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Food and Drug Administration
Science Backgrounder:
Safety of Sodium Phosphates Oral Solution
September 17, 2001
BACKGROUND
Sodium phosphates oral solution is available in the United States as an
over-the-counter preparation indicated "for the relief of occasional
constipation." It is professionally labeled "for use as part of
a bowel cleansing regimen in preparing the patient for surgery or
preparing the colon for x-ray or endoscopic examination." In 1998,
because of data indicating that accidental overdosing and deaths had
occurred when a 240 ml container was mistakenly used instead of the 45 ml
or 90 ml container, the FDA limited the bottle size of oral sodium
phosphate to no more than 90 ml. The agency also required that the product
be labeled with a warning to consumers not to exceed the recommended dose
of 20 to 45 ml unless directed by a doctor. At that time, the agency
concluded that the data were not sufficient to demonstrate the safety of
more than 45 ml of oral sodium phosphate solution in a 24-hour period as
part of a bowel-cleansing regimen.
REPORTS
The FDA has recently completed another safety review on oral sodium
phosphate from reports in the FDA Adverse Events Reporting System
database, the FDA Drug Quality Reporting System database, and
in the medical literature. Serious electrolyte disturbances (hypernatremia,
hypokalemia, hyperphosphatemia, hypocalcemia) dehydration, metabolic
acidosis, renal failure, tetany, and death have been attributed to
physicians prescribing more than the 45 ml dose (usually a minimum of 90
ml during a 24-hour period) as a bowel preparation for colonoscopy,
surgery, or barium enema and/or prescribing it for people at medical risk.1,
2, 3, 4, 5
Several articles demonstrate that even people without medical
contraindications receiving more than 45 ml of oral sodium phosphate
develop electrolyte shifts.6, 7, 8, 19, 10 Changes in
hematocrit, serum sodium, blood urea nitrogen, serum osmolality, and body
weight after ingesting sodium phosphate oral solution suggest that a mild
contraction of intravascular volume can occur in this population. Shifts
in serum calcium, serum phosphorus, serum sodium, and serum potassium can
be statistically significant when compared to baseline values but,
generally, electrolyte values remain within normal range. However, serum
sodium as high as 148 mEq/L, serum potassium as low as 2.9 mEq/L, serum
phosphorus as high as 12.4 mg/dL, and serum calcium as low as 8.0 mg/dL
have been reported.
There is a single case report of a young woman, treated with prednisone
and alendronate for Crohn’s disease, who developed hypocalcemia and
carpopedal spasm following oral sodium phosphate.11 This case
report, may suggest that bone anti-resorptive agents, known to be
associated with mild hypocalcemia, may increase the vulnerability of
developing hypocalcemia with oral sodium phosphate.
DISCUSSION:
These reports suggest that patients who are taking more than 45 ml of
oral sodium phosphate as a prescribed bowel preparation are vulnerable to
electrolyte shifts. In the populations with absolute or relative medical
contraindications to the use of sodium phosphate, these electrolyte shifts
can be clinically significant, resulting in symptomatic dehydration, renal
failure, metabolic acidosis, tetany, and death. A published survey of
Canadian colonoscopists, demonstrates that physicians who routinely
prescribe bowel preparations are not adequately informed as to the medical
risks and contraindications associated with the use of sodium phosphates
oral solution.12 Health professionals need to become better
informed about the safe use of oral sodium phosphate.
CONCLUSION
Physicians need to be aware that people at increased risk for
electrolyte disturbances (e.g., congestive heart failure, ascites, renal
insufficiency, dehydration, debility, gastrointestinal obstruction,
gastric retention, bowel perforation, colitis, megacolon, ileus, inability
to take adequate oral fluid, taking diuretics or other medications that
affect electrolytes) may experience serious adverse events if they use
sodium phosphates oral solution. It would be reasonable to consider
obtaining baseline and post-treatment sodium, potassium, chloride,
bicarbonate, calcium, phosphate, blood urea nitrogen and creatinine values
in people (especially those at increased risk) directed to take more than
45 ml of oral sodium phosphate in a 24-hour period. This may enable
physicians to avert serious electrolyte problems.
____________________________________________
1 Ahmed M, Raval P, Buganza G: Oral Sodium
Phosphate Catharsis and Acute Renal Failure. Am J Gastroenterol
91:1261-1262,1996.
2 Adverse Drug Reactions Advisory Committee (ADRAC): Electrolyte
Disturbances with Oral Phosphate Bowel Preparations. Australian Adverse
Drug Reactions Bulletin 16(1),1997.
3 Boivin MA, Kahn SR: Symptomatic Hypocalcemia from Oral Sodium
Phosphate: A Report of Two Cases. Am J Gastroenterol 93:2577-2579,1998.
4 Orias M, Mahnensmith RL, Perazella MA: Extreme Hyperphosphatemia
and Acute Renal Failure after a Phosphorus-Containing Bowel Regimen. Am J
Nephrol 19:60-63,1999.
5 Vukasin P, Weston LA, Beart RW: Oral Fleet Phospho-Soda Laxative
Induced Hyperphosphatemia and Hypocalcemic Tetany in an Adult. Dis Colon
Rectum 40:497-499,1997.
6 Clarkston WK, Tsen TN, Dies DF, Schratz L, Vaswani SK,
Bjerregaard P: Oral Sodium Phosphate Versus Sulfate-Free Polyethylene
Glycol Electrolyte Lavage Solution in Outpatient Preparation for
Colonoscopy: A Prospective Comparison. Gastrointest Endosc 43:42-48,1996.
7 DiPalma JA, Buckley SE, Warner BA, Culpepper RM: Biochemical
Effects of Oral Sodium Phosphate. Dig Dis Sci 41:749-753,1996.
8 Huynh T, Vanner S, Paterson W: Safety Profile of 5-h Oral Sodium
Phosphate Regimen for Colonoscopy Cleansing: Lack of Clinically
Significant Hypocalcemia or Hypovolemia. Am J Gastroenterol
90:104-107,1995.
9 Lieberman DA, Ghormley J, Flora K: Effect of Oral Sodium
Phosphate Colon Preparation on Serum Electrolytes in Patients with Normal
Serum Creatinine. Gastrointest Endoscopy 43:467-469,1996.
10 Vanner SJ, MacDonald PH, Paterson WG, Prentice RSA, DaCosta LR,
Beck IT: A Randomized Prospective Trial Comparing Oral Sodium Phosphate
with Standard Polyethylene Glycol-Based Lavage Solution (GoLYTELYâ
) in the Preparation of Patients for Colonoscopy. Am J Gastroenterol
85:422-427,1990.
11 Campisi P, Badhwar V, Morin S, Trudel JL: Postoperative
Hypocalcemic Tetany Caused by Fleet Phospho-Soda Preparation in a Patient
Taking Alendronate Sodium. Dis Colon Rectum 42:1499-1501,1999.
12 Chan A, Depew W, Vanner S: Use of Oral Sodium Phosphate Colonic
Lavage Solution by Canadian Colonoscopists: Pitfalls and Complications.
Can J Gastroenterol 11:334-338,1997.
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Last Updated: July 1, 2002
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