magnesium Hydrate, Hydroxide, Magnesium, Magnesium Hydroxide, Hydrate, Magnesium, Magnesium hydroxide (Mg(OH)2), magnesium hydroxide, Magnesium hydroxide [laxative], Magnesium hydrate, antacids magnesium OH, magnesium hydroxide (medication), MAGNESIUM HYDROXIDE, Magnesium Hydroxide [Chemical/Ingredient], magnesium hydrate, hydroxide laxative magnesium, hydroxide magnesium, Magnesium hydroxide [laxative] (product), Magnesium hydrate (substance), Magnesium hydroxide, Magnesium hydroxide (product), Magnesium hydroxide (substance), Magnesium hydroxide [laxative] (substance) |
| French | Hydroxyde de magnésium |
| Swedish | Magnesiumhydroxid |
| Czech | hydroxid hořečnatý |
| Finnish | Magnesiumhydroksidi |
| Russian | MAGNIIA GIDROOKIS', BRUSIT, BRUTSIT, MAGNIIA GIDROKSID, БРУСИТ, БРУЦИТ, МАГНИЯ ГИДРОКСИД, МАГНИЯ ГИДРООКИСЬ |
| Japanese | 水酸化マグネシウム, ブルーサイト |
| Italian | Idrato di magnesio, Idrossido di magnesio |
| Polish | Wodorotlenek magnezowy |
| Norwegian | Magnesiumhydrat, Magnesiumhydroksid |
| Spanish | hidróxido de magnesio (laxante), hidrato de magnesio (sustancia), hidróxido de magnesio (laxante) (producto), hidrato de magnesio, hidróxido de magnesio (producto), hidróxido de magnesio (sustancia), hidróxido de magnesio, Hidróxido de Magnesio |
| German | Magnesiumhydroxid |
| Portuguese | Hidróxido de Magnésio |
Ontology: Polyethylene Glycols (C0032483)
| Definition (MSH) | Polymers of ETHYLENE OXIDE and water, and their ethers. They vary in consistency from liquid to solid depending on the molecular weight indicated by a number following the name. They are used as SURFACTANTS, dispersing agents, solvents, ointment and suppository bases, vehicles, and tablet excipients. Some specific groups are NONOXYNOLS, OCTOXYNOLS, and POLOXAMERS. |
| Definition (NCI_NCI-GLOSS) | A polymer made by joining molecules of ethylene oxide and water together in a repeating pattern. Polyethylene glycol can be a liquid or a waxy solid. In medicine, forms of polyethylene glycol can be used in ointments, in drugs or substances to make them stay in the body longer, or in laxatives. |
| Definition (CSP) | an addition polymer of ethylene oxide and water. |
| Concepts | Organic Chemical (T109) , Biomedical or Dental Material (T122) , Pharmacologic Substance (T121) |
| MSH | D011092 |
| SnomedCT | 419116004, 8030004, 356076006 |
| English | Glycols, Polyethylene, Macrogols, Oxide, Polyethylene, Polyethylene Glycol, Polyethylene Glycols, Polyethylene Oxide, Polyethyleneoxide, Polyoxyethylenes, PEG, Polyethylene Glycols [Chemical/Ingredient], macrogol (medication), Oxides, Polyethylene, Polyoxyethylene, Polyethylene Oxides, Polyethyleneoxides, glycol polyethylene, macrogols, polyethylene oxide, polyoxyethylene, POLYETHYLENE GLYCOL, macrogol, polyethylene glycol, polyehtylene glycol, polythylene glycol, polyethylene glycols, Polyethylene glycols, POLYETHYLENE GLYCOLS, POLYETHYLENE GLYCOLs, Macrogol (substance), Glycol, polyethylene, Ethanol, 2,2'-(oxybis(2,1-ethanediyloxy)bis)-, PEG - Polyethylene glycol, Polyethylene glycol, Polyethylene glycol product, Macrogol, Polyethylene glycol (substance), Polyethylene glycol product (product), glycol, polyethylene, Polyethylene glycol, NOS, Polyethylene glycol product (substance), Glycol, Polyethylene, POLYOXYETHYLENE |
| Swedish | Polyetylenglykoler |
| Czech | polyethylenglykoly |
| Finnish | Polytetyleeniglykolit |
| French | Polyoxyéthylènes, Polyéthylène glycols, Macrogols, Polyéthylèneglycols |
| Russian | TRITONY (KHIM), POLIOKSIETILENY, MAKROGOLY, POLIETILENGLIKOLI, МАКРОГОЛЫ, ПОЛИОКСИЭТИЛЕНЫ, ПОЛИЭТИЛЕНГЛИКОЛИ, ТРИТОНЫ (ХИМ) |
| Japanese | マクロゴール, ポリエチレンオキシド, トリトン, ポリオキシエチレン, ポリエチレングリコール |
| Spanish | polietilénglicol, producto (producto), polietilénglicol, producto, polietilenglicol (sustancia), macrogol (producto), polietilenglicol, macrogol, polietilénglicol, polietilénglicol (producto), macrogol (sustancia), Glicoles de Polietileno, Macrogoles, Polioxietilenos |
| Croatian | POLIETILENGLIKOLI |
| Polish | Glikole polietylenowe, Trytony-chemia |
| Norwegian | Not Translated[Polyethylene Glycols] |
| Portuguese | Triton X-100, Macrogóis, Polietilenoglicóis, Polioxietileno |
| German | Makrogole, Polyethylenglycole, Polyoxyethylene |
| Italian | Glicoli polietilenici |
Ontology: Sorbitol (C0037688)
| Definition (NCI) | A sugar alcohol found in fruits and plants with diuretic, laxative and cathartic property. Unabsorbed sorbitol retains water in the large intestine through osmotic pressure thereby stimulating peristalsis of the intestine and exerting its diuretic, laxative and cathartic effect. In addition, sorbitol has one-third fewer calories and 60 % the sweetening activity of sucrose and is used as a sugar replacement in diabetes. |
| Definition (MSH) | A polyhydric alcohol with about half the sweetness of sucrose. Sorbitol occurs naturally and is also produced synthetically from glucose. It was formerly used as a diuretic and may still be used as a laxative and in irrigating solutions for some surgical procedures. It is also used in many manufacturing processes, as a pharmaceutical aid, and in several research applications. |
| Definition (CSP) | six-carbon sugar alcohol with about half the sweetness of sucrose; occurs naturally and is also produced synthetically from glucose. |
| Concepts | Pharmacologic Substance (T121) , Carbohydrate (T118) |
| MSH | D013012 |
| SnomedCT | 89939002, 19839007, 412513004 |
| LNC | LP62208-1 |
| English | Glucitol, Sorbitol, D-Glucitol, D glucitol, Sorbitol agent, Sorbitol [Chemical/Ingredient], d-glucitol, sorbitol, SORBITOL, Sorbitol agent (substance), Sorbitol preparation, Sorbitol (substance), Sorbitol preparation (substance), Sorbitol (product) |
| Swedish | Sorbitol |
| Czech | sorbitol, sorbit |
| Finnish | Sorbitoli |
| French | D-Glucitol, Sorbitol |
| Russian | GLIUTSIT, SORBIT, ГЛЮЦИТ, СОРБИТ |
| Italian | Glucitolo, Sorbitolo |
| Croatian | Not Translated[Sorbitol] |
| Polish | Glucitol, Sorbitol, Sorbit |
| Japanese | グルシトール, グルシット, ソルビット, ソルビトール |
| Spanish | preparado de sorbitol (sustancia), preparado de sorbitol, sorbitol (sustancia), sorbitol, sorbitol (producto), Glucitol, Sorbitol |
| Portuguese | Glicitol, Glucitol, Sorbitol |
| German | Glucitol, Glucit, Sorbitol, Sorbit |
Ontology: magnesium citrate (C0126774)
| Definition (NCI) | The citrate salt of the element magnesium with cathartic activity. The cathartic action of magnesium cations appears to result, in part, from osmotically mediated water retention, which subsequently stimulates peristalsis. In addition, magnesium ions may also stimulate the activity of nitric oxide (NO) synthase and increase the biosynthesis of the phospholipid proinflammatory mediator platelet activating factor (PAF) in the gut. NO may stimulate intestinal secretion via prostaglandin- and cyclic GMP-dependent mechanisms while PAF produces significant stimulation of colonic secretion and gastrointestinal motility. |
| Definition (PDQ) | The citrate salt of the element magnesium with laxative properties. The cathartic action of magnesium cations appears to result, in part, from osmotically mediated water retention, which subsequently stimulates peristalsis. In addition, magnesium ions may also stimulate the activity of nitric oxide (NO) synthase and increase the biosynthesis of the phospholipid proinflammatory mediator platelet activating factor (PAF) in the gut. NO may stimulate intestinal secretion via prostglandin- and cyclic GMP-dependent mechansisms while PAFproduces significant stimulation of colonic secretion and gastrointestinal motility. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=480467&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=480467&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C29241" NCI Thesaurus) |
| Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
| MSH | C110422 |
| SnomedCT | 12495006, 387052002 |
| English | Magnesium Acid Citrate, citrate of magnesia, Citrate of Magnesia, Mg citrate, mineral supplements magnesium citrate, magnesium citrate (medication), enemas magnesium citrate, magnesium citrate [Chemical/Ingredient], citrate magnesium, mg citrate, Magnesium Citrate, MAGNESIUM CITRATE, magnesium citrate, magnesium (as citrate), Magnesium citrate, Magnesium citrate (product), Magnesium citrate (substance) |
| Spanish | citrato de magnesio (producto), citrato de magnesio (sustancia), citrato de magnesio |
Ontology: Hyperosmotic laxative (C0304551)
| Concepts | Pharmacologic Substance (T121) |
| SnomedCT | 85760005 |
| Spanish | laxante hiperosmótico, laxante hiperosmótico (sustancia), laxante osmótico, laxante osmótico (sustancia) |
| English | HYPEROSMOTIC LAXATIVES, [GA202] HYPEROSMOTIC LAXATIVES, hyperosmotic laxative, hyperosmotic laxatives, Hyperosmotic laxative (substance), Hyperosmotic laxative, Hyperosmotic laxative, NOS |
Ontology: MILK OF MAGNESIA (C0591789)
| Concepts | Pharmacologic Substance (T121) , Inorganic Chemical (T197) |
| English | MILK OF MAGNESIA, Milk of Magnesia, MILK OF MAGNESIA [VA Product], magnesia milk, milk of magnesia |
Ontology: Miralax (C0876088)
| Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
| MSH | D011092 |
| English | Miralax, Miralaxs, miralax, MiraLax, MiraLax (obsolete) |
Ontology: PHOSPHO-SODA (C0982341)
| Concepts | Pharmacologic Substance (T121) |
| English | phospho-soda, phospho soda, PHOSPHO-SODA |
