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Sodium picosulfate, magnesium oxide, and citric acid: Drug information

Sodium picosulfate, magnesium oxide, and citric acid: Drug information
(For additional information see "Sodium picosulfate, magnesium oxide, and citric acid: Patient drug information" and see "Sodium picosulfate, magnesium oxide, and citric acid: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
Brand Names: US
  • Clenpiq;
  • Prepopik [DSC]
Brand Names: Canada
  • Oral Purgative;
  • Pico-Salax;
  • Picodan;
  • Picoflo;
  • Purg-Odan
Pharmacologic Category
  • Laxative, Osmotic;
  • Laxative, Stimulant
Dosing: Adult
Bowel cleansing

Bowel cleansing: Oral:

Note: Correct fluid and electrolyte imbalances prior to administration.

Clenpiq:

Split-dose regimen: 160 or 175 mL (1 bottle) the evening before the colonoscopy (5 PM to 9 PM), followed by a second 160 or 175 mL dose ~5 hours before the colonoscopy.

Prepopik:

Split-dose regimen (preferred): 150 mL (5 oz) the evening before the colonoscopy (5 PM to 9 PM), followed by a second 150 mL (5 oz) dose ~5 hours before the colonoscopy.

Day-before regimen (alternative): 150 mL (5 oz) in the early evening before the colonoscopy (4 PM to 6 PM), followed by a second 150 mL (5 oz) dose 6 hours later (10 PM to 12 AM) the night before the colonoscopy.

Pico-Salax; Purg-Odan [Canadian products]:

Early colonoscopy (before 12 PM): One sachet (mixed and dissolved in water) in the evening (5 PM) the day prior to the procedure, followed by a second dose of one sachet 5 hours later (10 PM) the night before the procedure

Late colonoscopy (after 12 PM): One sachet (mixed and dissolved in water) in the late evening (7 PM) the day prior to the procedure, followed by a second dose of one sachet in the morning (6 AM) on the day of the procedure

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

CrCl ≥30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling.

CrCl <30 mL/minute: Use is contraindicated.

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Sodium picosulfate, magnesium oxide, and citric acid: Pediatric drug information")

Bowel cleansing

Bowel cleansing: Note: Administered as a 2-dose regimen prior to colonoscopy; timing of doses and volume administered may vary between products; use precaution.

Children ≥9 years and Adolescents: Note: Following each dose, varying amounts of clear liquids should be consumed; see "Administration: Pediatric" for additional information.

Clenpiq: Split -dose regimen: First dose: Contents of 1 bottle (160 mL or 175 mL) administered the evening before the colonoscopy (eg, 5 PM to 9 PM). Second dose: 1 bottle (160 mL or 175 mL) administered the next morning ~5 hours before the colonoscopy.

Prepopik: Note: Sachets should be dissolved in water (5 oz) prior to administration (see "Preparation for Administration: Pediatric").

Split-dose regimen (preferred): First dose: 1 packet (dissolved in water) administered the evening before the colonoscopy (eg, 5 PM to 9 PM). Second dose: 1 packet administered the next morning ~5 hours before the colonoscopy.

Day-before regimen: First dose: 1 packet (dissolved in water) administered the early evening before the colonoscopy (eg, 4 PM to 6 PM). Second dose: 1 packet administered 6 hours later (eg, 10 PM to 12 AM) the night before the colonoscopy.

Canadian labeling: Pico-Salax; Purg-Odan:

Children 1 to 5 years: 1/4 of 1 sachet (mixed and dissolved in water) in the evening (6 PM) the day prior to the procedure, followed by a second dose of 1/4 of 1 sachet in the morning (8 AM) on the day of the procedure.

Children 6 to 12 years: 1/2 of 1 sachet (mixed and dissolved in water) in the evening (6 PM) the day prior to the procedure, followed by a second dose of 1/2 of 1 sachet in the morning (8 AM) on the day of the procedure.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Children ≥9 years and Adolescents: Oral:

Mild to moderate impairment (CrCl ≥30 mL/minute): There are no adjustments provided in the manufacturer labeling. Magnesium-containing bowel preparations should be used with caution in patients with mild to moderate renal impairment or patients receiving concomitant medications which may affect renal function (eg, diuretics, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, nonsteroidal anti-inflammatory drugs) due to increased risk of renal injury; ensure adequate hydration.

Severe impairment (CrCl <30 mL/minute): Use is contraindicated.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults, unless otherwise noted.

>10%:

Cardiovascular: Altered blood pressure (children, adolescents, and adults: ≤20%), change in pulse (children, adolescents, and adults: ≤20%)

Endocrine & metabolic: Hypermagnesemia (2% to 33%)

Renal: Decreased estimated GFR (eGFR) (day of colonoscopy: 10% to 13%; 24 to 48 hours after colonoscopy: 25% to 29%)

1% to 10%:

Endocrine & metabolic: Decreased serum bicarbonate (1% to 8%), decreased serum calcium (≤2%), decreased serum potassium (2% to 8%), decreased serum sodium (≤5%), dehydration (≤2%), hypochloremia (1% to 4%)

Gastrointestinal: Abdominal pain (children and adolescents: >5%; adults: 2%), nausea (children and adolescents: >5%; adults: 3%), vomiting (children and adolescents: >5%; adults: 1%)

Nervous system: Dizziness (≤2%), headache (2% to 3%)

Renal: Increased serum creatinine (1% to 5%)

Frequency not defined: Endocrine & metabolic: Decreased serum glucose (children and adolescents)

Postmarketing (any population):

Cardiovascular: Syncope

Dermatologic: Skin rash, urticaria

Gastrointestinal: Aphthous stomatitis (ileal), diarrhea, fecal incontinence, ischemic colitis, rectal pain

Hematologic & oncologic: Purpuric disease

Hypersensitivity: Anaphylaxis

Nervous system: Tonic-clonic seizure

Contraindications

Hypersensitivity to sodium picosulfate, magnesium oxide, anhydrous citric acid, or any component of the formulation; GI obstruction or ileus; bowel perforation; gastric retention; toxic colitis; toxic megacolon; severe renal impairment (CrCl <30 mL/minute).

Canadian labeling: Additional contraindications (not in US labeling): Congestive heart failure; GI ulceration; nausea; vomiting; acute surgical abdominal conditions (eg, acute appendicitis).

Warnings/Precautions

Concerns related to adverse effects:

• Arrhythmias: Serious arrhythmias have occurred rarely with the use of ionic osmotic laxative products; use caution in patients at increased risk for arrhythmias (eg, recent MI, unstable angina, cardiomyopathy, history of prolonged QT, HF, uncontrolled arrhythmias); consider baseline and postcolonoscopy ECGs in patients at increased risk for arrhythmias.

• Fluid and electrolyte abnormalities: May cause fluid and electrolyte disturbances, particularly in patients at increased risk (eg, renal impairment, concomitant medications that alter electrolyte balance). Any preexisting electrolyte abnormalities should be corrected prior to use and patients should be adequately hydrated before, during, and after use. Consider evaluating for and treating postcolonoscopy electrolyte abnormalities in patients who develop significant vomiting, dehydration, or orthostatic hypotension.

• GI effects: Osmotic laxatives may produce colonic mucosal aphthous ulcerations, including cases of ischemic colitis. Use caution when interpreting colonoscopy results in patients with inflammatory bowel disease.

• Seizures: Seizures and/or loss of consciousness associated with electrolyte abnormalities (eg, hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia) and low serum osmolality have occurred; use with caution in patients with underlying electrolyte disturbances and in patients at increased risk for seizures (eg, concomitant medications that lower seizure threshold, withdrawal from alcohol or benzodiazepines).

• Syncope: Syncope, sometimes associated with electrolyte abnormalities (eg, hypokalemia, hyponatremia), has been reported; some cases have been severe and led to falls associated with head injuries or fractures requiring hospitalization. Reported cases usually occurred within 12 hours of dosing but have also been reported after 1 or 2 doses. Patients should be instructed to adequately hydrate prior to initiation and during and after treatment, to consume a variety of clear liquids (eg, balanced electrolyte solution) and not just water after each dose, and to get up gradually from a lying or sitting position.

Disease-related concerns:

• Impaired gag reflex: Observe semiconscious patients with impaired gag reflex or those who are otherwise prone to regurgitation or aspiration during administration.

• Renal impairment: Use with caution in patients with renal impairment and/or in patients taking medications that may adversely affect renal function (eg, diuretics, NSAIDs, ACE inhibitors, ARBs); adequate hydration is particularly important in these patients. Patients with impaired renal function who develop severe vomiting should be closely monitored including measurement of electrolytes. Use is contraindicated in severe renal impairment (CrCl <30 mL/minute).

• Ulcerative colitis: Use with caution in patients with severe active ulcerative colitis. If obstruction or perforation is suspected, diagnostic studies should be performed to rule out conditions prior to therapy initiation.

Concurrent drug therapy issues:

• Antibiotics: Sodium picosulfate requires the presence of colonic bacteria for the conversion to the active metabolite; prior or concomitant administration of antibiotics may reduce the efficacy of sodium picosulfate.

• Oral medications: Oral medications administered ≤1 hour prior to the start of the bowel preparation regimen may not be absorbed. Chlorpromazine, digoxin, fluoroquinolones, iron, penicillamine, and tetracycline should be administered at least 2 hours before and 6 hours after administration of magnesium oxide to avoid chelation with magnesium.

Other warnings/precautions:

• Appropriate use: Evaluate patients with symptoms of bowel obstruction/perforation (nausea, vomiting, abdominal pain or distension) prior to use. Each Prepopik packet must be diluted with water prior to use; inadvertent administration of undiluted solution may increase the risk of nausea, vomiting, and fluid/electrolyte abnormalities.

Warnings: Additional Pediatric Considerations

Orthostatic changes have been reported in pediatric patients; a study of patients 9 to 16 years of age reported changes in blood pressure and/or heart rate in approximately 20% of patients compared to the comparator pediatric treatment group (7%); the orthostatic changes were observed to occur up to 5 days postcolonoscopy.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Powder for solution, Oral [kit]:

Prepopik: Sodium picosulfate 10 mg, magnesium oxide 3.5 g, and citric acid 12 g per packet (2s [DSC]) [orange flavor, cranberry flavor; packaged with dosing cup]

Solution, Oral:

Clenpiq: Sodium picosulfate 10 mg, magnesium oxide 3.5 g, and citric acid 12 g per 160 mL (1s [DSC], 2s [DSC]); Sodium picosulfate 10 mg, magnesium oxide 3.5 g, and citric acid 12 g per 175 mL (1s, 2s) [contains disodium edetate, sodium benzoate, sodium metabisulfite]

Generic Equivalent Available: US

No

Pricing: US

Solution (Clenpiq Oral)

10-3.5-12 MG-GM-GM/175ML (per mL): $0.60

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Powder for solution, oral [kit]:

Pico-Salax: Sodium picosulphate 10 mg, magnesium oxide 3.5 g, and citric acid 12 g per sachet (1s, 2s) [orange or cranberry flavor]

Purg-Odan: Sodium picosulphate 10 mg, magnesium oxide 3.5 g, and citric acid 12 g per sachet (1s, 2s) [orange flavor]

Administration: Adult

Oral:

Clenpiq: Ready to drink oral solution; dilution is not required. Consume only clear liquids on the day prior to the colonoscopy and up until 2 hours before the time of the procedure; stop consumption of all fluids at least 2 hours prior to the procedure. When consuming clear liquids after each dose, consume a variety (eg, balanced electrolyte solution [eg, sports drinks]), not just water. Do not eat solid food or dairy, consume red or purple liquids, consume alcohol, or take other laxatives while taking Clenpiq; do not take oral medications within 1 hour of beginning the cleansing.

Following the first dose, administer 5 or more 8-ounce clear liquid drinks (eg, water, black coffee or tea, clear broth or bouillon, clear juices without pulp, ginger ale and other sodas, plain gelatin, frozen juice bars) within 5 hours and before bed; following the second dose, administer 4 or more 8-ounce clear liquid drinks up to 2 hours before colonoscopy. The second dose may be delayed if severe bloating, distention, or abdominal pain occurs following the first dose.

Prepopik: Reconstitute immediately prior to each administration. Consume only clear liquids on the day prior to the colonoscopy and until ≤2 hours before the time of the procedure. When consuming clear liquids after each dose, consume a variety (eg, balanced electrolyte solution [eg, sports drinks]), not just water. Following the first dose, administer at least five 8-ounce clear liquid drinks (eg, water, black coffee or tea, clear broth or bouillon, clear juices without pulp, ginger ale and other sodas, plain gelatin, frozen juice bars) within 5 hours; do not consume anything red or purple. Following the second dose, administer at least three 8-ounce clear liquid drinks at least 2 hours before colonoscopy (split-dose regimen) or within 5 hours (day-before regimen). For either regimen, the second dose may be delayed if severe bloating, distention, or abdominal pain occurs following the first dose.

Pico-Salax; Purg-Odan [Canadian products]:

At least 3 days prior to the procedure: Avoid eating seeds, nuts, fresh fruits and vegetables, and multigrain bread.

Day prior to the procedure: Consume clear liquids only (eg, water, clear power drinks, apple juice, white [not red] cranberry juice, white [not purple] grape juice, ginger ale, broth, tea [without milk, cream, or soy]), and no solid food. Patients with diabetes may drink a fiber-free supplement.

Following each dose: Adults should drink 1.5 to 2 L of a variety of clear fluids (including a balanced electrolyte solution) over 4 hours up until 2 hours prior to the procedure; children should drink one 8-ounce drink every hour while awake and up until 2 hours prior to the procedure.

Administration: Pediatric

Oral:

Children ≥9 years and Adolescents: Administer orally at prescribed times. Clenpiq is a ready-to-drink oral solution; dilution is not required. Dissolve Prepopik packet prior to administration. Consumption of any other liquids (type [eg, clear], and timing [eg, nothing by mouth after midnight]) should be as directed by clinician.

Split-dose regimen: Following the first dose, administer five or more 8 oz clear liquid drinks (eg, water, clear broth, apple juice, white cranberry juice, white grape juice, ginger ale, plain gelatin [not purple or red], frozen juice bars [not purple or red]) using the supplied dosing cup (fill up to the upper line) within 5 hours. Following the second dose, administer four or more 8 oz clear liquid drinks using the supplied dosing cup (up to the upper line) at least 2 hours before colonoscopy. The second dose may be delayed if severe bloating, distention, or abdominal pain occurs following the first dose.

Day-before regimen: Prepopik: Following the first dose, administer at least five 8 oz clear liquid drinks (eg, water, clear broth, apple juice, white cranberry juice, white grape juice, ginger ale, plain gelatin [not purple or red], frozen juice bars [not purple or red]) using the supplied dosing cup (fill up to the upper line) within 5 hours. Following the second dose, administer at least three 8 oz clear liquid drinks using the supplied dosing cup (up to the upper line) within 5 hours of administration. The second dose may be delayed if severe bloating, distention, or abdominal pain occurs following the first dose.

Canadian labeling: Pico-Salax; Purg-Odan: Children and Adolescents: Administer orally at prescribed times. Dissolve sachet prior to administration.

At least 3 days prior to the procedure: Avoid eating seeds, nuts, fresh fruits and vegetables (raw), and multigrain bread.

Day prior to the procedure: Consume clear liquids only (eg, water, clear power drinks, apple juice, white [not red] cranberry juice, white [not purple] grape juice, ginger ale, broth, tea [without milk, cream, or soy]), and no solid food. Patients with diabetes may drink a fiber-free supplement.

Following each dose: Administer one 8 oz drink every hour while awake and up until 2 hours prior to the procedure.

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/209589s015lbl.pdf#page=14, must be dispensed with this medication.

Use: Labeled Indications

Bowel cleansing: Cleansing of colon prior to colonoscopy in adults and children ≥9 years of age

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Acalabrutinib: Antacids may decrease the serum concentration of Acalabrutinib. Management: Separate administration of acalabrutinib capsules from the administration of any antacid by at least 2 hours in order to minimize the potential for a significant interaction. Acalabrutinib tablets are not expected to interact with antacids. Risk D: Consider therapy modification

Alfacalcidol: May increase the serum concentration of Magnesium Salts. Management: Consider using a non-magnesium-containing antacid or phosphate-binding product in patients also receiving alfacalcidol. If magnesium-containing products must be used with alfacalcidol, serum magnesium concentrations should be monitored closely. Risk D: Consider therapy modification

Alpha-Lipoic Acid: Magnesium Salts may decrease the absorption of Alpha-Lipoic Acid. Alpha-Lipoic Acid may decrease the absorption of Magnesium Salts. Management: Separate administration of alpha-lipoic acid from that of any magnesium-containing compounds by several hours. If alpha-lipoic acid is given 30 minutes before breakfast, then administer oral magnesium-containing products at lunch or dinner. Risk D: Consider therapy modification

Aluminum Hydroxide: Citric Acid Derivatives may increase the absorption of Aluminum Hydroxide. Risk C: Monitor therapy

Antibiotics: May diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Antipsychotic Agents (Phenothiazines): Antacids may decrease the absorption of Antipsychotic Agents (Phenothiazines). Risk C: Monitor therapy

Atazanavir: Antacids may decrease the absorption of Atazanavir. Management: Administer antacids 1 to 2 hours before or 2 hours after atazanavir to minimize the risk of a clinically significant interaction. Risk D: Consider therapy modification

Baloxavir Marboxil: Polyvalent Cation Containing Products may decrease the serum concentration of Baloxavir Marboxil. Risk X: Avoid combination

Belumosudil: Antacids may decrease the serum concentration of Belumosudil. Management: Consider separating administration of belumosudil and antacids by 2 hours and monitor for reduced belumosudil efficacy. Risk D: Consider therapy modification

Bictegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Bictegravir. Management: Administer bictegravir under fasting conditions at least 2 hours before or 6 hours after polyvalent cation containing products. Coadministration of bictegravir with or 2 hours after most polyvalent cation products is not recommended. Risk D: Consider therapy modification

Bisacodyl: Antacids may diminish the therapeutic effect of Bisacodyl. Antacids may cause the delayed-release bisacodyl tablets to release drug prior to reaching the large intestine. Gastric irritation and/or cramps may occur. Management: Antacids should not be used within 1 hour before bisacodyl administration. Risk D: Consider therapy modification

Bismuth Subcitrate: Antacids may diminish the therapeutic effect of Bismuth Subcitrate. Management: Avoid administration of antacids within 30 minutes of bismuth subcitrate (tripotassium bismuth dicitrate) administration. Risk D: Consider therapy modification

Bisphosphonate Derivatives: Polyvalent Cation Containing Products may decrease the serum concentration of Bisphosphonate Derivatives. Management: Avoid administration of oral medications containing polyvalent cations within: 2 hours before or after tiludronate/clodronate/etidronate; 60 minutes after oral ibandronate; or 30 minutes after alendronate/risedronate. Risk D: Consider therapy modification

Bosutinib: Antacids may decrease the serum concentration of Bosutinib. Management: Administer antacids more than 2 hours before or after bosutinib. Risk D: Consider therapy modification

Bromperidol: Antacids may decrease the absorption of Bromperidol. Risk C: Monitor therapy

Cabotegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Cabotegravir. Management: Administer polyvalent cation containing products at least 2 hours before or 4 hours after oral cabotegravir. Risk D: Consider therapy modification

Calcitriol (Systemic): May increase the serum concentration of Magnesium Salts. Management: Consider using a non-magnesium-containing antacid or phosphate-binding product in patients also receiving calcitriol. If magnesium-containing products must be used with calcitriol, serum magnesium concentrations should be monitored closely. Risk D: Consider therapy modification

Calcium Polystyrene Sulfonate: Laxatives (Magnesium Containing) may enhance the adverse/toxic effect of Calcium Polystyrene Sulfonate. More specifically, concomitant use of calcium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of calcium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives. Risk X: Avoid combination

Captopril: Antacids may decrease the serum concentration of Captopril. Risk C: Monitor therapy

Cefdinir: Antacids may decrease the absorption of Cefdinir. Management: Administer cefdinir 2 hours before or 2 hours after aluminum- or magnesium-containing antacids. Risk D: Consider therapy modification

Cefditoren: Antacids may decrease the serum concentration of Cefditoren. Risk X: Avoid combination

Cefuroxime: Antacids may decrease the serum concentration of Cefuroxime. Management: Administer cefuroxime axetil at least 1 hour before or 2 hours after the administration of short-acting antacids. Risk D: Consider therapy modification

Chloroquine: Antacids may decrease the serum concentration of Chloroquine. Management: Separate the administration of antacids and chloroquine by at least 4 hours to minimize any potential negative impact of antacids on chloroquine bioavailability. Risk D: Consider therapy modification

Corticosteroids (Oral): Antacids may decrease the bioavailability of Corticosteroids (Oral). Management: Consider separating doses by 2 or more hours. Budesonide enteric coated tablets could dissolve prematurely if given with drugs that lower gastric acid, with unknown impact on budesonide therapeutic effects. Risk D: Consider therapy modification

Cysteamine (Systemic): Antacids may diminish the therapeutic effect of Cysteamine (Systemic). Risk C: Monitor therapy

Dabigatran Etexilate: Antacids may decrease the serum concentration of Dabigatran Etexilate. Management: Dabigatran etexilate Canadian product labeling recommends avoiding concomitant use with antacids for 24 hours after surgery. In other situations, administer dabigatran etexilate 2 hours prior to antacids. Monitor clinical response to dabigatran therapy. Risk D: Consider therapy modification

Dasatinib: Antacids may decrease the serum concentration of Dasatinib. Management: Simultaneous administration of dasatinib and antacids should be avoided. Administer antacids 2 hours before or 2 hours after dasatinib. Risk D: Consider therapy modification

Deferiprone: Polyvalent Cation Containing Products may decrease the serum concentration of Deferiprone. Management: Separate administration of deferiprone and oral medications or supplements that contain polyvalent cations by at least 4 hours. Risk D: Consider therapy modification

Delavirdine: Antacids may decrease the serum concentration of Delavirdine. Management: Separate doses of delavirdine and antacids by at least 1 hour. Monitor for decreased delavirdine therapeutic effects with this combination. Risk D: Consider therapy modification

Diacerein: Antacids may decrease the absorption of Diacerein. Risk C: Monitor therapy

Dichlorphenamide: Laxatives may enhance the hypokalemic effect of Dichlorphenamide. Risk C: Monitor therapy

Dolutegravir: Magnesium Salts may decrease the serum concentration of Dolutegravir. Management: Administer dolutegravir at least 2 hours before or 6 hours after oral magnesium salts. Administer the dolutegravir/rilpivirine combination product at least 4 hours before or 6 hours after oral magnesium salts. Risk D: Consider therapy modification

Doxercalciferol: May enhance the hypermagnesemic effect of Magnesium Salts. Management: Consider using a non-magnesium-containing antacid or phosphate-binding product in patients also receiving doxercalciferol. If magnesium-containing products must be used with doxercalciferol, serum magnesium concentrations should be monitored closely. Risk D: Consider therapy modification

Eltrombopag: Polyvalent Cation Containing Products may decrease the serum concentration of Eltrombopag. Management: Administer eltrombopag at least 2 hours before or 4 hours after oral administration of any polyvalent cation containing product. Risk D: Consider therapy modification

Elvitegravir: Antacids may decrease the serum concentration of Elvitegravir. Management: Separate administration of aluminum and magnesium containing antacids and elvitegravir-containing products by at least 2 hours in order to minimize the risk for an interaction. Risk D: Consider therapy modification

Elvitegravir: Polyvalent Cation Containing Products may decrease the serum concentration of Elvitegravir. Management: Administer elvitegravir 2 hours before or 6 hours after the administration of polyvalent cation containing products. Risk D: Consider therapy modification

Erdafitinib: Serum Phosphate Level-Altering Agents may diminish the therapeutic effect of Erdafitinib. Management: Avoid coadministration of serum phosphate level-altering agents with erdafitinib before initial dose increase period based on serum phosphate levels (Days 14 to 21). Risk D: Consider therapy modification

Erlotinib: Antacids may decrease the serum concentration of Erlotinib. Management: Separate the administration of erlotinib and any antacid by several hours in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification

Fexofenadine: Antacids may decrease the serum concentration of Fexofenadine. Management: Separate the administration of fexofenadine and aluminum- or magnesium-containing antacids. Risk D: Consider therapy modification

Fosinopril: Antacids may decrease the serum concentration of Fosinopril. Management: The US and Canadian fosinopril manufacturer labels recommend separating the doses of antacids and fosinopril by 2 hours. Risk D: Consider therapy modification

Gabapentin: Magnesium Salts may enhance the CNS depressant effect of Gabapentin. Specifically, high dose intravenous/epidural magnesium sulfate may enhance the CNS depressant effects of gabapentin. Magnesium Salts may decrease the serum concentration of Gabapentin. Management: Administer gabapentin at least 2 hours after use of a magnesium-containing antacid. Monitor patients closely for evidence of reduced response to gabapentin therapy. Monitor for CNS depression if high dose IV/epidural magnesium sulfate is used. Risk D: Consider therapy modification

Gefitinib: Antacids may decrease the serum concentration of Gefitinib. Management: Administer gefitinib at least 6 hours before or 6 hours after administration of an antacid, and closely monitor clinical response to gefitinib. Risk D: Consider therapy modification

Hyoscyamine: Antacids may decrease the serum concentration of Hyoscyamine. Management: Administer immediate release and sublingual oral hyoscyamine before meals, and antacids after meals, when these agents are given in combination. Risk D: Consider therapy modification

Infigratinib: Antacids may decrease serum concentrations of the active metabolite(s) of Infigratinib. Antacids may decrease the serum concentration of Infigratinib. Management: Avoid coadministration of infigratinib with antacids or other gastric acid-lowering agents. If antacids cannot be avoided, administer infigratinib 2 hours before or after administration of antacids. Risk D: Consider therapy modification

Iron Preparations: Antacids may decrease the absorption of Iron Preparations. Management: No action is likely necessary for the majority of patients who only use antacids intermittently or occasionally. Consider separating doses of oral iron and antacids in patients who require chronic use of both agents and monitor for reduced iron efficacy. Risk D: Consider therapy modification

Itraconazole: Antacids may decrease the serum concentration of Itraconazole. Antacids may increase the serum concentration of Itraconazole. Management: Administer Sporanox brand itraconazole at least 2 hours before or 2 hours after administration of any antacids. Exposure to Tolsura brand itraconazole may be increased by antacids; consider itraconazole dose reduction. Risk D: Consider therapy modification

Ketoconazole (Systemic): Antacids may decrease the serum concentration of Ketoconazole (Systemic). Management: Administer antacids at least 1 hour prior to, or 2 hours after, ketoconazole. Additionally, administer ketoconazole with an acidic beverage (eg, non-diet cola) and monitor patients closely for signs of inadequate clinical response to ketoconazole. Risk D: Consider therapy modification

Lanthanum: Antacids may diminish the therapeutic effect of Lanthanum. Management: Administer antacid products at least 2 hours before or after lanthanum. Risk D: Consider therapy modification

Ledipasvir: Antacids may decrease the serum concentration of Ledipasvir. Management: Separate the administration of ledipasvir and antacids by 4 hours. Risk D: Consider therapy modification

Levoketoconazole: Antacids may decrease the absorption of Levoketoconazole. Management: Advise patients to take antacids at least 2 hours after taking levoketoconazole. Risk D: Consider therapy modification

Levonadifloxacin: Magnesium Salts may decrease the serum concentration of Levonadifloxacin. Risk X: Avoid combination

Levonadifloxacin: Antacids may decrease the serum concentration of Levonadifloxacin. Risk X: Avoid combination

Levothyroxine: Magnesium Salts may decrease the serum concentration of Levothyroxine. Management: Separate administration of oral levothyroxine and oral magnesium salts by at least 4 hours. Risk D: Consider therapy modification

Mesalamine: Antacids may diminish the therapeutic effect of Mesalamine. Antacid-mediated increases in gastrointestinal pH may cause the premature release of mesalamine from specific sustained-release mesalamine products. Management: Avoid concurrent administration of antacids with the Apriso brand of mesalamine extended-release capsules. The optimal duration of dose separation is unknown. Other mesalamine products do not contain this interaction warning. Risk D: Consider therapy modification

Methenamine: Antacids may diminish the therapeutic effect of Methenamine. Management: Consider avoiding the concomitant use of medications that alkalinize the urine, such as antacids, and methenamine. Monitor for decreased therapeutic effects of methenamine if used concomitant with antacids. Risk D: Consider therapy modification

MiSOPROStol: Antacids may enhance the adverse/toxic effect of MiSOPROStol. More specifically, concomitant use with magnesium-containing antacids may increase the risk of diarrhea. Management: Avoid concomitant use of misoprostol and magnesium-containing antacids. In patients requiring antacid therapy, employ magnesium-free preparations. Monitor for increased adverse effects (e.g., diarrhea, dehydration). Risk X: Avoid combination

Multivitamins/Fluoride (with ADE): Magnesium Salts may decrease the serum concentration of Multivitamins/Fluoride (with ADE). Specifically, magnesium salts may decrease fluoride absorption. Management: To avoid this potential interaction separate the administration of magnesium salts from administration of a fluoride-containing product by at least 1 hour. Risk D: Consider therapy modification

Multivitamins/Minerals (with ADEK, Folate, Iron): Antacids may decrease the serum concentration of Multivitamins/Minerals (with ADEK, Folate, Iron). Specifically, antacids may decrease the absorption of orally administered iron. Management: Separate dosing of oral iron-containing multivitamins and antacids by as much time as possible to minimize impact of this interaction. Monitor for decreased therapeutic efficacy of oral iron preparations during coadministration. Risk D: Consider therapy modification

Neratinib: Antacids may decrease the serum concentration of Neratinib. Specifically, antacids may reduce neratinib absorption. Management: Separate the administration of neratinib and antacids by giving neratinib at least 3 hours after the antacid. Risk D: Consider therapy modification

Neuromuscular-Blocking Agents: Magnesium Salts may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Nilotinib: Antacids may decrease the serum concentration of Nilotinib. Management: Separate the administration of nilotinib and any antacid by at least 2 hours whenever possible in order to minimize the risk of a significant interaction. Risk D: Consider therapy modification

Nirogacestat: Antacids may decrease the serum concentration of Nirogacestat. Management: If acid-reducing therapy is required, separate nirogacestat administration from antacids by 2 hours. Risk D: Consider therapy modification

Octreotide: Antacids may decrease the serum concentration of Octreotide. Risk C: Monitor therapy

PAZOPanib: Antacids may decrease the serum concentration of PAZOPanib. Management: Avoid the use of antacids in combination with pazopanib whenever possible. Separate doses by several hours if antacid treatment is considered necessary. The impact of dose separation has not been investigated. Risk D: Consider therapy modification

PenicillAMINE: Polyvalent Cation Containing Products may decrease the serum concentration of PenicillAMINE. Management: Separate the administration of penicillamine and oral polyvalent cation containing products by at least 1 hour. Risk D: Consider therapy modification

Pexidartinib: Antacids may decrease the serum concentration of Pexidartinib. Management: Administer pexidartinib at least 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification

Phosphate Supplements: Antacids may decrease the absorption of Phosphate Supplements. Management: This applies only to oral phosphate administration. Separating administration of oral phosphate supplements from antacid administration by as long as possible may minimize the interaction. Risk D: Consider therapy modification

Phosphate Supplements: Magnesium Salts may decrease the serum concentration of Phosphate Supplements. Management: Administer oral phosphate supplements as far apart from the administration of an oral magnesium salt as possible to minimize the significance of this interaction. Risk D: Consider therapy modification

Polyethylene Glycol-Electrolyte Solution: Laxatives (Stimulant) may enhance the adverse/toxic effect of Polyethylene Glycol-Electrolyte Solution. Specifically, the risk of colonic mucosal aphthous ulcerations may be increased. Management: Consider avoiding this combination due to a potential for increased risk of colonic mucosal aphthous ulcerations. Risk D: Consider therapy modification

Potassium Phosphate: Antacids may decrease the serum concentration of Potassium Phosphate. Management: Consider separating administration of antacids and oral potassium phosphate by at least 2 hours to decrease risk of a significant interaction. Risk D: Consider therapy modification

QuiNINE: Antacids may decrease the serum concentration of QuiNINE. Risk X: Avoid combination

Raltegravir: Magnesium Salts may decrease the serum concentration of Raltegravir. Management: Avoid the use of oral / enteral magnesium salts with raltegravir. No dose separation schedule has been established that adequately reduces the magnitude of interaction. Risk X: Avoid combination

Rilpivirine: Antacids may decrease the serum concentration of Rilpivirine. Management: Administer antacids at least 2 hours before or 4 hours after oral rilpivirine when used with most rilpivirine products. However, administer antacids at least 6 hours before or 4 hours after the rilpivirine/dolutegravir combination product. Risk D: Consider therapy modification

Riociguat: Antacids may decrease the serum concentration of Riociguat. Management: Separate the administration of antacids and riociguat by at least 1 hour in order to minimize any potential interaction. Monitor clinical response to riociguat more closely in patients using this combination. Risk D: Consider therapy modification

Rosuvastatin: Antacids may decrease the serum concentration of Rosuvastatin. Risk C: Monitor therapy

Roxadustat: Polyvalent Cation Containing Products may decrease the serum concentration of Roxadustat. Management: Administer roxadustat at least 1 hour after the administration of oral polyvalent cation containing products. Risk D: Consider therapy modification

Selpercatinib: Antacids may decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and antacids should be avoided. If coadministration cannot be avoided, selpercatinib should be administered 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification

Sodium Polystyrene Sulfonate: Laxatives (Magnesium Containing) may enhance the adverse/toxic effect of Sodium Polystyrene Sulfonate. More specifically, concomitant use of sodium polystyrene sulfonate with magnesium-containing laxatives may result in metabolic alkalosis or with sorbitol may result in intestinal necrosis. Management: Avoid concomitant use of sodium polystyrene sulfonate (rectal or oral) and magnesium-containing laxatives. Risk X: Avoid combination

Sodium Sulfate: Laxatives (Stimulant) may enhance the adverse/toxic effect of Sodium Sulfate. Specifically, the risk of mucosal ulceration or ischemic colitis may be increased. Risk X: Avoid combination

Sotalol: Antacids may decrease the serum concentration of Sotalol. Management: Avoid simultaneous administration of sotalol and antacids. Administer antacids 2 hours after sotalol. Risk D: Consider therapy modification

Sotorasib: Antacids may decrease the serum concentration of Sotorasib. Management: Avoid coadministration of sotorasib and antacids. If use of a gastric acid suppressing medication cannot be avoided, administer sotorasib 4 hours before or 10 hours after oral antacid administration. Risk D: Consider therapy modification

Sparsentan: Antacids may decrease the serum concentration of Sparsentan. Management: Administer sparsentan 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification

Sucralfate: Antacids may diminish the therapeutic effect of Sucralfate. Management: Consider separating the administration of antacids and sucralfate by at least 30 minutes. Risk D: Consider therapy modification

Sulpiride: Antacids may decrease the serum concentration of Sulpiride. Management: Separate administration of antacids and sulpiride by at least 2 hours in order to minimize the impact of antacids on sulpiride absorption. Risk D: Consider therapy modification

Thyroid Products: Antacids may decrease the absorption of Thyroid Products. Risk C: Monitor therapy

Trientine: Polyvalent Cation Containing Products may decrease the serum concentration of Trientine. Management: Avoid concomitant use of trientine and polyvalent cations. If oral iron supplements are required, separate the administration by 2 hours. For other oral polyvalent cations, give trientine 1 hour before, or 1 to 2 hours after the polyvalent cation. Risk D: Consider therapy modification

Unithiol: May diminish the therapeutic effect of Polyvalent Cation Containing Products. Risk X: Avoid combination

Velpatasvir: Antacids may decrease the serum concentration of Velpatasvir. Management: Separate administration of velpatasvir and antacids by at least 4 hours. Risk D: Consider therapy modification

Pregnancy Considerations

Adverse events were not observed in animal reproduction studies using doses similar to a human dose.

Breastfeeding Considerations

Lactating women (n=8) were administered sodium picosulfate 10 mg as an oral solution once daily for 8 days. The active metabolite, BPHM, was detected in plasma and urine, but below the limit of detection in breast milk (<1 ng/mL) (Friedrich 2011). According to the manufacturer, the decision to continue or discontinue breastfeeding during therapy should take into account the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. Also refer to magnesium oxide individual monograph.

Monitoring Parameters

Serum electrolytes and renal function tests (baseline and post-colonoscopy) in patients with or at risk for renal impairment or seizure, and in patients who have a history of electrolyte abnormality; consider ECG (baseline and post-colonoscopy) in patients at risk for prolonged QT or arrhythmias.

Mechanism of Action

Sodium picosulfate, a prodrug, is hydrolyzed by colonic bacteria to an active metabolite which stimulates colonic peristalsis.

Magnesium oxide and citric acid react to create magnesium citrate which induces catharsis by the osmotic effects of the unabsorbed ions in the GI tract.

Pharmacokinetics (Adult Data Unless Noted)

Absorption: Magnesium cation: ≥20%.

Metabolism: Sodium picosulfate: Hydrolyzed by colonic bacteria to the active compound bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM).

Half-life elimination: Terminal: Sodium picosulfate: ~7.5 hours.

Time to peak: Sodium picosulfate: ~7 hours; Magnesium: 10 hours.

Excretion: Urine.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (BD) Bangladesh: Ezycolon;
  • (KR) Korea, Republic of: Picolight | Picosolution;
  • (PR) Puerto Rico: Clenpiq;
  • (QA) Qatar: Picoprep
  1. Clenpiq (sodium picosulfate/magnesium oxide/citric acid) [prescribing information]. Parsippany, NJ: Ferring Pharmaceuticals; August 2023.
  2. Friedrich C, Richter E, Trommeshauser D, et al, “Absence of Excretion of the Active Moiety of Bisacodyl and Sodium Picosulfate into Human Breast Milk: An Open-Label, Parallel-Group, Multiple-Dose Study in Healthy Lactating Women,” Drug Metab Pharmacokinet, 2011, 26(5):458-64. [PubMed 21697613]
  3. Pico-Salax (sodium picosulfate/magnesium oxide/citric acid) [product monograph]. North York, Ontario, Canada: Ferring Pharmaceuticals; October 2012.
  4. Prepopik (sodium picosulfate/magnesium oxide/citric acid) [prescribing information]. Parsippany, NJ: Ferring Pharmaceuticals Inc; August 2023.
  5. Purg-Odan (sodium picosulfate/magnesium oxide/citric acid) [product monograph]. Pointe-Claire, Quebec, Canada: Odan Laboratories Ltd; February 2016.
Topic 85869 Version 187.0

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