Bowel Prep Hesitancy: What's It All About?

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

Dave, let’s talk about a common scenario that we see in practice pretty frequently. And this is a scenario where you’re speaking with a patient prior to prescribing a bowel prep. Say it’s a 45-year-old male and this is his first colonoscopy, and obviously, we want the best possible outcome when it comes to prep and the quality of the preparation. But the patient tells you that he really doesn’t want to have one because he’s heard from friends how horrible the taste is for the bowel prep. So he’s very reluctant. Can you tell us what that conversation would sound like and what you would advise this patient, keeping in mind individualizing the prep kit based on the patient’s choice?

Dr. Johnson:
Sure, Aasma. A great conversation with the patient begins with, “What have you heard?” and then how do you address that? So the consequence of the taste is somewhat of a concern, and the volume is the other, that patients will tell you about. They just can’t drink that much. So there are, certainly, preps that have been increasingly improved, as relates to low volume, which Dr. Rex had talked about in the intro, but the palatability of the prep has been increasingly improved, as relates to even, particularly, some of the newer preps that we see with like Suflave, which has been increasingly well tolerated. And those are things that really are going to drive the patient’s acceptance, and in particular, you need to tell them about – or discuss with them, not tell them – about how important it is to get a good preparation. This is what I tell my patients: It’s an investment. So if we get a good investment, it is going to be the improvement as it relates to the outcome, where we can get the best screening and the best prevention of colon cancer. We don’t want to detect cancer; we want to prevent it. So the factors to really get there is what do we need to do to individualize you? Is it something that you’ve heard is, in addition to taste, it kept you up at night? So we can talk about ways to get around that, and particularly the ways that we separate preps and the afternoon prep is not necessarily any different than taking a dose later in the evening that keeps you up later at night. Maybe the patients are saying I don’t want to fast that long, and maybe I just want to get up in the morning and do my prep. And they can do that on a same-day prep, and certainly a same-day prep is equivalent to a split-dose prep if you have an afternoon colonoscopy. So there are modifications on top of that that may really play out. In particular, one that really is the standard of care, I think, and we put this in the colon prep guideline for the Multisociety Task Force, was that low-residue breakfast is something that certainly increases patients’ willingness to repeat. Doesn’t change the outcomes, and certainly may enhance the efficacy of the preparation. Again, subject to the individual. So patients that have mitigating circumstances for bad prep, we have to modify. But for the standard individual, this healthy 45-year-old, I think we could sell it up and talk about this is your investment. We can do that, but we need your help.

Dr. Shaukat:
Great. So for this particular patient, or patients like this, we can tell them there’s a lot of options. Lower-volume preps are great, where extra water needs to be consumed. And there’s options for low-residue diet, particularly for breakfast the day before.

This has been very informative. Thank you so much, Dave, and thank you for our audience for listening.

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