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Dr. Shaukat:
Hello, this is CME on ReachMD, and I’m Aasma Shaukat. Here with me today is Dr. Dave Johnson.

Dave, could you please take us through a comparison of different bowel preparations?

Dr. Johnson:
Sure, Aasma. So it’s a very complex comparison, but it begins with high volume versus low volume, and Dr. Doug Rex elucidated about the comparison of volumes that go from 1 to 4 liters. A key point here is to recommend that irrespective of the amount of active ingredient, it’s really the fluid that’s accompanying that that drives the best outcomes for avoiding dehydration. So if you say a low-volume prep, you still need to drink the fluid around that to achieve an effluent of between 2 and 3 liters, so you still need to make sure the patients know that even if it’s a lower volume of the active ingredient, they need to drink fluids around that. As it relates to the different preps, there are certainly components that separate it based on ingredients. There’s a PEG-based regimen, which starts with the GoLytely 4 liters, move to MoviPrep or Plenvu, and now the newest, Suflave as relates to lower-volume preps. So then sulfate-based preps are out there, as relates to Suprep and to Sutab, and sodium phosphate – Dr. Rex alluded to some of the consequences as relates to a phosphate regimen, and this would be OsmoPrep. And then Clenpiq, which is the sodium picosulfate-based regimens.

In relation to things that are over the counter, there are the PEG-based regimen with sports drink, which is the standard MiraLAX prep, which is something to be aware of. As it relates to consequences, I think we need to be aware that some of the preps, in particular the MoviPrep and the Plenvu, do contain ascorbic acid, so these are agents that should be avoided in patients that have G6PD deficiency. Also is a component of risk for patients that have phenylketonuria. Again, extremely rare, but just be aware of it. As it relates to the phosphate-based preps, you need to be aware that the patients that particularly have inflammatory bowel disease may have increased absorption, and there’s a risk of phosphate nephropathy. So again, these are things that are components. The over-the-counter PEG sports drink with MiraLAX has a component of potential hyponatremia, and personally, I don’t use that prep anymore, just as an FYI.

As it relates to the overall adequacy to repeat, the patients are willing to repeat almost all these, related to comparing with the 4 liters of GoLytely. I’m not sure how we got away with what we did when we only had GoLytely, but the more recent comparative data increasingly aware that patients as it relates to palatability and volume drives this. And the most recent is Suflave, which was compared to Suprep, which was related to an increase of about 20%-25%, as far as willingness to repeat. That’s what drives people willing to come back. If we lose these people downstream, then those are people that really are lost to the system. And, Aasma, I am concerned about good news spreads very slowly, but bad news spreads very fast and quickly, and certainly, phone-a-friend, tell a friend about something that you had a bad experience with a prep – that’s what we want to avoid. We want to keep these people in the system. We want to do the best we can to prevent colon cancer.

Aasma?

Dr. Shaukat:
Yeah, thank you, Dave. Those are all excellent points. So to summarize, low-volume preps are available. However, we still need to advise the patient about drinking enough fluid with them. And there’s certain medical conditions where we need to be cognizant of the types of preps we prescribe. Particularly in practice we see renal failure, heart failure, pregnancy-related, and tolerability and efficacy both go hand-in-hand when it comes to patients’ willingness to repeat.

Thank you so much for listening, and thank you so much for talking with us today, Dave.

Dr. Johnson:
Thanks, Aasma.

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