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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

  • 2. Editorial Board

    Editor-in-Chief + MORE

    Editor-in-Chief
    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

    Deputy Editor

    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Letter to the Editor

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Comments on Oral Sulfate Solution Is as Effective as Polyethylene Glycol with Ascorbic Acid in a Split Method for Bowel Preparation in Patients with Inactive Ulcerative Colitis: A Randomized, Multicenter, and Single-Blind Clinical Trial

Ji Eun Kim

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Ji Eun Kim
ORCID https://orcid.org/0000-0003-2149-7979
E-mail happyjinny0706@gmail.com

Received: September 6, 2023; Accepted: September 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2024;18(1):192-193. https://doi.org/10.5009/gnl230355

Published online November 30, 2023, Published date January 15, 2024

Copyright © Gut and Liver.

To the Editor:

We extend our congratulations on the study conducted by Lee et al.,1 which demonstrated the efficacy of oral sulfate solution (OSS) administration in patients with ulcerative colitis (UC) based on the results of colonoscopic procedures. While there have been numerous reports within the scientific community regarding the usefulness and efficiency of OSS in patients with UC, this study is the first publication in the literature to emphasize the advantages of such findings. Through this paper, we hope to provide a hopeful message to patients suffering from UC, who have been experiencing difficulty undergoing periodic colonoscopies2 due to the discomfort associated with the procedure of bowel preparation.

Colonoscopy is primarily conducted periodically for cancer surveillance, with the most crucial step to ensure its efficiency being bowel preparation. Furthermore, with the heightened rigor in treatment goals for patients with inflammatory bowel diseases following the release of the Selecting Therapeutic Targets in Inflammatory Bowel Disease II guidelines,3 the assessment of mucosal healing has gained importance. In the case of UC, the state of colonic mucosal healing, allowing direct visual inspection of a patient's inflammatory activity, holds substantial importance.4

UC is a condition that causes inflammation of the colon due to various etiologies.5 UC has prompted ongoing concerns about safety, as it encompasses a variety of components with the development of new bowel preparations over time. To substantiate this, comparative studies between 2-L polyethylene glycol (PEG) and 4-L PEG have been conducted,6 and in the case of a low-volume agent at 1 L, it also demonstrated noninferiority in terms of safety and efficacy.7 This establishes the need for bowel preparation designs that consider not only efficacy but also compliance and safety.

In their study, Lee et al. demonstrated the safety of OSS through evaluations encompassing differences in various electrolytes from blood tests pre- and postendoscopy, as well as changes in the activity index, represented by the partial Mayo score. However, this evaluation pertains to acute complications, and longitudinal tracking of baseline intestinal inflammatory states provoked by bowel preparation might also be necessary. In clinical practice, instances of ischemic colitis have been reported following the use of OSS,8 but the underlying mechanisms remain elusive, necessitating further investigation into direct causality. This is particularly important due to the known effect of OSS in stimulating colon motility, potentially leading to bowel hypoperfusion.9

An aspect of disappointment within the study findings is the lack of difference between the two groups in terms of nausea or bloating. This conclusion contrasts with the anticipation that OSS administration would result in fewer instances. A previous study comparing OSS to sodium picosulfate with magnesium citrate found that patient satisfaction was actually higher in the sodium picosulfate with magnesium citrate group, and statistically, the OSS group exhibited greater levels of nausea.10 Consequently, there remains a need for future large-scale prospective studies to establish the superiority of OSS.

OSS not only allows for consumption with minimal fluid intake but also enhances compliance due to its palatability, thereby aiding in bowel preparation.11 Furthermore, its inclusion of simethicone facilitates effective gas removal. An ideal bowel preparation should swiftly clear all fecal matter without inducing histological changes in the colonic mucosa, while ensuring patient comfort and safety. In this regard, the authors' conclusion that OSS is noninferior to PEG with ascorbic acid for bowel preparation in patients with UC is agreed upon. However, to sufficiently establish its safety, long-term data collection is needed. Ultimately, since the goal is to safely prepare the colon, even in cases of active UC, additional research is necessary to address any potential concerns.

No potential conflict of interest relevant to this article was reported.

  1. Lee JM, Lee KM, Kang HS, et al. Oral sulfate solution is as effective as polyethylene glycol with ascorbic acid in a split method for bowel preparation in patients with inactive ulcerative colitis: a randomized, multicenter, and single-blind clinical trial. Gut Liver 2023;17:591-599.
    Pubmed KoreaMed CrossRef
  2. Kim ES, Kang B. Assessment of medication adherence and pharmacist intervention are important for the care of patients with inflammatory bowel disease. Gut Liver 2022;16:665-666.
    Pubmed KoreaMed CrossRef
  3. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology 2021;160:1570-1583.
    Pubmed CrossRef
  4. Sood A, Mahajan R, Singh A, Midha V, Mehta V. Endoscopy for assessment of mucosal healing in ulcerative colitis: time bound or response guided?. Intest Res 2022;20:297-302.
    Pubmed KoreaMed CrossRef
  5. Tsai KY, You JF, Tsai TY, et al. Improvement of ulcerative colitis control by searching and restricting of inflammatory trigger factors in daily clinical practice. Intest Res 2023;21:100-109.
    Pubmed KoreaMed CrossRef
  6. Kim MS, Park J, Park JH, et al. Does polyethylene glycol (PEG) plus ascorbic acid induce more mucosal injuries than split-dose 4-L PEG during bowel preparation?. Gut Liver 2016;10:237-243.
    Pubmed KoreaMed CrossRef
  7. Koo JS, Byeon JS, Lee BI, Jung SA, Kim TI, Jeen YT. Efficacy and safety of TJP-008 compared to 2 L PEG with ascorbate in colon cleansing: a randomized phase 3 trial. Gut Liver 2022;16:259-268.
    Pubmed KoreaMed CrossRef
  8. Chung JW, Lee JM, Sohn YW, Han WC, Yoon K. Ischemic colitis associated with low-volume oral sulfate solution for bowel preparation. Korean J Gastroenterol 2020;75:216-219.
    Pubmed CrossRef
  9. Hass DJ, Kozuch P, Brandt LJ. Pharmacologically mediated colon ischemia. Am J Gastroenterol 2007;102:1765-1780.
    Pubmed CrossRef
  10. Kim J, Kim HG, Kim KO, et al. Clinical comparison of low-volume agents (oral sulfate solution and sodium picosulfate with magnesium citrate) for bowel preparation: the EASE study. Intest Res 2019;17:413-418.
    Pubmed KoreaMed CrossRef
  11. Ali IA, Roton D, Madhoun M. Oral sulfate solution versus low-volume polyethylene glycol for bowel preparation: meta-analysis of randomized controlled trials. Dig Endosc 2022;34:721-728.
    Pubmed CrossRef

Article

Letter to the Editor

Gut and Liver 2024; 18(1): 192-193

Published online January 15, 2024 https://doi.org/10.5009/gnl230355

Copyright © Gut and Liver.

Comments on Oral Sulfate Solution Is as Effective as Polyethylene Glycol with Ascorbic Acid in a Split Method for Bowel Preparation in Patients with Inactive Ulcerative Colitis: A Randomized, Multicenter, and Single-Blind Clinical Trial

Ji Eun Kim

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to:Ji Eun Kim
ORCID https://orcid.org/0000-0003-2149-7979
E-mail happyjinny0706@gmail.com

Received: September 6, 2023; Accepted: September 21, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

To the Editor:

We extend our congratulations on the study conducted by Lee et al.,1 which demonstrated the efficacy of oral sulfate solution (OSS) administration in patients with ulcerative colitis (UC) based on the results of colonoscopic procedures. While there have been numerous reports within the scientific community regarding the usefulness and efficiency of OSS in patients with UC, this study is the first publication in the literature to emphasize the advantages of such findings. Through this paper, we hope to provide a hopeful message to patients suffering from UC, who have been experiencing difficulty undergoing periodic colonoscopies2 due to the discomfort associated with the procedure of bowel preparation.

Colonoscopy is primarily conducted periodically for cancer surveillance, with the most crucial step to ensure its efficiency being bowel preparation. Furthermore, with the heightened rigor in treatment goals for patients with inflammatory bowel diseases following the release of the Selecting Therapeutic Targets in Inflammatory Bowel Disease II guidelines,3 the assessment of mucosal healing has gained importance. In the case of UC, the state of colonic mucosal healing, allowing direct visual inspection of a patient's inflammatory activity, holds substantial importance.4

UC is a condition that causes inflammation of the colon due to various etiologies.5 UC has prompted ongoing concerns about safety, as it encompasses a variety of components with the development of new bowel preparations over time. To substantiate this, comparative studies between 2-L polyethylene glycol (PEG) and 4-L PEG have been conducted,6 and in the case of a low-volume agent at 1 L, it also demonstrated noninferiority in terms of safety and efficacy.7 This establishes the need for bowel preparation designs that consider not only efficacy but also compliance and safety.

In their study, Lee et al. demonstrated the safety of OSS through evaluations encompassing differences in various electrolytes from blood tests pre- and postendoscopy, as well as changes in the activity index, represented by the partial Mayo score. However, this evaluation pertains to acute complications, and longitudinal tracking of baseline intestinal inflammatory states provoked by bowel preparation might also be necessary. In clinical practice, instances of ischemic colitis have been reported following the use of OSS,8 but the underlying mechanisms remain elusive, necessitating further investigation into direct causality. This is particularly important due to the known effect of OSS in stimulating colon motility, potentially leading to bowel hypoperfusion.9

An aspect of disappointment within the study findings is the lack of difference between the two groups in terms of nausea or bloating. This conclusion contrasts with the anticipation that OSS administration would result in fewer instances. A previous study comparing OSS to sodium picosulfate with magnesium citrate found that patient satisfaction was actually higher in the sodium picosulfate with magnesium citrate group, and statistically, the OSS group exhibited greater levels of nausea.10 Consequently, there remains a need for future large-scale prospective studies to establish the superiority of OSS.

OSS not only allows for consumption with minimal fluid intake but also enhances compliance due to its palatability, thereby aiding in bowel preparation.11 Furthermore, its inclusion of simethicone facilitates effective gas removal. An ideal bowel preparation should swiftly clear all fecal matter without inducing histological changes in the colonic mucosa, while ensuring patient comfort and safety. In this regard, the authors' conclusion that OSS is noninferior to PEG with ascorbic acid for bowel preparation in patients with UC is agreed upon. However, to sufficiently establish its safety, long-term data collection is needed. Ultimately, since the goal is to safely prepare the colon, even in cases of active UC, additional research is necessary to address any potential concerns.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Lee JM, Lee KM, Kang HS, et al. Oral sulfate solution is as effective as polyethylene glycol with ascorbic acid in a split method for bowel preparation in patients with inactive ulcerative colitis: a randomized, multicenter, and single-blind clinical trial. Gut Liver 2023;17:591-599.
    Pubmed KoreaMed CrossRef
  2. Kim ES, Kang B. Assessment of medication adherence and pharmacist intervention are important for the care of patients with inflammatory bowel disease. Gut Liver 2022;16:665-666.
    Pubmed KoreaMed CrossRef
  3. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology 2021;160:1570-1583.
    Pubmed CrossRef
  4. Sood A, Mahajan R, Singh A, Midha V, Mehta V. Endoscopy for assessment of mucosal healing in ulcerative colitis: time bound or response guided?. Intest Res 2022;20:297-302.
    Pubmed KoreaMed CrossRef
  5. Tsai KY, You JF, Tsai TY, et al. Improvement of ulcerative colitis control by searching and restricting of inflammatory trigger factors in daily clinical practice. Intest Res 2023;21:100-109.
    Pubmed KoreaMed CrossRef
  6. Kim MS, Park J, Park JH, et al. Does polyethylene glycol (PEG) plus ascorbic acid induce more mucosal injuries than split-dose 4-L PEG during bowel preparation?. Gut Liver 2016;10:237-243.
    Pubmed KoreaMed CrossRef
  7. Koo JS, Byeon JS, Lee BI, Jung SA, Kim TI, Jeen YT. Efficacy and safety of TJP-008 compared to 2 L PEG with ascorbate in colon cleansing: a randomized phase 3 trial. Gut Liver 2022;16:259-268.
    Pubmed KoreaMed CrossRef
  8. Chung JW, Lee JM, Sohn YW, Han WC, Yoon K. Ischemic colitis associated with low-volume oral sulfate solution for bowel preparation. Korean J Gastroenterol 2020;75:216-219.
    Pubmed CrossRef
  9. Hass DJ, Kozuch P, Brandt LJ. Pharmacologically mediated colon ischemia. Am J Gastroenterol 2007;102:1765-1780.
    Pubmed CrossRef
  10. Kim J, Kim HG, Kim KO, et al. Clinical comparison of low-volume agents (oral sulfate solution and sodium picosulfate with magnesium citrate) for bowel preparation: the EASE study. Intest Res 2019;17:413-418.
    Pubmed KoreaMed CrossRef
  11. Ali IA, Roton D, Madhoun M. Oral sulfate solution versus low-volume polyethylene glycol for bowel preparation: meta-analysis of randomized controlled trials. Dig Endosc 2022;34:721-728.
    Pubmed CrossRef
Gut and Liver

Vol.18 No.1
January, 2024

pISSN 1976-2283
eISSN 2005-1212

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