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A Guide to Colon Preps
Better tasting solutions, meal kits, and a new pill are some of the products that may make the prepping process easier for your patients
Kristin McKee
Publish Date: June 9, 2008   |  Tags:   Gastroenterology
For many patients, prepping for a colonoscopy can be the most uncomfortable aspect of the procedure. Until now, a regimen of fasting and drinking large amounts of unpleasant tasting prepping solution was the only way to prepare. This made it difficult for some patients to complete the entire prep, which could lead to inadequate visualization during the colonoscopy, or, in some cases, a need to reschedule the procedure altogether. But now, manufacturers are developing new products that are gentler on the digestive system and easier to tolerate.

A bowel prep should have three characteristics:

It should be easy for the patient to take. The directions for preparing the prep should be easy to follow, and the prep should also taste tolerably pleasant.

It should be safe. The prep shouldn't significantly change the patient's fluid and electrolyte balance.

It must provide effective results. The goal of the prep is to purge the colon, allowing the gastroenterologist to clearly see the colon lining and detect any abnormalities.

Bowel preps contain one of two active ingredients: Polyethylene glycol (PEG) or a saline laxative, such as sodium phosphate or magnesium citrate. There are several different brands to choose from, including a new sodium phosphate pill. The following is a guide to help you better understand how these products work and introduce you to some new preps on the market.



PEG lavages
PEG preps fall into the category of hyperosmolar laxatives. The active ingredient, polyethylene glycol, is an undigestible, unabsorbable compound that remains in the colon and retains any water that is there, as well as any water that the patient takes with the solution. Patients need to drink about four liters of water with the PEG prep. The water softens the stool and causes diarrhea, which flushes out the bowel. PEG preps are typically the most standard regimen, because they are very effective. However, they often do not taste pleasant, and many patients have a hard time drinking the required 14 to 17 eight-ounce glasses of water.

"At our facility, we give the patient the option to do a modified PEG prep. The patient drinks half the PEG solution and then finishes with magnesium citrate (a saline laxative)," says Robert Fusco, MD, CEO and endoscopist at the Three Rivers Endoscopy Center, Coraopolis, Pa. "We found that most patients could tolerate eight glasses of the PEG solution, but for many people all 16 glasses was hard to take."

PEG solutions on the market include Braintree's Nulytely and Golytely, as well as Colyte from Schwarz Pharma. All of these liquid solutions are diluted in four liters of water; the patient then drink the solution the day before the exam. Golytely is the original PEG lavage, and then Braintree later introduced, Nulytely. It was developed with 52 percent less salt than Golytely; it also contains no sodium sulfate, an added laxative ingredient. Reducing the amount of sodium and sodium sulfate has two advantages. First it decreases the amount of salt and water that the patient absorbs, allowing the patient to maintain a normal electrolyte balance and reducing the chance of dehydration. It also has an improved, less salty taste. Nulytely is available in cherry flavor, lemon-lime, orange or regular, which has a mild mineral-water taste. Nulytely is also the first and only bowel prep that has been tested and proven safe for children.

Colyte combines polyethylene glycol with an electrolyte concentration, which allows virtually no net absorption or excretion of ions or water. Therefore, patients can ingest large volumes of the solution without significant changes in the balance of fluids and electrolytes. Patients should fast for at least three hours prior to taking Colyte. It is available in citrus, berry, lemon lime, cherry, and pineapple as well as in unflavored varieties.

Saline laxatives
Saline laxatives contain non-absorbable ions, such as sodium, magnesium, sulfate, citrate, or in most cases, phosphate; sodium phosphate and magnesium citrate are the most common saline laxatives. These ions remain in the colon and draw water to the bowel, inducing diarrhea and cleansing the colon. If the lost fluid is not replaced with enough water, however, patients can become dehydrated; this is particularly true for older patients. Some doctors to whom we spoke cited this as a reason they prefer to use the PEG preps, but others felt that sodium phosphate preps could be very effective, and because they do not require patients to drink nearly as much liquid as the PEG solutions, they can also be more tolerable for patients.

Fleet Phospho-soda is one popular brand of sodium phosphate. The patient needs to be on a clear liquid diet for two days before the procedure. Then either the morning before or the night before the test, the patient mixes one tablespoon of the Fleet solution with eight ounces of ginger ale or other clear liquid and drinks it. Then the patient repeats this twice again in 20 minutes. The company also suggests drinking three eight-ounce glasses of water with the first dose.

"I like to use the sodium phosphate preps, like Fleet Phospho-soda. We've found this product to be very effective, and we've had a good response from the patients about the taste," says James Leavitt, MD, Medical Director at the Miami Endoscopy Center, Miami, Fla.

New products
About a year ago, the FDA approved a sodium phosphate tablet, InKine Pharmaceutical Company's Visicol Tablets, as an alternative to solutions. Patients begin taking the pills after at least 12 hours of only clear liquids and take two doses of 48 grams approximately twelve hours apart, typically at 6:00 PM the night before the procedure, and at 6:00 AM the next morning. Because each pill is about two grams, the patient must take 20 pills at intervals of three pills every 15 minutes with at least eight ounces of clear liquids with each set of three tablets. The pill works like the sodium phosphate solutions to draw water to the colon, which then purges the bowels.

Some of the doctors we talked to were still skeptical about the tablet. One doctor mentioned that the pills were very large, and patients had found 40 of them difficult to swallow. The pill prep requires that the patients drink seven eight-ounces glasses of water in the evening and then again in the morning, which is almost as much liquid as the PEG prep and more than the sodium phosphate prep. The pill can also leave behind a white residue in the colon from a compound called MCC, one of the binding agents of the pill. Some doctors believe that because of the residue, the pill does not provide as good a prep as the solutions..

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Some physicians with whom we spoke had questions about the safety of the pill. They are not recommended for patients with a number of different medical conditions, including sodium, potassium, calcium, or phosphorus electrolyte disturbances, kidney disease, heart disease, liver disease, and some intestinal diseases, such as acute ulcerative colitis, Crohn's disease, severe constipation, intestinal blockage, or slow intestinal function.

"We haven't had much success with the pills so far," says Dr. Fusco. "But I have heard some talk about reducing the dosage from 40 pills to 28, and I think I lowering the dosage would make it safer for patients."

Dr. Fusco is referring to a recent study that evaluated the efficacy of two lower dosages of the Visicol tablets, 32 and 28 pills. The study found that both the lower dosage preps produced very good preliminary results. In the study, patients took 20 tablets, four at a time, with eight ounces of water, repeating this four more times. The morning of the colonoscopy the patients took either eight tablets with 16 ounces of water or 12 pills with 24 ounces of water. These new regimens not only reduce the amount of sodium phosphate that the patient is taking in, but they also reduce the amount of time it takes to do the prep and the amount of water the patient needs to drink.

The company has also been working to reduce the amount of MCC currently found in the tablets. InKine has developed a new formula with 50 percent less MCC, and the new pill will be 15 percent smaller as well. The new formula has been submitted to the FDA for approval, and the company should know by April of this year if the FDA has approved it.

Another new product is E-Z-EM's NutraPrep meal kit, designed to replace a clear liquid diet prior to examination of the colon. The meal kit contains a full day's worth of shakes, soup, energy bars and chips, all specially prepared to provide essential nutrition and significantly reduce the amount of residue remaining in the colon after digestion. The NutraPrep meal kit was developed to make it easier for patients to comply with their colon prep regimens, and the company believes they will much more satisfying than the traditional liquid diet. NutraPrep can be used in conjunction with a laxative preparation, such as E-Z-Em's LoSo Prep, a magnesium-citrate bowel prep.

When the prep doesn't work
Most of the doctors we talked to agreed that they don't have many problems with patients properly completing the prep. "I think for most patients, once they start the prep regimen, they don't stop because they don't want to have to do it again. It's easier just to finish it," suggests David Rausher, MD, Medical Director at the Atlanta Endoscopy Center, Decatur, Ga.

But in some cases, even when the patient has followed all the directions correctly and has completed the prep process, the colon can still not be completely clean. In these cases there are three things that doctors can do:

Reschedule the appointment. If the colon is unmanageable, it may be best to reschedule the appointment and give the patients an increased dose of the prep for the next time.

Proceed with the colonoscopy. Once patients have gone through the prep process once, they are not going to want to do it again anytime soon. A few of the doctors we talked to said that if they can perform the procedure, even if it is not optimal, they try to continue with it. If this is the case, doctors often bring the patient back sooner for a subsequent colonoscopy, for example, in two or three years instead of four.

Give the patient an enema, and then proceed with the colonoscopy. "If we suspect that the colon is not completely cleaned out. We have the nurses give the patient a tap-water enema," says Dr. Rausher. "It's not a job that our nurses enjoy, but none of us want to that have the patient go through the prep process again. So we try to avoid that if it's possible."

Braintree Labs
(800) 874-6756
www.braintreelabs.com.

E-Z-EM
(800) 544-4624
www.ezem.com.

InKine
(215) 283-6850
www.inkine.com.

Schwarz Pharma
(800) 558-5114
www.schwarzusa.com.