II. Mechanism

  1. Poorly absorbed, they act as hyperosmolar agents
  2. Stimulate colonic activity (via cholecystokinin)

III. Complications

  1. Hypermagnesemia (in patients with Renal Failure)
  2. Hypocalcemia (phosphate Overdose)

IV. Contraindications

  1. Renal Failure (except Lactulose and Sorbitol)

V. Preparations: Poorly-absorbed sugars (may be used in Renal Failure)

  1. Lactulose (Chronulac)
    1. Easier to administer to young children
    2. May cause abdominal cramping and flatus
    3. More expensive then Sorbitol ($10-30 per 480 ml)
    4. Onset of action within 24-48 hours
    5. Dose
      1. Adults: 15-60 ml PO daily
      2. Child (10 mg/15 ml): 1-3 cc/kg/day divided qd-bid
  2. Lactitol
    1. As effective as Lactulose with less pain and flatus
    2. Pitzalis (1995) Pediatr Med Chir 17(3):223-6
  3. Sorbitol 70%
    1. Less expensive than Lactulose ($7 per 480 ml)
    2. Sweet taste
    3. Dosing
      1. Adult: 15-60 ml PO daily
      2. Child: 1-3 ml/kg/day divided twice daily

VI. Preparations: Magnesium salt Osmotic Laxatives

  1. Rapid onset (within 3 hours)
  2. Avoid longterm use due to electrolyte loss risk
  3. Milk of Magnesia (Magnesium Hydroxide)
    1. Cost: $3 per 360 ml
    2. Concentration: 400 mg/5 ml
      1. Adults: 15-60 ml PO qd prn
      2. Children: 1-3 cc/kg/day divided bid prn
    3. Concentration 800 mg/5 ml
      1. Children: 0.5 cc/kg/day divided bid prn
    4. Adverse effects
      1. May cause abdominal cramping in higher doses
  4. Magnesium Citrate (Citroma)
    1. Cost: $1.50 per 300 ml
    2. Dose
      1. Adult: 8 ounces PO daily prn
      2. Child: 4 ml/kg up to 200 ml PO daily prn

VII. Preparations: Mineral Oil

  1. Child: 1-3 cc/kg/day divided daily to twice daily
  2. Contraindicated if aspiration risk
  3. Not recommended under age 18 months
  4. Give chilled in juice to maximize tolerability
  5. Coadminister multivitamin daily if used chronically

VIII. Preparations: Sodium salt Osmotic Laxatives

  1. Phopho-Soda (Osmoprep, Visicol) 2 tablespoons in 4 ounces water orally
  2. Fleets Enema (sodium phosphate) 120 ml enema
  3. Alternative agent: Tap Water Enema
  4. Precaution: Acute phosphate nephropathy (FDA Black Box Warning)
    1. Risk of permanent impact on Renal Function following use
    2. Risk Factors
      1. Diabetes Mellitus
      2. Age over 65 years
      3. Dehydration
      4. Concurrent NSAID, ACE Inhibitor, ARB or Diuretic
    3. Prevention of Renal Function impact
      1. Consider alternative Bowel Preparation if risk factors above
      2. Maintain clear fluid intake to replace fluid losses from Diarrhea

IX. Preparations: Polyethylene glycol 3350 (PEG, Miralax)

  1. Similar to bowel prep solution (GoLytely, Colyte)
  2. Onset of action with 24-48 hours
  3. No salty taste
  4. More expensive then Sorbitol: $2/day
  5. Preparation
    1. Use PEG powder 17 grams (one capful)
    2. Dissolve in 240 ml (8 ounces) water or juice
    3. May chill PEG solution or mix with flavoring (e.g. Crystal Light) to improve taste
      1. If for Colonoscopy prep, avoid colored flavoring that might interfere with visibility
  6. Dose:
    1. Adult: 17 grams (1 capful) daily
    2. Child
      1. Start 0.8-1 g/kg/day (15 ml/kg/day) divided bid
      2. Adjust dose for two soft painless stools per day
      3. Taper dose over time
  7. Efficacy
    1. Safe, well tolerated and effective
    2. More effective and better tolerated than Lactulose
  8. References
    1. Gremse (2002) Clin Pediatr 41:225-9
    2. Pashankar (2003) Arch Pediatr Adolesc Med 157:661-4
    3. Voskuijl (2004) Gut 53:1590-4

X. Preparations: Not recommended

  1. Castor oil or Ricinoleic Acid (Purge)
    1. Avoid due to electrolyte disturbance
    2. Adult: 15-30 ml PO qhs
    3. Child: 5-15 ml PO qhs
  2. Soapsuds Enemas (never use)
    1. Risk of irritation or hemorrhagic colitis

Images: Related links to external sites (from Google)

Cost: Medications

Polyethylene Glycol 3350 (on 2/9/2012 at DrugStore.com)
Polyethylene Glycol 3350 30 Packets Box #1 for $49.99 ($49.99/unit)
Polyethylene Glycol 3350 Powder 527gm Bottle #1 for $39.99 ($39.99/unit)
Pegasys (on 2/9/2012 at DrugStore.com)
Pegasys 180mcg/ml Solution 1ml Vial #1 for $704.02 ($704.02/unit)
Pegasys 180mcg/0.5ml Kit Box #1 for $2454.02 ($2454.02/unit)
Peg-Intron (on 2/9/2012 at DrugStore.com)
Peg-Intron "150mcg (1 Box= 1 Kit), Manufacturer Allows Up To A 30-Day Supply" Kit #1 for $671.02 ($671.02/unit)
Peg-Intron "80mcg (1 Box= 1 Kit), Manufacturer Allows Up To A 30-Day Supply" Kit #1 for $630.01 ($630.01/unit)
Peg-Intron "120mcg (1 Box= 1 Kit), Manufacturer Allows Up To A 30-Day Supply" Kit #1 for $640.99 ($640.99/unit)
Peg-Intron "50mcg (1 Box= 1 Kit), Manufacturer Allows Up To A 30-Day Supply" Kit #1 for $579.98 ($579.98/unit)
Peg-Intron Redipen (on 2/9/2012 at DrugStore.com)
Peg-Intron Redipen 120mcg/0.5ml Kit #1 for $632.00 ($632.00/unit)
Peg-Intron Redipen 80mcg/0.5ml Kit #1 for $609.98 ($609.98/unit)
Peg-Intron Redipen 150mcg/0.5ml Kit #1 for $659.98 ($659.98/unit)
Peg-Intron Redipen Pak 4 (on 2/9/2012 at DrugStore.com)
Peg-Intron Redipen Pak 4 4 50mcg/0.5ml Kit Box #1 for $2281.32 ($2281.32/unit)
Gris-PEG (on 2/9/2012 at DrugStore.com)
Gris-PEG 125mg Tablets #90 for $206.37 ($2.29/unit)
PEG-3350/Electrolytes (on 2/9/2012 at DrugStore.com)
PEG-3350/Electrolytes 236gm Solution 4000ml Bottle #1 for $19.99 ($19.99/unit)
PEG 3350-KCl-Na Bicarb-NaCl (on 2/9/2012 at DrugStore.com)
PEG 3350-KCl-Na Bicarb-NaCl 420gm Solution 4000ml Bottle #1 for $32.99 ($32.99/unit)
PEG 3350/Electrolytes (on 2/9/2012 at DrugStore.com)
PEG 3350/Electrolytes 240gm Solution 4000ml Bottle #1 for $21.99 ($21.99/unit)
Peganone (on 2/9/2012 at DrugStore.com)
Peganone 250mg Tablets #100 for $136.65 ($1.37/unit)
MiraLax (on 2/9/2012 at DrugStore.com)
MiraLax Powder 119gm Bottle #1 for $15.99 ($15.99/unit)
Sorbitol (on 2/9/2012 at DrugStore.com)
Sorbitol 70% Solution #473 for $17.99 ($0.04/unit)

Ontology: Magnesium Hydroxide (C0024476)

Definition (MSH) An inorganic compound that occurs in nature as the mineral brucite. It acts as an antacid with cathartic effects.
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.
Concepts Pharmacologic Substance (T121) , Inorganic Chemical(T197)
MSH D008276
SnomedCT 25550008, 387337001, 317584009, 60468008
English Magnesium Hydrate, Hydroxide, Magnesium, Magnesium Hydroxide, Hydrate, Magnesium, Magnesium hydroxide (Mg(OH)2), magnesium hydroxide, Magnesium hydroxide [laxative], Magnesium hydrate (substance), Magnesium hydrate, Magnesium hydroxide [laxative] (product), antacids magnesium OH, magnesium hydroxide (medication), MAGNESIUM HYDROXIDE, Magnesium Hydroxide [Chemical/Ingredient], magnesium hydrate, hydroxide laxative magnesium, hydroxide magnesium, Magnesium hydroxide, Magnesium hydroxide (product), Magnesium hydroxide (substance), Magnesium hydroxide [laxative] (substance)
French Hydroxyde de magnésium
Swedish Magnesiumhydroxid
Czech hydroxid hořečnatý
Spanish hidrato de magnesio (sustancia), hidrato de magnesio, hidróxido de magnesio (laxante), hidróxido de magnesio (laxante) (producto), hidróxido de magnesio (producto), hidróxido de magnesio (sustancia), hidróxido de magnesio, Hidroxido de Magnesio, Hidróxido de Magnesio
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
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) 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) , Pharmacologic Substance(T121) , Biomedical or Dental Material(T122)
MSH D011092
SnomedCT 419116004, 8030004, 356076006
English Glycols, Polyethylene, Macrogols, Oxide, Polyethylene, Polyethylene Glycol, Polyethylene Glycols, Polyethylene Oxide, Polyethyleneoxide, Polyoxyethylenes, Polyethylene glycol, NOS, Glycol, polyethylene, Macrogol (substance), PEG, Polyethylene Glycols [Chemical/Ingredient], macrogol (medication), macrogol, Oxides, Polyethylene, Polyoxyethylene, Polyethylene Oxides, Polyethyleneoxides, glycol polyethylene, polyethylene glycols, macrogols, polyethylene oxide, polyoxyethylene, POLYETHYLENE GLYCOL, PEG - Polyethylene glycol, Polyethylene glycol, Polyethylene glycol product, Macrogol, Polyethylene glycol (substance), Polyethylene glycol product (product), polyethylene glycol, glycol, polyethylene, 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
Portuguese Triton X-100, Macrogóis, Polietilenoglicóis, Polioxietileno
Polish Glikole polietylenowe, Trytony-chemia
German Makrogole, Polyethylenglycole, Polyoxyethylene
Italian Glicoli polietilenici

Ontology: Sorbitol (C0037688)

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.
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.
Concepts Carbohydrate (T118) , Pharmacologic Substance(T121)
MSH D013012
SnomedCT 89939002, 19839007, 412513004
English Glucitol, Sorbitol, sorbitol, D-Glucitol, Sorbitol preparation, D glucitol, Sorbitol agent, Sorbitol [Chemical/Ingredient], d-glucitol, Sorbitol (substance), Sorbitol agent (substance), Sorbitol preparation (substance), Sorbitol (product), SORBITOL
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
German Glucitol, Glucit, Sorbitol, Sorbit
Portuguese Glicitol, Glucitol, Sorbitol

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 Organic Chemical (T109) , Pharmacologic Substance(T121)
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 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
English Hyperosmotic laxative, NOS, HYPEROSMOTIC LAXATIVES, [GA202] HYPEROSMOTIC LAXATIVES, hyperosmotic laxative, hyperosmotic laxatives, Hyperosmotic laxative (substance), Hyperosmotic laxative
Spanish laxante hiperosmótico, laxante hiperosmótico (sustancia), laxante osmótico, laxante osmótico (sustancia)

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 Organic Chemical (T109) , Pharmacologic Substance(T121)
MSH D011092
English Miralax, Miralaxs, miralax, MiraLax, MiraLax (obsolete)

Ontology: PHOSPHO-SODA (C0982341)

Concepts Pharmacologic Substance (T121)
English phospho-soda, phospho soda, PHOSPHO-SODA