Preparation for a colonoscopy, a procedure in which a doctor passes a flexible tube through the colon to view the inside of the body with a camera, remains perhaps the biggest barrier to screening. So last year’s approval of a less painful preparation option for patients was welcome news.
A preliminary colon cleansing is essential to detect and remove polyps, often precursors of cancer, during the procedure. Over the years, several new-generation preparation solutions have become available, each with advantages and disadvantages, and others—including those in the form of flavored shakes and food bars—have been tested but not yet approved.
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The solutions that most patients drink cleanse the colon, but patients have to drink large amounts — four liters or a little more than a gallon — and still taste awful.
Doctors now recommend that patients split the dose in half, taking half the day before and the rest a few hours before the procedure.
“We tell people to refrigerate it, drink it through a straw, hold their nose, chew gum in the middle or suck on hard candy,” says Louis Korman, a semi-retired DC-area gastroenterologist. “Everybody hears stories about how terrible preparation is. Preparedness is on everyone’s mind, and it can prevent you from getting a colonoscopy.
But last year — in what experts say could end a threat that keeps many people from this important screening — the Food and Drug Administration approved a regimen of Sutab pills that studies show work as well as liquid solutions without the bad taste. . This is a regimen of 24 pills: 12 pills a few hours before the procedure and 12 pills the next day.
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Patients should still drink plenty of water, a total of 48 ounces the first day and another 48 ounces the next day. But at least plain water is tasteless.
“The beauty of water is that it solves the problem of taste,” says Douglas K. Rex, MD, professor emeritus of medicine at Indiana University School of Medicine. “You still have to go to the toilet, but you don’t have to drink something that tastes terrible – that’s a huge plus.”
Oncologist Arif Kamal, associate professor of medicine at Duke University, agrees. “It’s a good option for those with taste issues,” says Kamal, chief patient officer for the American Cancer Society. It also outlines simple alternatives to a full-blood colonoscopy for patients at moderate risk of colon cancer, including home screening tests for blood that can detect the presence of cancer and altered DNA.
“Pros: It’s convenient to do at home,” says Kamal. “Cons: You still have to get your own stool sample. Also, the frequency is greater — every two to three years,” compared to seven to 10 years for a colonoscopy. Most insurance plans, including Medicare, cover these.
Experts say “virtual” colonoscopies are also available, but patients still need to be prepared and some “flat” polyps are easier to see on a regular colonoscopy. Virtual colonoscopies are not at-home procedures because they involve imaging of the colon and insurance coverage is unclear. They are only covered in exceptional circumstances when a routine colonoscopy cannot be completed for any reason.
The American Cancer Society now recommends screening for people 45 and older who are at risk for colon cancer. This is a change from previous guidelines that recommended screening for those 50 and older.
Colorectal cancer is the third most common cancer in the United States, excluding skin cancer, with an estimated 106,180 new cases of colon cancer and 44,850 new cases of rectal cancer this year, according to the American Cancer Society. According to the Centers for Disease Control and Prevention, 7 out of 10 US adults between the ages of 50 and 75 have a colonoscopy screening. Experts believe that avoidance is probably one of the main reasons for the rest.
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New pills can change that, but they have downsides.
Many insurance drug plans do not cover them, and they can cost $120 or more out of pocket. (A friend in Florida had $150 after her insurance plan was denied, and after mine was denied, I paid $60 using a discount coupon my doctor received from Sebela Pharmaceuticals.)
“For people who can’t get a colonoscopy because of bad taste, this could be a game changer,” says gastroenterologist Clement Boland, M.D., emeritus professor of medicine at the University of California, San Diego School of Medicine. Medicine. Medicine. “This is funny. It shouldn’t be that expensive. It’s just salt [sodium sulfate, magnesium sulfate, potassium chloride]not something fancy like monoclonal antibodies.
Experts say the most likely reason for insurance denials is that the pills are new and haven’t been proven ahead of cheaper alternatives. “The insurance company says, ‘If it’s equivalent, we’ll pay for the cheaper one,'” says Kamal.
Many gastroenterologists are reluctant to train their patients and see this as backward thinking. “Insurance companies try very hard to force people to use generic products, which they don’t do well,” says Rex. “When it comes to preparation, efficiency is not the issue. From the patient’s point of view, this is tolerance. It’s very important for patients.”
John McGowan, head of gastroenterology research and development at Sebela Pharmaceuticals.
It’s probably a good idea to check with your personal plan to determine if the pill is covered or not, because others aren’t.
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For those who don’t have insurance or whose plans don’t cover the pill, McGowan recommends checking his company’s website at sutab.com/savings for ways to save. The company also provides free samples and discount coupons to doctors for patients who can’t afford the pills, he said.
He acknowledges that cost can be a barrier for some patients. Even so, “if the patient can’t complete the fluid preparation properly, the colonoscopy must be repeated, in which case the additional upfront, out-of-pocket expense for Sutab is worth it,” he says.
The newest pills should not be confused with earlier pills, which are often made of sodium phosphate, which the FDA said in 2006 caused serious kidney damage in some patients. Although still on the market, the old pills are rarely used today, experts say.
“The new ones contain sodium sulfate and are safe,” says Rex, stressing that patients should still drink the recommended amount of water to avoid dehydration. “You don’t want to drink something that doesn’t taste good, but you have to drink something,” he says.
Di Palma, who conducted the Sutab study, says he has tried all the preparations and used them in colonoscopies.
“I’ve had five colonoscopies, and Sutab was the easiest,” she says.