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Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum.

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Dr. Rex:
Hi, this is CME on ReachMD, and I’m Doug Rex from Indiana University, and I want to welcome you to a series of discussions about colonoscopy.

We can use colonoscopy for screening, it’s still the most common screening test performed in the United States, but also if we do screening by any method, patients that are unwilling to have colonoscopy should undergo fecal test, and if those are positive, then they undergo colonoscopy. So colonoscopy is a pivotal aspect of how we prevent colorectal cancer, and we want it to be of very high quality. And we’re going to focus, in these sessions, on the importance of bowel preparation to achieving high-quality colonoscopy. We judge colonoscopy by 3 criteria. One of them is the safety of the bowel preparation. And I think, for the most part, while any bowel preparation can produce some electrolyte imbalance, some problems with GI distress, what we expect is that it’s not going to have organ-specific damage. There’s one preparation that is still on the market but rarely used, sodium phosphate, that can cause a rare, but very serious sometimes, renal injury, and so we tend to not use that. Otherwise, the commercially available bowel preparations approved by the FDA are all pretty much free of any organ-specific toxicity. So the choice of preparation comes down to efficacy versus tolerability, and efficacy is the key, because by getting the prep very clean, very high quality, so that we can see even the flattest lesions, that’s how we truly get the colon cleared. That’s how we prevent people from getting colorectal cancer.

Efficacy, if it’s not high, has a lot of consequences. One of them is increased cost, because when patients have an inadequate preparation, we have to cycle them back through the process. And there’s an old study showing that for each 1% increase in inadequate preparations, we increase the total cost of delivering colonoscopy for a healthcare system by 1%. So we want to get that rate of adequate preparation now up above 90%, and we can do that by using effective preparations. In fact, the old preparations, the so-called 4-liter or high-volume preparations that we used to prescribe on a regular basis, we’ve now learned that we can get equal efficacy for the great majority of patients by choosing a preparation that is lower in the volume of active ingredient. Instead of 4 liters of solution, that may to many people not taste good, now they only need 1-3 liters of active ingredient, with some addition of water, which is easier to drink, and we even have, now, a tablet preparation. So for the great majority of patients, if we choose a low-volume preparation, we can get that efficacy that is primary, that’s essential, but not sacrifice tolerability. Tolerability is so important to patients. The bowel preparation is the thing that our patients complain about most often, and it’s the reason they most often give for why they’re unwilling to repeat the preparation when they may be due for it in 3 years, or 5 years, or 10 years – unwilling to repeat the procedure, and that becomes a safety issue. So we want to get that right balance between the efficacy of the preparation and the tolerability of the preparation.

In terms of, of the future, I think it’s exciting that we’re going to see new preparations, and in many cases, they’re going to focus on even confining this volume of active ingredient to a smaller amount and improving the taste. And by doing that, further improving the tolerability that is so important to patients. So over the next few sessions, we’re going to hear some further detail about how to really maximize the efficacy of the preparation and how to identify patients who are at increased risk of having an inadequate preparation and make adjustments to the instructions and to make adjustments in the volume of preparation that we give. And that’s an important part of the entire process, and we’re also going to learn about how to maximize the tolerability of the bowel preparation. So look forward to this discussion. Thank you so much for joining us, and it’s going to be exciting to learn about high-quality bowel preparation and how it leads to high-quality colonoscopy.

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