Introduction: Hypermagnesemia is a rare but recognized side effect of bowel preparation use that worsens with concurrent gastrointestinal motility dysfunction. Current consensus guidelines by the United Kingdom note that although Mg-containing bowel cleansers present a risk for hypermagnesemia in patients with stage 4 or 5 chronic kidney disease, they are acceptable for patients with early CKD (stages 1–3) and in patients with stage 5 CKD who are receiving hemodialysis. Herein, we report a case of severe symptomatic hypermagnesemia resulting from Clenpiq bowel preparation in an individual with age-appropriate renal function and chronic constipation.
Case Description/Methods: An 82-year-old female with a past medical history of chronic pancreatitis was brought by EMS for altered mental status after being found down in her bathroom at home. The patient was recently diagnosed with Barrett’s esophagus and was scheduled for a surveillance endoscopy and colonoscopy as an outpatient and took Clenpiq bowel preparation the night before. On presentation, patient was found to be obtunded, hypothermic at 89.3°F, bradycardic at 45 beats/minute, and hypotensive at 73/47. Her laboratory findings were significant for a magnesium level greater than the quantifiable limit >9.6 mg/dL. Her creatinine was 0.87 mg/dL with a blood urea nitrogen of 16 mg/dL. CT scan of the abdomen and pelvis with contrast showed significant constipation. Initial treatment with intravenous furosemide to decrease serum magnesium level was unsuccessful. She subsequently underwent two rounds of intermittent hemodialysis along with an aggressive bowel regimen with improvement of symptoms and was ultimately discharged home at baseline function.
Discussion: In a post hoc analysis by Hookey et al. evaluating the safety profile of ClenPiq, it was found to be associated with transient hypermagnesemia. Magnesium levels normalized in 24-48 hours and did not appear to be clinically significant. There have been no previously reported cases of a patient with age-appropriate renal function developing symptomatic hypermagnesemia requiring treatment after the use of the ClenPiq bowel preparation agent. While bowel preparations are typically safe and well-tolerated, one important consideration when selecting an agent is evaluating for co-existing GI disorders such as impaired motility. These can result in increased magnesium absorption and progress to symptomatic hypermagnesemia particularly in elderly patients.
