The days of drinking a gallon of oily liquid the night before a colonoscopy are over.
Volumes of some preparations are smaller, and physicians now routinely order patients to split the dose so about half is taken the night before the colonoscopy and half is taken early the morning of the procedure. That makes it easier to drink the solution, but it also has been found to flush the colon better and make the colonoscopy more effective.
Preparing for a colonoscopy is viewed by many patients as the toughest part of the process. Doctors now say the preparation, which includes drinking the solution followed by many trips to the bathroom, now is tolerable enough that it shouldn't bar any patient from getting a colonoscopy.
That's encouraging news because colon and rectum cancers are the third-leading killers among cancers. Colonoscopies have helped reduce colon cancer incidence rates by 2 percent to 3 percent per year, the American Cancer Society said.
“There's no doubt that colonoscopies save lives,” said Dr. Ed Schafer, a physician with Midwest Gastrointestinal Associates in Omaha. “There have been great advances in the preparations so it's not so onerous.”
Nancy Brown had a colonoscopy this month, preparing for it with doses a week ago Sunday night and Monday morning. “Really, not that bad,” is the way Brown described the preparation process.
“It's not unpleasant,” said Brown, 60, who took a solution called Suprep, which was approved by the Food and Drug Administration three years ago. “The quantity's very tolerable.”
Her son, Casey, had a colonoscopy a dozen years ago because he has colitis. He tried to drink the gallon's worth of bowel-prep solution but couldn't. “He just started vomiting and vomiting,” Nancy Brown said.
The American College of Gastroenterology four years ago began recommending a split dose for colon preparation. Clinical studies have shown the split dose to be better than the night-before preparation because the small intestine continuously dumps a thick, gelatinous goo into the colon. That substance can hide pre-cancerous polyps that should be removed during the colonoscopy.
Dr. David Johnson, past president of the American College of Gastroenterology, said the difficulty involved in drinking the solution has been exaggerated. “Patients have heard that the prep is not good, or horrible, and it really isn't,” said Johnson, a practitioner in Virginia.
Splitting the dose enables the solution to clear out the gelatinous substance, called chyme, closer to the procedure and leaves the colon cleaner, said Dr. Bob Kizer, a gastroenterologist with Alegent Creighton Clinic. Further, “we give patients a break” by splitting the dose, Kizer said.
Most people have their first colonoscopy at about 50 years old, although the American College of Gastroenterology recommends that African-Americans have their first at 45. Johnson said African-Americans have a tendency toward earlier onset of colon cancer. If the colonoscopy yields normal results, a second usually isn't necessary for 10 years.
Patients who had the gallon of solution a few years ago should know it's a new day in colonoscopies. “Don't let that stop you,” Kizer said, because “we have better options” today.
Increasingly, prescription products have become available that allow patients to down a lower volume than the gallon of GoLytely, a solution that won FDA approval 29 years ago. Among those products are the following:
╗ MoviPrep, FDA-approved in 2006, calls for 32 ounces of solution to be consumed the night before. Then the patient should drink 16 ounces of clear liquid, such as water, apple juice or tea. This process is repeated in the morning, several hours before the procedure.
╗ Suprep, approved in 2010, calls for mixing six ounces of the solution with 10 ounces of water and drinking it. Then the patient should drink 32 more ounces of water. This process is repeated in the morning, several hours before the procedure.
╗ Prepopik, approved last year, calls for drinking five ounces of the solution, followed by 40 ounces of water, apple juice, ginger ale or other clear liquid. The next morning, about five hours before the procedure, five ounces of solution is followed by 24 ounces of clear liquids.
Without insurance, the preps range from $25 for GoLytely to about $145 for Prepopik. Insurance typically participates, although some plans direct patients to the least expensive preps, Johnson said.
The colonoscopy itself may cost $2,000 or considerably more, depending on the physician and place it's done. The Affordable Care Act since 2010 generally has prohibited co-pays and deductibles for colonoscopies performed by in-network providers as part of the law's covered preventive health services.
The American Cancer Society estimated that there will be 142,820 new colon and rectum cancer cases this year, and 50,830 deaths. The society said that when colorectal cancers are found early, the five-year survival rate is 90 percent. But only about 40 percent are diagnosed early, largely because of low screening rates, the society reported. Only slightly more than half of Americans 50 years of age and older are screened within recommended intervals, the society reported.
Nevertheless, science has improved the tube and scope used to explore the four feet of colon, and more pre-cancerous polyps are found and removed. And the formulas to prepare for the colonoscopy are improving, too.
Dr. Grant Hutchins, assistant professor of gastroenterology at the University of Nebraska Medical Center, said patients dread the prep. “That's the biggest thing that patients complain about,” Hutchins said.
Ultimately, patients need to do a good job of cleaning out the colon before the procedure or they may have to do it all over again. Doctors who specialize in the gut have a little joke. The only thing worse than a colonoscopy, they say, is two colonoscopies.