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Decades ago, to prepare for a colonoscopy, patients first had to cleanse their colon with laxatives such as castor oil or magnesium citrate, sometimes for several days. It wasn’t pleasant.
Things improved in 1984 with the introduction of a powder solution that patients could drink the day before a colonoscopy. The colon cleansing drink, called GoLYTELY, tastes bad, but “turned 3½ days of torture into 3½ hours of torture,” says gastroenterologist Jack DiPalma, professor of internal medicine at the University of South Alabama College of Medicine.
Preparation for a colonoscopy, a procedure in which a doctor passes a flexible tube through the colon to view the inside of the organ with a camera eye, remains perhaps the biggest obstacle to screening. So the approval last year of a much less disgusting preparation option for patients was welcome news.
Colon cleansing beforehand is critical to identifying and removing polyps, often a precursor to cancer, during the procedure. Over the years, several newer-generation off-the-shelf solutions have emerged, 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 most patients drink cleanse the colon, but patients have to ingest copious amounts — four liters, or a little more than a gallon — and the taste is still pretty awful.
Doctors now recommend that patients split the dose in two, taking half the day before and the rest a few hours before the procedure.
“We tell people to chill it, drink it through a straw, hold their nose, chew gum in between, or suck on hard candy,” says Louis Korman, a semi-retired DC gastroenterologist. “Everyone hears the stories about how terrible the preparation is. Preparation is what everyone remembers, and it’s a deterrent to getting a colonoscopy.
But last year — in what experts say could end the fear that keeps many people from this important screening — the Food and Drug Administration approved a pill regimen, Sutab, that studies show works just as well. as much as the liquid solutions – without the disgusting taste. This is a schedule of 24 pills: 12 pills the day before and 12 the next day, a few hours before the procedure.
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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 great thing about Sutab is that it eliminates the taste problem,” says Douglas K. Rex, distinguished professor emeritus of medicine at Indiana University School of Medicine. “You’ll still have to sit on the toilet, but not drinking something that tastes awful is a big plus.”
Oncologist Arif Kamal, associate professor of medicine at Duke University, agrees. “It’s a good option for those for whom taste is an issue,” says Kamal, who is also the American Cancer Society’s chief patient officer. It also points to simpler alternatives to full colonoscopies for patients who are at average risk of colon cancer, including at-home screening tests for blood and altered DNA that suggest the presence of cancer.
“The pros: It’s more convenient to do it at home,” says Kamal. “The downsides: You still have to sample your own stool. Also, the frequency is more frequent — every two to three years,” compared to a seven- to 10-year interval for colonoscopies. Most insurance plans, including Medicare, cover these.
“Virtual” colonoscopies are also available, although patients still need to do the preparation, and some “flat” polyps are easier to see with conventional colonoscopies, experts say. Virtual colonoscopies are not at-home procedures because they involve imaging of the colon, and insurance coverage is spotty. They are only covered in special circumstances, such as when a conventional colonoscopy cannot be completed for some reason.
The American Cancer Society now recommends that people 45 and older at average risk of colon cancer get screened. This is a change from previous guidelines that recommended screening only for those 50 and older at normal risk.
Excluding skin cancers, colorectal cancer is the third most common cancer in the United States, according to the American Cancer Society, which predicts about 106,180 new cases of colon cancer this year and 44,850 cases of rectal cancer. About 7 in 10 U.S. adults ages 50 to 75 are up-to-date for a colonoscopy, according to the Centers for Disease Control and Prevention. Experts believe that avoiding preparation is probably one of the main reasons why others are not.
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New pills can change that, but they have a downside.
Many drug insurance plans won’t cover them, and their out-of-pocket cost can be $120 or more. (It cost a friend of mine in Florida $150 after her insurance plan declined, and—after mine declined—I paid $60 using a discount coupon my doctor got from Sebela Pharmaceuticals.)
“For people who won’t get a colonoscopy because of the bad taste of the preparation, this could be a game changer — if they can afford it,” says gastroenterologist Clement Boland, emeritus professor of medicine at the University of California, San Diego School of Medicine. “That’s ridiculous. It shouldn’t be that expensive. It’s just salt [sodium sulfate, magnesium sulfate, potassium chloride]and not something fancy like monoclonal antibodies.
Experts say the most likely reason for insurance denials is that the pills are new and haven’t yet been proven to be an improvement over cheaper alternatives. “An insurance company will say, ‘Well, if it’s equivalent, we’ll just cover the cheaper one,'” says Kamal.
Many gastroenterologists dealing with patient reluctance to prepare consider this backward thinking. “Insurance companies are trying very hard to force people to use the generic products, which are not very well tolerated,” says Rex. “When it comes to training, efficiency is not the issue. From the patient’s point of view, this is tolerability. This is really important for patients.
Several major insurance plans cover the pills, including some in Medicare Part D, says John McGowan, head of gastroenterology research and development at Sebela Pharmaceuticals.
However, since others do not, it is probably a good idea to check with your own individual plan to determine if the pills are covered.
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For those who don’t have insurance or whose plans don’t cover the pills, McGowan suggests checking out sutab.com/savings on his company’s website for ways to save. The company also provides free samples and discount coupons to doctors for patients who can’t afford the pills, he says.
He acknowledges that cost can be a barrier for some patients. However, “in the event that the patient cannot properly complete the liquid preparation, the colonoscopy should be repeated, in which case the additional upfront out-of-pocket cost for Sutab would be worthwhile,” he says.
The newest pills should not be confused with the earlier tablets, made mostly of sodium phosphate, which the FDA found in 2006 caused serious kidney damage in some patients. While still on the market, the old pills are rarely used today, experts say.
“The newer ones have sodium sulfate and are safe,” says Rex, stressing that patients should still drink the recommended amounts of water to avoid dehydration. “You don’t want to drink things that taste bad, but you have to drink something,” he says.
Di Palma, who conducted the Sutab study, says he tried all the preparations and used them for his own colonoscopies.
“I’ve had five colonoscopies and Sutab was the easiest so far,” he says.
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