Transcript Colon Prep Update

Colon Prep Update: 2015
Let’s be clear
Harish K Gagneja, MD, AGAF, FACG, FASGE
President, TSGE
President, Austin Gastroenterology, P.A.
www.austingastro.com
“The colonoscopy was a great
experience except for the
horrible bowel prep. There has to
be an easier way to get cleaned
out, doc!!”
A cleanly prepped colon
is a
critical component
of a
successful colonoscopy
Colon Prep
Oh no……..
Risk Factors for Poor Prep
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Male
Elderly
Higher BMI
Unmarried
Co-morbities
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Dementia
Sedentary life style
Diabetes
Opioids use
• Prior inadequate
bowel prep
• Inpatient status
Bowel Prep is Important!!
• Inadequate prep leads to
– Longer procedure time
– Lower ADR
– Increased complications
– Need for repeat examination – cost
• Over 20 million colonoscopies are
performed in US
Focus on Quality Bowel Prep
• The success of a colonoscopy is closely
linked to good bowel preparation, with
poor bowel prep often resulting in missed
precancerous lesions
– 40% miss rate for all polyps
– 27% miss rate large polyps
Focus on Quality Bowel Prep
• Poor bowel cleansing can result in
increased costs related to early repeat
procedures. (1% rule: for each 1% of
preparations that are inadequate the cost
of delivering colonoscopy increases by
1%)
Focus on Quality Bowel Prep
• The discomfort and inconvenience of
bowel preparation affects participation in
colonoscopy screening programs
• The quality of bowel cleansing affects:
– Cecal intubation rate
– polyp detection rate
– Flat polyps detection rate
– Patients lost to follow up
Focus on Quality Bowel Prep
• Bowel Prep added to Key Quality measures to be
reported
– Bowel Prep (New)
– Detection
– Documentation of cecal intubation
– Screening & surveillance intervals
• Up to 20 to 25 percent of all colonoscopies are
reported to have an inadequate bowel
preparation – target to reduce to less than 15%.
(Adequate preparation should be achieved in
≥90% of exams (my opinion)
Ideal Bowel Prep for
Colonoscopy
• Should be
Safe
Tolerable by the patient
Effective to clean the colon and hence improve
adenoma detection
Which one is the ideal bowel
prep for the colonoscopy?
NONE!!
Preps for Colonoscopy – FDA
approved
• GoLYTELY/NuLYTELY/TriLyte/colyte
– 4-L PEG 3350 ES
• HalfLytely - 2L PEG 3350ES/Bisacodyl
• MoviPrep – 2L PEG 3350 ES/Ascorbic
acid
• SUPREP – Oral sulfate solution
• Osmoprep – Sodium Phosphate tablets
• Prepopik – Picosulfate solution
Preps for Colonoscopy –
Non-FDA approved
• MiraLAX and Gatorade mixture
• MagCitrate combined with Bisacodyl
(LoSoPrep)
• MagCitrate and MiraLAX
• MiraLAX/Gatorade combined with
Bisacodyl
• Any combination of the above – Really!!
New Considerations in Prep
• Low pressure intra-colonic water
infusion system aka “HyGIeacare”
4-L PEG Solutions
• PROS - safe, effective especially with split
dose
• CONS – large volume, caution with
elderly, nausea, cramps, fullness, bloating
and palatability issues for some patients,
• C/I – GI obstruction, gastric retention,
bowel perforation, toxic colitis and toxic
maegacolon
HalfLytely
• PROS – safe, better tolerated than 4L
solutions
• CONS – Less effective than 4L solutions,
similar side-effects as with 4L solutions,
concerns about Ischemic colitis changes
with Bisacodyl use
• C/I – GI obstruction, gastric retention,
bowel perforation, toxic colitis and toxic
maegacolon
MoviPrep
• PROS – safe, better tolerated than 4L
solutions (overall volume is 2L prep and
1L clear liquids), effective
• CONS – Taste, may cause malaise,
nausea, abdominal pain and vomiting,
serious AEs may occur as a result of
electrolyte abnormalities, use with caution
in patients with renal dysfunction
SUPREP
• PROS – Well tolerated due to small
volume, effective
• CONS – Taste, may cause discomfort,
abdominal distension, pain, nausea and
vomiting, may cause temporary elevations
in uric acid, caution in renal disease,
expensive with variable insurance
coverage
OSMOPREP – “pills”
• PROS - Well tolerated, effective, better tolerated
than the PEG solutions
• CONS – May cause bloating, abdominal pain,
nausea and vomiting, rare reports of phosphate
nephrotoxicity (black box warning from the
FDA)
• C/I – Renal disease, cirrhosis, CHF, concomitant
use of medications that can affect renal function
such as ACEI, diuretics, elderly are at risk for
complications
MiraLAX Prep
• PEG-3350 solution without added electrolytes –
not balanced
• Not FDA approved
• Pros – Low volume prep (2L), tolerated well
(although study comparing the 4L golytely and
MiraLAX prep showed no difference in
tolerability)*
• Cons – Electrolyte disturbances especially
hyponatremia has been reported, inferior to 4L
PEG solution when used as split dose. **
*Enestvedt BK, et al. Aliment Pharmacol Ther. 2011;33(1):33-40
**Hjelkrem M, et al. Clin Gastroenterol Hepatol. 2011;9(4):326-332.
Comparison of Different Preps
Purgative
Number of Trials
ITT Patients
OR (95% CI)
PEG split HD
PEG split LD
6
1,305
1.89 (1.01-3.46)
PEG split vs NaP split
1
218
0.35 (-0.15-0.85)
PEG split vs PICO
split
1
89
6.32 (1.30-30.81)
PEG split vs OSS split
1
379
1.07 (0.50-2.29)
NaP split vs PICO split 1
372
1.15 (0.49-2.67)
Menard et al, GIE, 2014
Miralax/Gatorade Prep
• Patients like this
• Physicians use it frequently
• Siddiqui et al 2014, 5 trials, 1960-2014
– Adequate prep
– ADR
– Side effects
– Willingness to repeat
0.65 (0.4-0.98)
NS
NS
7.3 (4.9-11.0)
• Multiple case reports of hyponatremia, not
FDA approved
Timing of Prep
• Day before
• Split dose
• Same day prep
Split Dose Prep : Efficacy
Author
Timeframe
No. of Trials
Efficacy/OR
Kilgore 2011
1960-2011
5
3.7 (2.8-4.9)
Enestvedt 2012
1960-2011
9
3.5 (2.5-4.9)
Bucci 2014
1960-2013
29
85% vs 63%
Martel 2015
1980-2014
47
2.5 (1.9-3.4)
Split Dose Prep – Patient
Considerations
• Well accepted
• Increased compliance (94% vs 84%)
• Willingness to repeat (OR 1.8-1.9)
The Split-Dose Difference
Split Dose Prep: ADR
• Martel et al 2015, meta-analysis
• 47 trials
• OR 1.5 (0.7-3.3)
Split Dose Prep is the
standard of care in
2015
Same Day Prep for PM cases
Author
No. of
Patients
Comparison
Adequacy of
Prep
P-value
Church 1998
317
AM vs PM
90% vs 73%
<0.01
Varughesa 2010
136
AM vs PM
4.7 vs 7.1
Ottawa scale
<0.01
Matro 2010
116
AM vs PM/AM 92% vs 94%
0.01*
*non-inferior
Longcroft 2012
227
AM vs PM/AM 98% vs 90%
<0.01
Low Pressure Intra-colonic
water infusion system
Low Pressure Intra-colonic
water infusion system
Prep Tech introduces lubricated, sterile
disposable nozzle into the rectum.
Gentle stream of temperature controlled
gravity-flow water loosens stool and
induces peristalsis for natural evacuation of
the colon.
Patient evacuates bowel and urinates
freely and naturally throughout the
procedure.
Prep is complete when clear water exits
the body and the trained practitioner
determines that patient has completed all
phases of cleansing (usually less than one
hour).
Low Pressure Intra-colonic water infusion
system – Safety Features
• Stringent validated disinfection protocol
• Rectal nozzle is gently arched and ergonomic, with a
diameter of less than 1 cm.
• Water flows through both a sediment and UV filter.
• Temperature of the water is steadily maintained in the
safe range between 37-39° C as set by the operator.
• Water automatically stops flowing to the patient should
the temperature go above 39° C.
• Water pressure is maintained at approximately 1 psi
(well below the 2 psi limit the large intestine can safely
tolerate
Low Pressure Intra-colonic water
infusion system - AG Experience
ADR: AG vs National Average
ADR-Male
National Average
25%
Austin Gastro
39%
ADR-Female
18%
27%
W/D Time
6 minutes
9 minutes
Low Residue Diet and Prep
• Clear liquids versus low residue diet
• Gut activity, stimulated by food
• DDW 2015, abstract, Nguyen et al
– 5 studies, meta-analysis
– OR 3.2 (2.0-5.3)
Adjuncts to Preparation
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Simethicone
Bisacodyl
Lubiprostone
Prokinetics
Lopermide
Probiotics
Olive oil
Patient Education
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Patient must be engaged
Written instructions +/- visual aids - works
Educational booklet – better prep
YouTube videos – increased ADR
Smartphone Apps – not widely used
Conclusions
• Split the dose
– Shoot for 4 hr runway time
• Consider low residue diet
– Non-inferior cleaning
– Increased tolerability
• Patient education
Thank You