Finally, an easier way to prepare for a colonoscopy


Decades ago, to prepare for a colonoscopy, patients first had to clean their colon with laxatives such as castor oil or magnesium citrate, sometimes over several days. It wasn’t fun.

Things improved in 1984 with the introduction of a powder-based solution that patients could drink the day before their colonoscopy. The colon cleansing drink, called GoLYTELY, tastes bad but “turned three and a half days of torture into three and a half hours of torture,” says Jacques de Palma, M.D., gastroenterologist, professor of internal medicine at the University of South Alabama School of Medicine.

Perhaps the biggest obstacle to the examination remains preparations for a colonoscopy, a procedure in which a doctor inserts a flexible tube through the colon to take a camera look at the inside of the organ. So last year’s approval of a less troublesome preparation option for patients was welcome news.

A pre-cleansing of the colon is critical to identifying and removing polyps, which are often a precursor to cancer, during the procedure. Over the years, several new-generation prep solutions have become available, each with advantages and disadvantages, and others—including those in the form of shakes and food bars—have been tested but not yet approved.

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The solutions that most patients drink clean their colon, but patients have to eat copious amounts—four liters, or a little more than a gallon—and the taste still sucks.

Doctors now recommend that patients split the dose into two parts, half taken the day before and the rest several hours before the procedure.

“We tell people to cool off, drink it through a straw, hold their noses, chew gum between them or suck on hard candy,” says Louis Corman, MD, a gastroenterologist in the metropolitan area. “Everyone hears stories about how awful the preparation is. The preparation is what everyone remembers, and is a disincentive to having a colonoscopy.”

But last year — in what experts believe could end the dread that keeps many people from this important screening — the Food and Drug Administration approved a pill regimen, Sutab, studies show that works just like a liquid solution — without the vile flavor. It’s a 24-tablet regimen: 12 tablets the day before and 12 the next day, several hours before the procedure.

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Patients still have to drink plenty of water, a total of 48 ounces the first day and another 48 ounces the next. But at least plain water is tasteless.

Says Douglas K. Rex, MD, Distinguished Professor of Medicine at Indiana University School of Medicine: “The great thing about Sutab is that it takes the taste problem away.” “You still have to sit on the toilet, but not having to drink something that tastes bad is a huge advantage.”

Arif Kamal, professor of medicine at Duke University, agrees. “This is a good option for those who are a problem for them,” says Kamal, who is also chief patient officer for the American Cancer Society. It also points to simpler alternatives to a full colonoscopy for patients at high risk of colon cancer, including home screening tests for blood and altered DNA that indicate the presence of cancer.

“The pluses: It’s more convenient to do it at home,” says Kamal. “Cons: You still have to have your stool sample taken. Also, the frequency is more often — every two to three years,” compared to a seven to 10 year interval for colonoscopy. Most insurance plans, including Medicare, cover this.

Experts say a “virtual” colonoscopy is also available, although patients still need to prepare, and some “flat” polyps are more easily seen with a conventional colonoscopy. Virtual colonoscopies are not home procedures, because they include colonography, and insurance coverage is intermittent. It is only covered under special circumstances, such as when a conventional colonoscopy cannot be completed for some reason.

The American Cancer Society now recommends that people 45 years of age or older who are at risk of colon cancer get screened. This is a change from previous guidelines that recommended screening only for those 50 and over who are at normal risk.

Excluding skin cancers, colorectal cancer is the third most common type of cancer in the United States, according to the American Cancer Society, which projects an estimated 106,180 new cases of colon cancer this year and 44,850 cases of rectal cancer. About 7 in 10 adults in the United States between the ages of 50 and 75 are informed of a screening colonoscopy, according to the Centers for Disease Control and Prevention. Experts believe that avoiding prep is probably one of the main reasons why the rest isn’t there.

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New pills can change that, but they have a downside.

Many insurance drug plans don’t cover it, and it can be out of pocket for $120 or more. (A friend of mine in Florida charged $150 after her insurance plan was declined—and after I was denied—she paid $60 using a discount coupon my doctor got from Sebela Pharmaceuticals.)

says gastroenterologist Clement Poland, MD, retired professor of medicine at the University of California, San Diego School of Medicine. “That’s ridiculous. It shouldn’t be too expensive. It’s just salt. [sodium sulfate, magnesium sulfate, potassium chloride]is not something as fancy as a monoclonal antibody.”

Experts say the most likely reason for the insurance denial is that the pills are new and have not yet been shown to offer better alternatives. An insurance company will say, ‘Okay, if it’s equivalent, we’ll just cover the cheapest company,’ Kamal says.

Many gastroenterologists who deal with a patient’s reluctance to prepare consider this to be retrograde thinking. “Insurance companies are trying very hard to force people to use generic products, which are not well tolerated,” Rex says. “When it comes to the settings, efficacy is not the issue. From a patient’s point of view, that is tolerability. This is really important for patients.”

Many major insurance plans cover birth control pills, including some in Medicare Part D, says John McGowan, chief of gastroenterology research and development at Sebela Pharmaceuticals.

Since others don’t, it’s best to check your individual plan to determine if the pills are covered.

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For those who lack insurance or whose plans don’t cover pills, McGowan suggests checking out on his company’s website for ways to save. The company also offers free samples and discount coupons to doctors for patients who can’t afford pills, he says.

He acknowledges that cost can be a barrier for some patients. However, “in the event that the patient cannot complete the fluid preparation properly, the colonoscopy must be repeated, in which case the additional costs provided by the Sutab pocket are worth it,” he said.

The newer pills should not be confused with the earlier tablets, made mostly of sodium phosphate, which the FDA found in 2006 to have caused serious kidney damage in some patients. Experts say that while the ancient pills are still on the market, they are rarely used today.

“The newer ones contain sodium sulfate and are safe,” Rex says, stressing that patients should still drink the recommended amounts of water to avoid dehydration. “You don’t want to drink things that taste bad, but you have to drink something,” he says.

De Palma, who conducted the Sutab study, says he tried all the prep and used them on his colonoscopy.

“I’ve had five colonoscopies, and Sotap has been the easiest by far,” he says.

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