Colorectal Cancer Screening: Update on Bowel Preps

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1 Colorectal Cancer Screening: Update on Bowel Preps What we don t want What we want Frank Friedenberg, MD, MS (Epi) Professor, Gastroenterology t Temple University School of Medicine 5 Modified Aronchick Scale Inadequate re-preparation needed Quality of Bowel Prep: Why Does It Matter? Bowel preparation is inadequate in up to 25% of patients undergoing colonoscopy Consequences of inadequate prep: - Increased difficulty of colonoscopy - Prolonged procedure time - Reduced d cecal intubation ti rates - Repeat procedures and shorter surveillance intervals - Reduced Adenoma Detection Rates (ADR) - Risk of polymicrobial peritonitis if perforation - Risk of repeat anesthesia Nelson DB, et al. Gastrointest Endosc 2002;55: Rex DK, et al. Am J Gastroenterol 2002;97: Froehlich F, et al. Gastrointest Endosc 2005;61: Harewood GC et al. Gastrointest Endosc 2003;58:76-9 1

2 Tandem Colonoscopy Study - Korea Aronchick Score (n=277 patients) Polyps (n=133) Miss Rate % Adenoma (n=127) Miss Rate % Advanced Adenoma (n=31) Miss Rate % Bowel Prep is a Quality Indicator High-quality practice should monitor prep quality as a quality indicator Excellent Good Fair Poor/Inadequate Hong, et al. Clin Endosc Nov;45(4): Target: 90 % preps should be good or excellent Consider practice level interventions if > 10% preps inadequate (e.g., patient education, use of split-dose regimens) Lieberman et al. Gastrointest Endoscopy 2007;65: Types of Bowel Preps Isosmotic Full Volume (4L) Preps Isosmotic full volume Isosmotic low volume Preparation Colyte (SchwarzPharm) GoLYTELY (Braintree Lab) Active Ingredient PEG-ELS PEG-ELS Suggested Prep Regimen 8 AM - Noon 240 ml (8 oz) every 15 min beginning at 8 pm evening before colonoscopy [done ~ midnight]. i Better 3L at 8PM and 1 L at 5AM. Hyper Osmotic NuLYTELY (Braintree Lab) TriLyte (SchwarzPharm) PEG (sulfate free) PEG (sulfate free) Afternoon procedure: Split dosing: 2 L at 8 PM night before 2L at 8 AM day of procedure 2

3 Preparation HalfLytely (Braintree Labs) Miralax (Schering-Plough) MoviPrep (Salix) Isosmotic Low Volume Preps Active Ingredient PEG and bisacodyl PEG and bisacodyl PEG and ascorbic acid Recommended Use 1 bisacodyl delayed-release tablets at noon the day before colonoscopy-wait 6 hours. 240 ml (8 oz) PEG every 15 min at 6 PM (1 L); Repeat 240 ml (8 oz) every 15 min beginning 3 to 4 h before colon (1 L) Mix in Gatorade 64 ounces (1.9 L) Instructions same as for HalfLytely 240 ml ( 8 oz) every 15 min at 5 to 6 PM evening before colonoscopy (1 L), followed by at least 16 oz of fluid (0.5L); Repeat 3-4 hours before colonoscopy. Preparation OsmoPrep * (Salix) Suprep (Braintree Labs) Prepopik (Ferring) Hyper Osmotic Preps Active Ingredient NaP tablets Na Sulfate Na Picosulfate/ Mg citrate Recommended Use 20 tablets (4 tabs every 15 min with 8 oz. water) at 5 to 6 PM the evening before colonoscopy; Repeat with 12 tablets 10 to 12 h later (at least 3 h before colonoscopy) 6 oz bottle diluted with 16 oz of water followed by 32 oz water over the next hour ; take the evening before and repeat the morning of colonoscopy Step 1: dissolve 1 packet in 5 oz. liquid and consume followed by 5, 8 oz glasses of clear liquids at 4 to 6 PM; Step 2: repeat step 1 followed by 3, 8 oz glasses of clear liquids (later that evening, or 4 to 6 hr before procedure) * Black box warning for phosphate nephropathy Split Dose Preps Colonoscopy should be performed within 6-8 hours of the last dosing More effective and better tolerated than full dose p.m. Demonstrated superiority Recommended in ACG guidelines for CRC screening ALL SEGMENTS Excellent-Good Percentage of being rated PEG (4L) vs. PEG Ascorbate (2L+1L H2O) Preps P cecum after PM only dosing Rex DK, et al. Am J Gastroenterol. 2009;104: cecum after PM/AM split dosing 11 Marmo R et al. Gastrointest Endosc 2010;72:

4 PEG Split-Dosing: Meta-analysis Split-dose PEG is superior to full-dose PEG with respect to Satisfactory colon cleansing (OR 3.70; 95% CI, ;p<0.01) Likelihood of not discontinuing prep (OR 0.53; 95% CI, ;p=0.04) Willingness to repeat same prep (OR 1.76; 95% CI, ;p=0.03) Side effects, e.g., nausea (OR 0.55; 95% CI, ;p<0.01) Kilgore TW et al. Gastrointest Endosc. 2011;73: PM/AM Split-Dosing: What are the Barriers? Patient acceptance of sleep disturbance? 85% surveyed willing to get up at night to take 2 nd dose 78% complied Unger RZ, Rex DK, et al. Dig Dis Sci 2010;55: Bowel activity in transit to procedure pit stop? No difference taken PM or same day PM/AM (5-15%) Parra-Blanco A et al. World J Gastroenterol 2006;12: Khan MA et al. Gastrointest Endosc 2008;67(suppl):AB246 Non-compliance with pre-procedure fasting guidelines (increased risk of aspiration)? ASA guideline: clears OK up to 2 hours prior American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting and Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2011;114: Is Dietary Restriction Necessary? Meta-analysis of Split-dosing Diet Take Home Message: Optimal pre-procedure diet with split-dose regimen not well-defined. Most would consider a clear liquid diet as standard of care. I add on no fruits or veggies for 3 days. Kilgore TW et al. Gastrointest Endosc. 2011;73:

5 High vs. Low Residue Diet Prospective cohort study in Taiwan -patients educated on eating a low-residue diet 2 days prior to colonoscopy Low residue = well-cooked meats, eggs, white bread, white rice,,p pasta, no skins Findings: Only 44% adhered to low-residue diet Higher-residue diets were associated with worse bowel preparations Wu et al. Dis Colon Rectum 2011;54: How to Prep after Patient has a Bad Prep No studies to provide evidence-based guidance Most Important identify the problem Ate the day before, did not finish prep, constipation, etc. Approaches Extend period of diet modification from 24 to 48h Split dosing if not done initially Increase total volume of PEG (e.g. add 4 48 hours before) Add Magnesium 48 hours before Add oral bisacodyl or senna 6 hours before prep Miscellaneous Issues Iron stop 5 days before procedure Avoid hyperosmotic preps in patients with renal insufficiency (GFR < 60 ml/min/1.73 m 2 ) and CHFunexpected electrolyte abnormalities (e.g. Na) Safety of Gatorade regimens not established 1 Limit Bisacodyl dose to 5-10 mg to avoid ischemic colitis (HalfLytely now uses 5 mg) Schoenfeld P. Safety of MiraLAX/Gatorade bowel preparation has not been established in appropriately designed studies. Clin Gastroenterol Hepatol 2013; 11:

6 MSTF Guidelines If the bowel preparation is poor the examination should be repeated within 1 year. If the bowel preparation is fair but adequate (to detect lesions >5 mm) and if small (<10 mm) tubular adenomas are detected, follow-up at 5 years should be considered? Bowel prep is fair and nothing found on index colonoscopy. I individualize based on age and co-morbidities. Thanks Lieberman DA, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology Sep;143(3):