Bottoms Up! Help Sort Out Bowel Prep Options

You can help patients succeed with bowel preps for colonoscopies.

Deaths from colon cancer are rising by about 1% each year in people under 55. Recommend colon cancer screening for patients age 45 and up.

For patients getting a colonoscopy, work with the patient and prescriber to suggest a bowel prep based on preference, comorbidities, and cost. Point out that payers may cover some prep options at $0 co-pay.

Any option is effective...if patients can tolerate and use it properly. Inadequate prep can lead to missed polyp detection, etc.

PEG with electrolytes is still the “gold standard,” especially when fluid or electrolyte shifts may be harmful...diuretic use, kidney or liver disease, heart failure, etc. But taste and volume can be an issue.

Lean toward a sulfate-free option, such as TriLyte, among the high-volume 4 L preps. These taste less salty than GoLytely, etc...don’t smell like rotten eggs...and cost about $20.

If patients find 4 L daunting, suggest 2 bisacodyl tabs and drinking half the jug...evidence suggests this can work as well as 4 L. Low-volume PEG options (MoviPrep, etc) are available...but can be costly.

Non-PEG products, such as Clenpiq or Suprep, are also low volume.

But these shouldn’t be used if fluid or electrolyte shifts are a concern. Also avoid these in patients on meds that may increase risk of kidney injury (ACEIs, ARBs, NSAIDs, etc).

If patients want to try tablets, point out that Sutab still requires 3 L of fluid, plus 24 tabs...and costs about $165.

OTC regimens are an option, especially if Rx products are limited.

Think of PEG 3350 (Miralax) 238 g mixed in 2 L of a light-colored sports drink, such as Gatorade...sometimes along with bisacodyl. This costs around $6 to $10...but has less electrolytes than Rx PEG products.

Save magnesium citrate as a last resort...due to limited efficacy data and risk of hypermagnesemia, especially in the elderly.

With any prep, recommend a split-dose regimen...taking half the night before and half 4 to 6 hours before the colonoscopy. This may get patients up early...but improves prep quality and tolerability.

Suggest other ways to make preps easier to swallow...chilling the solution, drinking through a straw to bypass taste buds, using light-colored flavored beverage mixes (Mio, Crystal Light, etc).

Remind patients to avoid red and purple drinks...since these can be mistaken for blood during colonoscopies.

Weigh prep options with our chart, Comparison of Bowel Preps.

• Chart: Comparison of Bowel Preps