Efficacy and safety of Bowel Preparation Strategies in Inflammatory Bowel Disease Patients Undergoing Colonoscopy: A Systematic Review and Meta-Analysis

Abstract

Aims The ESGE guidelines recommend high or low volume PEG-based bowel preparation for inflammatory bowel disease (IBD).[1] Recently available, non-PEG sulphate-based options provide additional choices. This systematic review meta-analysed efficacy and safety of bowel preparations for IBD patients undergoing colonoscopy

Methods We searched CENTRAL, ClinicalTrials.gov, Embase via Ovid, MEDLINE via Ovid, WHO ICTPR for RCTs until October 2023, covering all preparation types. Primary outcomes included bowel preparation success, tolerability, willingness to repeat, and safety. Secondary outcomes were caecal intubation rates (CIR) and abnormal serum electrolyte levels. Pooled estimates used risk ratio (RR) and 95% confidence interval (CI). GRADE assessed evidence certainty.

Results Ten RCTs(1479 IBD patients) were included, which compared 4L-PEG, with/without simethicone, castor oil vs. senna, two commercial low-volume PEG-based preparations, 2L PEG vs. 4L PEG, and low-volume PEG with additives vs. non-PEG-based preparations. For 2L vs. 4L PEG, bowel prep success showed no difference (RR 0.95,95% CI:0.88-1.09;I2=33%,2 RCTs;high certainty evidence). Willingness to repeat favored 2L (RR 0.69,95% CI:0.59-0.80; I2=18%,2 RCTs;high certainty evidence). In low-volume non-PEG vs. PEG, bowel prep success probably equaled (RR 0.96,95% CI:0.90-1.01;I2=6%,3 RCTs;moderate certainty evidence). Tolerability and willingness to repeat evidence was very uncertain (RR 0.81,95% CI:0.67-0.99;I2=76%,3 RCTs; very-low certainty evidence), (RR 0.77,95% CI:0.59-0.99; I2=83%,3 RCTs;very-low certainty evidence). No difference in CIR (RR 0.98,95% CI:0.93-1.03;I2=0%,2 RCTs;high certainty evidence). No abnormal post-bowel preparation electrolyte levels were noted in either group. Sub-group analysis showed comparable effectiveness of picosulphate-based (RR 0.89,95% CI:0.78-1.01;I2=0%,1 RCT) and sulphate-based preparations (RR 0.96,95% CI: 0.90-1.05;I2=28%,2 RCTs) compared to low-volume PEG-based preparations. Similar trends were noted for tolerability (RR 0.86,95% CI: 0.73-1.01;I2=22%,1 RCT with picosulphate-based, and RR 0.76,95% CI:0.45-1.26; I2=91%,2 RCTs with sulphate-based vs. low-volume PEG-based,respectively) and willingness to repeat (RR 0.62,95% CI:0.33-1.16;I2=86%,1 RCT with picosulphate-based, and RR 0.88,95% CI:0.65-1.20;I2=86%,2 RCTs with sulphate-based vs. low-volume PEG-based, respectively). Safety data were inconsistently reported.

Conclusions High-certainty evidence from two trials supports low-volume PEG with additives as comparably successful to high-volume PEG, with increased willingness to repeat. Moderate-certainty evidence from three trials indicates similar success between non-PEG-based and PEG-based preparations. Both low-volume PEG-based and non-PEG-based preparations have evidence supporting their clinical utility for IBD patients, expanding choices beyond ESGE 2019 guidelines.