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Review
. 2025 Apr 16;5(1):e70113.
doi: 10.1002/deo2.70113. eCollection 2025 Apr.

Efficacy and safety of oral sulfate solution versus polyethylene glycol for colonoscopy: A systematic review and meta-analysis of randomized controlled trials

Umar Akram  1 , Shahzaib Ahmed  2 , Eeshal Fatima  3 , Eeman Ahmad  2 , Hamza Ashraf  1 , Syed Adeel Hassan  4 , Zaheer Qureshi  5 , Faryal Altaf  6 , Daniel Buckles  7 , Javed Iqbal  8 , Khabab Abbasher Hussien Mohamed Ahmed  9
Affiliations
Review

Efficacy and safety of oral sulfate solution versus polyethylene glycol for colonoscopy: A systematic review and meta-analysis of randomized controlled trials

Umar Akram et al. DEN Open. .

Abstract

Background: Colonoscopy is the gold standard for early detection and monitoring of colorectal cancer. Procedural effectiveness is dependent on optimal bowel preparation. Traditional polyethylene glycol (PEG) solutions are difficult to tolerate, whereas newer low-volume alternatives, including PEG with ascorbic acid and oral sulfate solutions (OSS), offer improved efficacy and tolerability. The meta-analysis was performed to evaluate the efficacy and safety of OSS compared to PEG for bowel preparation in colonoscopy.

Methods: Studies were identified by searching PubMed, Embase, Cochrane CENTRAL, and clinicaltrials.gov from inception until June 2024. Only randomized controlled trials comparing OSS with PEG were included. Data was analyzed using R version 4.4.0 using a random effects model to calculate risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

Results: Twenty-one studies with 6346 participants met the inclusion criteria. OSS significantly improved adenoma detection (RR, 1.13; 95% CI, 1.04-1.22; p-value <0.01; I2 = 0%) and polyp detection rates (RR, 1.16; 95% CI, 1.06-1.26; p-value <0.01; I2 = 0%), and had a higher Boston Bowel Preparation Scale (BBPS) score (MD, 0.31; 95% CI, 0.13-0.50; p-value <0.01; I2 = 81%). PEG was associated with more sleep disturbances (RR, 0.45; 95% CI, 0.25-0.82; p-value = 0.03; I2 = 0%). However, other adverse effects were similar between both solutions.

Conclusion: OSS demonstrated superior adenoma and polyp detection rates. When compared to PEG, patients utilizing OSS achieved higher BBPS scores. Data gleaned support enhanced cleansing efficacy and safety of OSS as a bowel preparation regimen.

Keywords: adenoma; colonoscopy; colorectal neoplasms; meta‐analysis; polyethylene glycols.

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Conflict of interest statement

None.

Figures

FIGURE 1
FIGURE 1
Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) flow diagram summarizing the screening process.
FIGURE 2
FIGURE 2
(a) Forest plot of pooled adenoma detection rate (ADR). (b) Forest plot of pooled polyp detection rate (PDR).
FIGURE 3
FIGURE 3
Subgroup analysis of adenoma detection rate on the basis of mean age >55 years, Morning colonoscopy, 2‐L protocol, BMI <25 kg/m2, and outpatient settings.
FIGURE 4
FIGURE 4
Subgroup analysis of polyp detection rate on the basis of mean age >55 years, morning colonoscopy, 2‐L protocol, BMI <25 kg/m2, and outpatient settings.
FIGURE 5
FIGURE 5
(a) Forest plot of Pooled Boston Bowel Preparation Scale (BBPS) score. (b) Forest plot of Pooled Ottawa Bowel Preparation Scale (OBPS) score.
FIGURE 6
FIGURE 6
Subgroup analysis of BBPS score on the basis of mean age >55 years, morning colonoscopy, 2‐L protocol, BMI <25 kg/m2, and outpatient settings.
FIGURE 7
FIGURE 7
(a) Forest plot of pooled cecal insertion time (CIT). (b) Forest plot of pooled cecal intubation rate (CIR).
See this image and copyright information in PMC

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