Which bowel prep is best to use prior to colonoscopy? This is a fairly common question from our endoscopy centers and as usual there is no one-size-fits-all answer. What are the available options? How do you decide which patient gets what prep? How are drug shortages affecting the decision process? In this post we will discuss the available options and how to pick the right bowel prep for patients undergoing a colonoscopy.

It’s not a secret that patients dread getting a colonoscopy to screen for colon cancer. It’s also no surprise that no one enjoys the bowel preparation that precedes it. In fact, for most patients, the biggest fear usually includes drinking the “awful-tasting” liquid and then spending “all day and night” in the bathroom. Some also fear getting “sick” from the preparation. In reality, bowel preps have changed and become much easier in recent years. We now have better tasting liquids and lower-dose regimens available to get the job done. The newer preps are often lower in volume and divided into two doses, the first dose is taken the night before and the second dose six hours prior to the procedure.

What is the best bowel preparation product?

Provided the patient uses it properly and can tolerate it, any of the available options will be effective. Studies have shown that split-dose regimens are easier to tolerate, and they clean the colon better. The choice often comes down to the prescriber’s preference, any comorbidities the patient may have, and of course, cost.

There are many options available today, but the gold standard is still polyethylene glycol (PEG) with electrolytes (there are various preparations available). These are generally preferred over the sodium phosphate containing products, especially for patients with heart failure, kidney impairment, or advanced liver disease. Of the large volume preps, taste is generally better with NuLytely and Trilyte, which are sulfate free. GoLytely is not sulfate free and tends to have a saltier taste. Lower volume PEG preparations include MoviPrep and Plenvu, but these require the patient to take additional clear liquids and are much more expensive. An equally effective alternative for prescribers to consider is using a generic version of one of the large volume preparations, having the patient take only half and adding over the counter oral bisacodyl.

What about non-PEG options? Clenpiq, Suprep and Sutab are low-volume, non-PEG options, but should be used with caution in patients with heart failure, kidney impairment, or advanced liver disease. Osmoprep is a sodium phosphate based oral product, but this one should be avoided in patients with heart failure, kidney impairment, or advanced liver disease. It also has a FDA Boxed Warning for acute phosphate nephropathy.

Finally, there is magnesium citrate, which is rarely used alone and generally not recommended due to lack of efficacy data and the risk of magnesium toxicity. If considering this option, prescribers need to take several things into consideration including kidney function, the risk of electrolyte imbalances and the need for adequate hydration.

How to improve prep quality while also improving the experience for the patient:

1. Recommend the patient make time in their schedule to properly prepare without additional pressure. Consider scheduling a day that does not include other activities or distractions.
2. Recommend cutting back on fiber a few days before the scheduled appointment.
3. Recommend a clear liquid diet the day before the exam.
4. Recommend a split-dose approach. Generally, this requires taking half the dose the night before and the other dose about four to six hours before the colonoscopy.
5. Suggest ways to make the solutions more palatable: Chilling the solution helps to improve taste. Also, recommend the use of a straw, rather than a glass to drink the solution. Using a straw will help bypass the taste buds and will go a long way to avoiding any unpleasant tastes. Finally, suggest patients suck on hard candy after drinking the preparation liquid.

As usual, we recommend using your professional judgment and consulting other necessary or appropriate sources prior to making clinical judgments. Each clinician will have a preferred approach and will need to take into consideration patient specific factors. Consult an expert with additional questions. We routinely guide our clients through these decisions and if we can help in any way, please don’t hesitate to contact us.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.