Picoprep

White crystalline powder.
Each sachet contains sodium picosulfate 10.0 mg, light magnesium oxide 3.5 g and anhydrous citric acid 12.0 g.
Excipients/Inactive Ingredients: Potassium hydrogen carbonate; Sodium saccharin; Natural, spray dried orange flavour which contains acacia gum, lactose, ascorbic acid and butylated hydroxyanisole.
Each sachet also contains: Potassium hydrogen carbonate 0.5 g [equivalent to 5 mmol (195 mg) potassium]; Lactose (as a component of the flavour).

Pharmacotherapeutic group: Contact laxatives. ATC code: A06A B58.
Pharmacology: Pharmacodynamics: The active components of PICOPREP are sodium picosulfate and magnesium citrate. Sodium picosulfate is a locally acting stimulant cathartic, which after bacterial cleavage in the colon, forms the active laxative compound, bis-(p-hydroxyphenyl)-pyridyl-2-methane (BHPM), which has a dual-action with stimulation of the mucosa of both the large intestine and of the rectum. Magnesium citrate acts as an osmotic laxative by retaining moisture in the colon. The combined action of the two substances is of a 'washing out' effect combined with peristaltic stimulation to clear the bowel. The product is not intended for use as a routine laxative.
Pharmacokinetics: Both active components are locally active in the colon, and neither are absorbed in any detectable amounts.

To clean the bowel prior to X-ray examination or endoscopy.
To clean the bowel prior to surgery, when judged clinically necessary (see Precautions regarding open colorectal surgery).

Method of administration: Route of administration: Oral.
There are two dosing regimens, each requires two separate dosing times: The preferred method is the "Split Dose" method and consists of two separate doses: the first dose during the evening before the procedure and the second dose the next day, during the morning prior to the procedure.
The alternative method is the "Day Before" method and consists of two separate doses: the first dose during the afternoon or early evening before the procedure and the second dose 6 hours later during the evening before the procedure.
A low residue diet is recommended on the day prior to the procedure. A clear liquid diet is recommended on the day of the procedure. To avoid dehydration, it is important to follow the liquid intake recommendation as advocated together with the PICOPREP dosing whilst the effects of PICOPREP persist (see Posology as follows). Apart from the liquid intake together with the treatment regimen (PICOPREP + additional liquids), a normal, thirst driven intake of clear liquids is recommended.
Clear liquids should include a variety of fruit juice without pulp, soft drinks, clear soup, tea, coffee (without milk, soy or cream) and water. Do not drink only water.
Directions for Reconstitution: (a) Reconstitute the PICOPREP powder right before each administration. Do not prepare the solution in advance.
(b) Fill a cup with cold water (approximately 150 ml) and pour in the contents of one packet of PICOPREP powder.
(c) Stir for 2 to 3 minutes. The reconstituted PICOPREP solution may become slightly warm as the powder dissolves.
Posology: Split-Dose Dosing Regimen (Preferred Method): The Split-Dose regimen is the preferred dosing method. Instruct patients to take two separate doses in conjunction with fluids, as follows: Take the first dose during the evening before the procedure (e.g., 5:00 to 9:00 PM) followed by at least five 250 ml drinks of clear liquids before bed. Consume clear liquids within 5 hours.
Take second dose, the next day approximately 5 hours before the procedure followed by at least three 250 ml drinks of clear liquids before the procedure. Consume clear liquids within 5 hours up until 2 hour before the time of the procedure.
Day-Before Dosing Regimen (Alternative Method): The Day-Before regimen is the alternative dosing method for patients for whom the Split-Dosing is inappropriate. Instruct patients to take two separate doses in conjunction with fluids, as follows: Take the first dose in the afternoon or early evening (e.g., 4:00 to 6:00 PM) before the procedure followed by at least five 250 ml drinks of clear liquids before the next dose. Consume clear liquids within 5 hours.
Take the second dose approximately 6 hours later in the late evening (e.g., 10:00 PM to 12:00 AM), the night before the procedure followed by three 250 ml drinks of clear liquids before bed. Consume clear liquids within 5 hours.
Children: The first dose reconstituted in water as directed, taken before 8 am on the day before the procedure. Second dose 6 to 8 hours later.
1 - 2 years: ¼ sachet morning, ¹/₄ sachet afternoon.
2 - 4 years: ½ sachet morning, ¹/₂ sachet afternoon.
4 - 9 years: 1 sachet morning, ¹/₂ sachet afternoon.
9 and above: adult dose.

Overdose would lead to profuse diarrhoea. Treatment is by general supportive measures and correction of fluid and electrolyte balance.

Hypersensitivity to the active substances or to any of the excipients listed in Description; Congestive cardiac failure; Gastric retention; Gastro-intestinal ulceration; Toxic colitis; Toxic megacolon; Ileus; Nausea and vomiting; Acute surgical abdominal conditions such as acute appendicitis; Known or suspected gastro-intestinal obstruction or perforation; Severe dehydration; Rhabdomyolysis; Hypermagnesemia; Active inflammatory bowel disease; In patients with severely reduced renal function, accumulation of magnesium in plasma may occur. Another preparation should be used in such cases.

Because a clinically relevant benefit of bowel cleansing prior to elective, open colorectal surgery could not be proven, bowel cleansers should only be administered before bowel surgery if clearly needed. The risks of the treatment should be carefully weighed against possible benefits and needs depending on surgical procedures performed.
An insufficient or excessive oral intake of water and electrolytes could create clinically significant, deficiencies, particularly in less fit patients. In this regard patients with low body weight, children, the elderly, debilitated individuals and patients at risk of hypokalaemia or hyponatremia may need particular attention. Prompt corrective action should be taken to restore fluid/electrolyte balance in patients with signs or symptoms of hypokalaemia or hyponatremia.
Drinking only water to replace the fluid losses may lead to electrolyte imbalance.
Care should also be taken in patients with recent gastro-intestinal surgery as well as in patients with renal impairment, heart disease or inflammatory bowel disease. Use with caution in patients on drugs that might affect water and/or electrolyte balance e.g. diuretics, corticosteroids, lithium (see Interactions).
PICOPREP may modify the absorption of regularly prescribed oral medication and should be used with caution e.g. there have been isolated reports of seizures in patients on antiepileptics, with previously controlled epilepsy (see Interactions and Adverse Reactions).
The period of bowel cleansing should not exceed 24 hours because longer preparation may increase the risk of water and electrolyte imbalance.
For an early time of the day procedure, it may be required to take the second dose during the night and possible sleep disturbance may occur.
This medicine contains 5 mmol (or 195 mg) potassium per sachet. This should be taken into consideration by patients with reduced kidney function or patients on a controlled potassium diet.
This medicine contains lactose as a component of the flavour. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase glucose-galactose malabsorption deficiency or should not take PICOPREP.
PICOPREP should not be used as a routine laxative.
Effects on Ability to Drive and Use Machines: Not applicable.

Pregnancy: For PICOPREP, no clinical data on exposed pregnancy are available. Studies in animals have shown reproductive toxicity. As picosulfate is a stimulant laxative, for safety measure, it is preferable to avoid the use of PICOPREP during pregnancy.
Fertility: There are no data on the effect of PICOPREP on fertility in humans.
Male and female rat fertility was not affected by oral doses of sodium picosulfate up to 100 mg/kg.
Breastfeeding: There is no experience with the use of PICOPREP in nursing mothers. However, due to the pharmacokinetic properties of the active ingredients, treatment with PICOPREP may be considered for females who are breastfeeding.

The most frequent adverse reactions seen in clinical trials are nausea, headache and vomiting. (See table.)

Click on icon to see table/diagram/image

Diarrhoea and faecal incontinence are the primary clinical effect of PICOPREP. Isolated cases of severe diarrhoea have been reported post-marketing.
Hyponatraemia has been reported with or without associated convulsions. In epileptic patients, there have been isolated reports of seizure/grand mal convulsion without associated hyponatraemia. There have been isolated reports of anaphylactoid reaction.

As a purgative, PICOPREP increases the gastrointestinal transit rate. The absorption of other orally administered medicines (e.g. anti-epileptics, contraceptives, anti-diabetics, antibiotics) may therefore be modified during the treatment period (see Precautions). Tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine and penicillamine, should be taken at least 2 hours before and not less than 6 hours after administration of PICOPREP to avoid chelation with magnesium.
The efficacy of PICOPREP is lowered by bulk-forming laxatives.
Care should be taken with patients already receiving drugs which may be associated with hypokalaemia (such as diuretics or corticosteroids, or drugs where hypokalaemia is a particular risk i.e. cardiac glycosides). Caution is also advised when PICOPREP is used in patients on NSAIDs or drugs known to induce SIADH e.g. tricyclic antidepressants, selective serotonin re-uptake inhibitors, antipsychotic drugs and carbamazepine as these drugs may increase the risk of water retention and/or electrolyte imbalance.

Incompatibilities: Not applicable.

Store below 30°C in the original package in order to protect from moisture.
Shelf Life: 3 years. Once the sachet has been opened, use immediately and discard any unused powder or solution.

Laxatives, Purgatives

A06AB58 - sodium picosulfate, combinations ; Belongs to the class of contact laxatives.

NP