Understanding Colonoscopies: Importance & Preparation

The Colonoscopy: Why is it necessary and how to prep By: Jennifer Vlasic Ohio State University PharmD Candidate June Rotation - Meijer Pharmacy

Objectives Review what a colonoscopy is and why it is important Discuss which patient populations a colonoscopy is recommended for Discuss why prepping is necessary Describe the pharmacological options for preparing for the procedure

What is a Colonoscopy? A procedure done as a preventative measure to detect changes/abnormalities in the large intestine and rectum.2 https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/11/15/17/44/ca00083_- ds00035_-ds00669_-ds00705_-ds00824_-ds01195_-my00621_im04054_hdg7_colonoscopythu_jpg.jpg http://eugenegi.com/assets/uploads/The_Colonoscopy.jpg

A colonoscopy is the best way to screen for colon cancer, which is the third leading cause of death in the U.S.. Why is it important and who should get one? During the procedure, doctors can find and cut out abnormalities such as polyps as well as biopsy concerning areas2 The United States Preventative Services Task Force recommends offering a colonoscopy starting at age 45. There may be more strict recommendations for those populations at higher risk including: Family history of colon caner or polyps, African Americans, and having Chron s, IBD, or UC.2

The Prep Prepping for the procedure is necessary to empty and allow for clear visualization of the interior layer of the colon2 Begin eating a low fiber diet 2-3 day before, then clear liquids only the day before until after the procedure2 Avoid any red, purple, or blue liquids 2 days before2 Split-dose ( the night before and the morning of) instructions are preferred especially for morning procedures Oral bowel preps are contraindicated in those with: ileus Gastric retention bowel obstruction severe/infectious colitis https://www.thegeriatricdietitian.com/wp-content/uploads/2021/05/Low-Fiber-Foods.png

Polyethylene Glycol (PEG) 3350 Brand names include: Colyte, Gavilyte, GoLYTELY, Moviprep, NuLYTELY, Plenvu, and TriLyte Isosmotic Formulation minimizes fluid exchange across the colonic membrane Administration: Drink 4L total liquid, usually split into 2 L evening before and 2 L morning of procedure at prescriber s discretion1 The low volume formulations (Moviprep, Plenvu, Gavilyte-H) require the patient to drink a total of 2 L of fluid These formulations are sometimes given with Bisacodyl to ensure clean out https://www.grxstatic.com/d4fuqqd5l3dbz/products/Package_23516.JPG

Suprep Sodium sulfate potassium sulfate magnesium sulfate Hyperosmotic Formulation pulls large amounts of water into the colon1 Administration: Drink 6 oz of Suprep liquid diluted with 10 oz of water for a total of 16 oz the night before and the morning of6 Follow up with 32 oz of water within 1 hour after6 Carries a higher chance for electrolyte disturbances and dehydration although it is rare6 Should not be combined with other laxatives1 https://suprepkit.com/img/content/how_to_title.jpg Cost: ~$120 ; but can be cheaper with manufacturer discount card

Prepopik & Clenpiq Sodium picosulfate magnesium oxide citric acid Hyperosmotic formulation and stimulant laxative (sodium picosulfate) Administration: mix 1 packet with 5 oz of water and drink between 5 and 9 pm the night before, follow with 5 - 8 oz drinks before bed4 Repeat in the morning at least 5 hours before procedure and follow with at least 3 8 oz drinks4 Found to be better tolerated and had better colon cleansing with split-dosing compared to PEG1 Should not be used in patients with heart failure, renal insufficiency, end-stage liver disease, or electrolyte abnormalities4 Cost: $150 https://www.bad-drug.net/wp-content/uploads/2012/09/Prepopik.jpg

OsmoPrep Sodium Phosphate tablets Hyperosmotic formulation Administration: Take 4 tablets by mouth with 8 oz of water every 15 minutes for a total of 20 tablets the night before3 Day of: 3-5 hours before procedure, take 4 tablets with 8 oz of water every 15 minutes for total of 12 tablets3 Not approved for patients with heart failure, renal insufficiency (CrCl < 60 mL/min), those with increased risk for electrolyte disturbances, those taking ACEis, ARBs, or NSAIDs3 Not as benign as other preps due to potential renal damage Cost: $250 https://i2.wp.com/bowelprepguide.com/wp- content/uploads/2017/10/osmoprep.jpg?resize=500%2C483&ssl=1

Sutab Sodium sulfate magnesium sulfate potassium chloride Hyperosmotic formulation Administration: Night before - Take 1 tablet with a sip of water for a total of 12 tablets and 16 oz of water over 15 20 minutes 1 hour after last tablet is taken, drink another 16 oz of water over 30 minutes repeat once more with another 16 oz of water7 Morning of repeat and finish entire series listed above at least 2 hours before procedure7 Use with caution in patients with seizures, renal impairment, and cardiac arrythmias7 Cost: $140 https://mma.prnewswire.com/media/1394415/SUTAB_App roved_FinalHR_Group_New_Cup.jpg?p=publish

Supportive Care: tips for a smooth ride Simethicone is very important to take both before and after to reduce the amount of gas bubbles that occur Chilling the solution can improve taste If feeling sick, slow the down the intake of prep https://img.makeup alley.com/9/1/8/8/2 622737.JPG https://www.meijer.com/conte nt/dam/meijer/product/0071/92 /8336/00/0071928336002_1_A1C 1_0600.png Administer other medications at least 1 hour prior to each dose of prep Administer tetracycline and fluoroquinolone antibiotics, iron, digoxin, chlorpromazine, and penicillamine at least 2 hours before and not less than 6 hours after Stay hydrated by drinking lots of water! https://images-na.ssl-images- amazon.com/images/I/81ZlDuJDubL._AC_SL1500_.jpg

References 1. A-Rahim YI, Falchuk M. Bowel Preparations before colonoscopy in adults. FDA-Approved Preparations. Up To Date. https://www-uptodate-com.proxy.lib.ohio-state.edu/contents/bowel-preparation-before- colonoscopy-in- adults?search=colonoscopy%20preparation&source=search_result&selectedTitle=2~135&usage_type =default&display_rank=1#H2028906320. May 2021. Jun 28, 2021. 2. Colonoscopy. Mayo Clinic. https://www.mayoclinic.org/testsprocedures/colonoscopy/about/pac- 20393569. Accessed June 28, 2021. 3. Osmoprep [package insert]. Morrisville, NC; Salix Pharmaceuticals; Revised March 2009. 4. Prepopik [package insert]. Parsippany, NJ; Ferring Pharmaceuticals; July 2012 5. Rex DK, Katz PO, Bertiger G, et al. Split-dose administration of a dual-action, low-volume bowel cleanser for colonoscopy: the SEE CLEAR I study. Gastrointest Endosc 2013; 78:132. 6. Suprep [package insert]. Braintree, MA; Braintree Laboratories; Revised August, 2020. 7. Sutab [package insert]. Hollbrook, MA; Braintree Laboratories; November 2020.