Comment Decades ago, to prepare for a colonoscopy, patients first had to cleanse their colon using laxatives such as castor oil or magnesium citrate, sometimes for several days. It was not pleasant. Things improved in 1984 with the introduction of a powder-based 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 Di Palma, professor of internal medicine at the University of South Alabama College of Medicine. Preparing 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, remains perhaps the biggest barrier to screening. So the approval last year of a much less morbid 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 preparation solutions have become available, each with advantages and disadvantages, and others – including those in the form of flavored shakes and food bars – have been tried but not yet approved. Impressive cancer drug trial results have researchers asking: What’s next? The solutions most patients drink clear the colon, but patients have to drink 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, half taken the day before and the rest several 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 candies,” says Louis Korman, a semi-retired DC-area gastroenterologist. “Everyone hears the stories about how horrible the preparation is. Preparation is what everyone remembers and represents a disincentive to get a colonoscopy.” But last year — in what experts believe could end the trepidation that keeps many people from this important test — the Food and Drug Administration approved a pill regimen, Sutab, that studies show works just as well as liquid solutions – without the bad taste. It is a regimen of 24 tablets: 12 pills the day before and 12 the next day, several hours before the procedure. National Task Force Finalizes Recommendation for Earlier Colon Cancer Screening Patients still need to 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 takes away the issue of taste,” says Douglas K. Rex, distinguished professor emeritus of medicine at the Indiana University School of Medicine. “You still have to sit on the toilet, but not having to drink something that tastes awful is a big plus.” Oncologist Arif Kamal, associate professor of medicine at Duke University, agrees. “This is a good option for those for whom taste is an issue,” says Kamal, who is also the American Cancer Society’s patient chief. It also points to simpler alternatives to full colonoscopies for patients at average risk of colon cancer, including home tests for blood and abnormal DNA that indicate the presence of cancer. “The advantages: It’s more convenient to do it at home,” says Kamal. “The Cons: You still have to test 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 them. “Mock” colonoscopies are also available, although patients still need to do the preparation and some “flat” polyps are easier to see on conventional colonoscopies, experts say. Mock colonoscopies are not home procedures, as they involve imaging of the colon and insurance coverage is insufficient. They are only covered in special cases, 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 for colon cancer get screened. This is a change from previous guidelines that recommended screening only for people age 50 and older at normal risk. Excluding skin cancers, colon 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 knowledgeable about colonoscopy screening, according to the Centers for Disease Control and Prevention. Experts believe that avoiding preparation is likely one of the main reasons they are not. Colonoscopy prep isn’t fun, but the benefits of the exam are quantifiable New pills could change that, but they have a downside. Many drug insurance plans won’t cover them, and their projected price can be $120 or more. (It cost a friend of mine in Florida $150 after her insurance plan was denied, and — after mine was also denied — I paid $60 using a discount coupon my doctor received from Sebela Pharmaceuticals.) “For people who won’t get a colonoscopy because of the unpleasant taste preparation, it 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. Medicine. “That’s ridiculous. It shouldn’t be that expensive. It’s just salt [sodium sulfate, magnesium sulfate, potassium chloride]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 hold up against less expensive alternatives. “An insurance company will say, ‘Well, if it’s equivalent, we’ll just cover the cheaper one,’” says Kamal. Many gastroenterologists who are faced with reluctance to prepare the patient consider this to be 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 preparation, it’s not about efficiency. On the patient’s side, it’s tolerance. This is very important for patients.” Many major insurance plans cover the pills, including some under Medicare Part D, says John McGowan, head of gastroenterology research and development at Sebela Pharmaceuticals. Because others don’t, however, it’s probably a good idea to check with your individual plan to determine if the pills are covered. A small cancer drug trial sees tumors disappear in 100 percent of patients For those without insurance or whose plans don’t cover the pills, McGowan suggests checking sutab.com/savings on his company’s website for ways to save. Also, the company 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 a patient cannot complete the liquid preparation properly, the colonoscopy must be repeated, so the additional upfront cost for Sutab would be worth it,” he says. The newer pills should not be confused with earlier tablets, made mostly of sodium phosphate, which the FDA found in 2006 caused severe 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,” Rex says, stressing that patients should still drink the recommended amounts of water to avoid dehydration. “You don’t want to drink something bad, but you have to drink something,” he says. Di Palma, who conducted the Sutab study, says he has tried all the preparations and used them for his own colonoscopies. “I’ve had five colonoscopies and Sutab has been the easiest so far,” she says.
