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

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.