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Decades ago, to prepare for a colonoscopy, patients first had to cleanse their colons with 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 nasty, but “turned 3 1/2 days of torture into 3 1/2 hours of torture,” says gastroenterologist Jack Di Palma, 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 get a camera look inside the organ, remains perhaps the biggest impediment to screening. So the approval last year of a much less disgusting preparation option for patients was welcome news.
Colon cleansing beforehand is essential to identify and remove polyps, often a precursor to cancer, during the procedure. Over the years, several next-generation preparation solutions have become available, each with advantages and disadvantages, and others, including those in the form of flavored smoothies and food bars, have been tried but not yet have been approved.
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The solutions that most patients drink clear the colon, but patients have to ingest copious amounts (four liters or a little over a gallon) and the taste is still pretty terrible.
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 candy,” says Louis Korman, a semi-retired gastroenterologist in the DC area. “Everyone hears the stories about how horrible the prep is. The prep is what everyone remembers and is a disincentive to get a colonoscopy.”
But last year, in what experts believe could end many people’s fear of this important screening, the Food and Drug Administration approved a pill regimen, Sutab, that studies show works just as well better than liquid solutions, without the vile taste. . It is a 24-pill regimen: 12 pills the day before and 12 the next day, several hours before the procedure.
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Patients still need to drink plenty of water, a total of 48 ounces on the first day and another 48 ounces the next day. But at least plain water is tasteless.
“What’s great 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 having to drink something that tastes awful is a huge 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 director. It also points to simpler alternatives to full-blown colonoscopies for patients at average risk of colon cancer, including at-home screening tests for blood and altered DNA that suggest 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 an interval of seven to 10 years for colonoscopies. Most insurance plans, including Medicare, cover them.
“Virtual” colonoscopies are also available, although patients still have to undergo preparation, and certain “flat” polyps are more easily seen on conventional colonoscopies, experts say. Virtual colonoscopies are not 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 age 45 and older at average risk of colon cancer undergo screening. This is a change from previous guidelines that recommended screening only for those age 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 projects about 106,180 new cases of colon cancer this year and 44,850 cases of rectal cancer. About 7 in 10 American adults ages 50 to 75 are up to date on colonoscopy screening, according to the Centers for Disease Control and Prevention. Experts believe that the avoidance of preparation is probably one of the main reasons why the rest are not.
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New pills could change that, but they have a downside.
Many insurance drug plans do not cover them, and their out-of-pocket cost can be $120 or more. (It cost a friend of mine in Florida $150 after his insurance plan was denied, and after mine was also denied, I paid $60 with a discount coupon my doctor got from Sebela Pharmaceuticals. )
“For people who won’t get a colonoscopy because of the unpleasant tasting 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 Francisco. at the School of San Diego. 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 shown to be an improvement over less expensive 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 an afterthought. “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 the preparation, the issue isn’t efficacy. From the patient’s perspective, it’s tolerability. That’s really important to patients.”
Several major insurance plans cover the pills, including some under Medicare Part D, says John McGowan, head of gastroenterology research and development at Sebela Pharmaceuticals.
Since others don’t, it’s probably a good idea to check with your own individual plan to determine if the pills are covered.
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For those without insurance or whose plans don’t cover the pills, McGowan suggests checking out sutab.com/savings on her company’s website for ways to save. In addition, the company offers 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, a colonoscopy should be repeated, in which case the additional out-of-pocket costs for Sutab would be worth it,” he says.
The newer pills should not be confused with the older pills, made mostly of sodium phosphate, which the FDA found in 2006 caused serious kidney damage in some patients. Although still on the market, the old pills are rarely used today, experts say.
“The newer ones have sodium sulfate in them and they’re safe,” says Rex, stressing that patients should still drink the recommended amounts of water to avoid dehydration. “You don’t want to drink stuff that tastes bad, but you have to drink something,” he says.
Di Palma, who did the Sutab study, says he has tried all the preparations and used them for his own colonoscopies.
“I’ve had five colonoscopies, and Sutab was the easiest so far,” she says.