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Letters to the Editor

stool was not clear the morning of the colonoscopy. We have just finished a second study with 1,000 subjects comparing three formulations of G+PEG, MoviPREP, and SuPREP, which may help clarify these issues. CONFLICT OF INTEREST The author declares no conflict of interest. REFERENCES 1. Siddique S, Lopez KT, Hinds AM et al. Miralax with gatorade for bowel preparation: a metaanalysis of randomized controlled trials. Am J Gastroenterol 2014;109:1566–74. 2. Gerard DP, Holden JL, Foster DB et al. Randomized trial of Gatorade/polyethylene glycol with or without bisacodyl and NuLYTELY for colonoscopy preparation. Clin Transl Gastroenterol 2012;3:1–9. 1

Gastroenterology Services Ltd, Downers Grove, Illinois, USA. Correspondence: David P. Gerard, MD, Gastroenterology Services Ltd, 3825 Highland Avenue, Suite 203, Downers Grove, Illinois 60515, USA. E-mail: [email protected]

Response to Gerard et al. Matthew L. Bechtold, MD, FACP, FASGE, FACG1, Sameer Siddique, MD1 and Douglas L. Nguyen, MD2 doi:10.1038/ajg.2014.392

To the Editor: We read the comments by Gerard et al. (1) with great interest. We appreciate the comments, mostly regarding the details of their own study, and recognize that some clarifications may be necessary. Based on our interpretation, two questions seem to be the focus: (1) Did we ignore the side effects aspect of the Gerard et al. study?, (2) Should we have included the study by Gerard et al. in the overall analysis? Both of these are valid concerns that we will try to clarify. Our meta-analysis (2) demonstrated that Miralax-Gatorade (M-G) bowel preparation prior to colonoscopy had no statistically significant improvement in side effects as compared to polyethylene glycol with electrolytes (PEG) (odds ratio (OR) 0.88; 95% confidence interval (CI): The American Journal of GASTROENTEROLOGY

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0.46–1.72; P=0.71). The data collected from these two studies were dichotomous data, which were able to be pooled appropriately. Unfortunately, the study by Gerard et al. involved continuous data presented as means with standard deviations. Attempts were made to contact the authors of the Gerard et al. study to obtain dichotomous statistics necessary for pooling in the meta-analysis; however, those attempts were unsuccessful. Given the inability to adequately pool the Gerard et al. data with other studies in the meta-analysis, we were forced to exclude the Gerard et al. study from the side effects analysis. In regards to bowel preparation, the Gerard et al. study utilized adjuncts with the standard Miralax (255 g) and Gatorade (64 ounces) bowel preparation by adding an extra dose of Miralax (51 g) at noon the day prior to the colonoscopy; occasional use of enemas for those preparations deemed unsatisfactory prior to the procedure. We do agree that these two factors are unique to this study and are not found in the other studies included in our meta-analysis. Owing to these factors, our authors debated much on the inclusion or exclusion of the Gerard et al. study. Given that the Gerard et al. study was the largest single positive randomized control trial on the subject of M-G for bowel preparation prior to colonoscopy and the standard dose the night prior to the colonoscopy was comparable to the other studies (255 g of Miralax with 64 ounces of Gatorade) except for the addition of an adjunct to the regimen, the authors reached an agreement to include this study. The authors believed a significant bias would be induced if we excluded this positive study based on 20% extra Miralax the day before the colonoscopy at 1200. Furthermore, with the exclusion of the Gerard et al. study, the results of our meta-analysis are strengthened for M-G being inferior to PEG in regards to satisfactory bowel preparations (OR 0.49; 95% CI: 0.30–0.80; P

Response to Gerard et al.

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