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Dr. Rex:
Hi, this is CME on ReachMD. I’m Doug Rex, and with me today is Dr. Aasma Shaukat.

Aasma, I want to ask you about bowel preparation. How do you ensure that your patients are taking the bowel preparation that you prescribed and that they’re taking it correctly?

Dr. Shaukat:
Thank you so much for having me, Doug, and what an excellent question. So we do prescribe preps, but where it’s really crucial is did the patients understand our instructions? And how can we help them? The first and foremost thing to remember is that one size does not fit all, meaning our patient population is very different, and hence, their ability to self-activate, their self-efficacy, their comprehension might be very different, so we have to meet the patients where they’re at. Knowing that, again, we have to meet our patients at their individual situations, and some patients need more instructions, hand-holding, reinforcement, and repeated instructions than others. So it’s important to recognize who those patients might be in our practice, and then some of the best practices are providing the instructions at a grade 6 or even lower reading level, providing written as well as either oral or instructions via text.

And then perhaps a reinforcement call that could either be automated or could be generated by one of our endoscopy staff prior to the procedure to ensure that the patients are following the instructions that we provided them. Again, having instructions that are easy are easier to follow, and there, split-dose regimens are extremely beneficial, not just for tolerability and efficacy, but again, if explained well, patients can understand them. What we usually tell them is having a split-dose prep, meaning taking half the prep the evening before and half the day of the procedure and finishing the second half 4 hours – or whatever your anesthesia practice allows – prior to the procedure. And usually our patients will take prep between – somewhere between 7 to 9 pm. Half of it the night before. We tell them they’ll have a lot of sleep disturbances, probably having to go to the bathroom during the night. But then the second half of the prep is taken between, say, 6 and 8 am for a procedure that’s at noon or later. So that’s extremely important, and then same-day preps, same concept. The prep can be taken the morning of, particularly for afternoon procedures.

So this really enhances tolerability as well as prep efficacy. And making sure that they drink plenty of fluids during the time that they’re taking the prep and making sure that the patients are taking what we prescribed and not using over-the-counter things that may or may not be safe in their particular medical conditions.

So in summary, it really takes an interdisciplinary village, usually from the endoscopy suite. It’s the nursing team, it’s the provider, maybe a champion that oversees all of this effort. The receptionists can sometimes be helpful, and definitely having a nurse line to answer patient questions.

Dr. Rex:
Thank you so much, Aasma. I think the points that you’re making about how clearly we have to present these instructions to patients are so important, and split dosing, which you’ve really emphasized, I think some physicians don’t even understand what it really means. We think because the 2 doses are just split in time, maybe they’re both taken the evening before, that that’s split dosing. Split dosing means that half the preparation is taken on the day of the examination and, as you said, ideally starting 4-5 hours before the time of the colonoscopy and finishing by whenever the anesthesiologist says that you need to. The time of that first dose the day before is less important. It’s often taken in the evening because people are working, but if they’re not working or they’re retired, they could take it a bit earlier in the day. It’s that second dose that cleans all that mucus out of the right colon, the so-called chyme, C-H-Y-M-E, that comes out of the small bowel.

These are fantastic points. It’s important for us to all understand that split dosing is more important than the kind of preparation. Anytime you take a prep and change it from evening before to split, you improve the efficacy.

Thank you so much, Aasma.

Dr. Shaukat:
Thank you.

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