Colonoscopy:Pre-procedure Considerations

July, 2013

Paul C. Schroy III, MD, MPH

David Lichtenstein MD, and

Brian Jacobson MD, MPH

Boston Medical Center

Boston MA

Bowel Preparation

Quality of Bowel Prep:Why Does It Matter?

• Bowel preparation is inadequate in up to 25% of patients undergoing colonoscopy

• Consequences of inadequate prep:- Increased difficulty of colonoscopy- Prolonged procedure time- Reduced cecal intubation rates- Repeat procedures and shorter surveillance intervals- Reduced Adenoma Detection Rates- Exposure to higher malpractice risk

Nelson DB, et al. Gastrointest Endosc 2002;55:307-14Nelson DB, et al. Gastrointest Endosc 2002;55:307-14Rex DK, et al. Am J Gastroenterol 2002;97:1696-700Rex DK, et al. Am J Gastroenterol 2002;97:1696-700Froehlich F, et al. Gastrointest Endosc 2005;61:378-84Froehlich F, et al. Gastrointest Endosc 2005;61:378-84Harewood GC et al. Gastrointest Endosc 2003;58:76-9Harewood GC et al. Gastrointest Endosc 2003;58:76-9 3

http://phpa.dhmh.maryland.gov July 2013

Prevention and Health Promotion AdministrationCenter for Cancer Prevention and ControlCigarette Restitution Fund Program

Negative Consequences of Negative Consequences of Inadequate ColonoscopyInadequate Colonoscopy

Repeat procedures mean:Repeat procedures mean:•Additional expenditure by client, insurance, government, and/or Additional expenditure by client, insurance, government, and/or program program •Time lost by client from work and related consequences, for example, Time lost by client from work and related consequences, for example, lost wageslost wages•Additional risk of possible negative side effects from: Additional risk of possible negative side effects from:

– repeated bowel preparation (electrolyte imbalance, etc.); or repeated bowel preparation (electrolyte imbalance, etc.); or

– repeated procedure (bowel perforation, complications from anesthesia, etc.)repeated procedure (bowel perforation, complications from anesthesia, etc.)

Types of Bowel Preps

• Isosmotic full volume

• Isosmotic low volume

• Hyper Osmotic

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Isosmotic Full Volume Preps

PreparationActive

IngredientRecommended Use

Colyte (SchwarzPharm)

GoLYTELY (Braintree Lab)

NuLYTELY(Braintree Lab)

TriLyte(SchwarzPharm)

PEG-ELS

PEG-ELS

PEG (sulfate free)

PEG (sulfate free)

• 240 mL (8 oz) every 10 min beginning at 5 to 6 pm evening before colonoscopy (total, 4 L);

or

• Split dosing as (3L pm/1L am or 2L pm/2L am) with second dose 3-6 h before procedure)

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Isosmotic Low Volume Preps

PreparationActive

IngredientRecommended Use

HalfLytely

(Braintree Labs)PEG and bisacodyl

• 2 bisacodyl delayed-release tablets at noon the day before colonoscopy; • 240 mL (8 oz) PEG every 10 min at 5 to 6 PM (total, 1 L); • Repeat 240 mL (8 oz) every 10 min beginning 3 to 4 h before colon (1 L)

Miralax

(Schering-Plough) PEG and bisacodyl

• Mix in Gatorade• Instructions same as for halfLytely

MoviPrep (Salix)

PEG and ascorbic acid

• 240 mL ( 8 oz) every 15 min at 5 to 6 PM evening before colonoscopy (total, 1 L), followed by at least 16 oz of fluid; • 240 mL (8 oz) every 15 min at least 3 to 4 h before colon (1 L) followed by 16 oz fluid

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Hyper Osmotic Preps

PreparationActive

IngredientRecommended Use

OsmoPrep * (Salix)

NaP tablets

• 20 tablets (4 every 15 min) at 5 to 6 PM the evening before colonoscopy; • Repeat with 12 tablets 10 to 12 h later (at least 3 h before colonoscopy)

Suprep (Braintree Labs)

Na Sulfate• 6 oz bottle diluted with 16 oz of water followed by 32 oz water over the next hour ; take the evening before and repeat the morning of colonoscopy

Prepopik (Ferring)

Na Picosulfate/

Mg citrate

• Step 1: dissolve 1 packet in 5 oz. og liquid and consume followed by 5, 8 oz glasses of clear liquids at 4 to 6 PM;• Step 2: repeat step 1 followed by 3, 8 oz glasses of clear liquids (later that evening, or 4 to 6 hr before procedure)

* Black box warning8

Split Dose Preps

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Split Dose Preps• Part (usually ½) of laxative taken the evening prior and remainder a.m.

of procedure

• Colonoscopy should be performed within 8 hours of the last dosing

• More effective and better tolerated than full dose p.m.

• Demonstrated superiority

– PEG

• High volume (3L/1L or 2L/2L)

• Low volume (1L/1L)

– Osmotics-NaP, Mg citrate, Na sulfate

• Recommended in ACG guidelines for CRC screening

Rex DK, et al. Am J Gastroenterol. 2009;104:739-750. 10

PEG (4L) vs. PEG 3350 + Ascorbate (2L+1L H2O)P

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Marmo R et al. Gastrointest Endosc 2010;72:313-2011

Kilgore TW et al. Gastrointest Endosc. 2011;73:1240-45

PEG Split-Dosing: Meta-analysis

Split-dose PEG is superior to full-dose PEG with respect to…

• Satisfactory colon cleansing (OR 3.70; 95% CI, 2.79-4.91;p<0.01)

• Likelihood of discontinuing prep (OR 0.53; 95% CI, 0.28-0.98;p=0.04)

• Willingness to repeat same prep (OR 1.76; 95% CI,1.06-2.91;p=0.03)

• Side effects, e.g., nausea (OR 0.55; 95% CI, 0.38-0.79;p<0.01)

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Timing

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Bowel Preps for Afternoon Colonoscopy:Bowel Preps for Afternoon Colonoscopy:Timing is EverythingTiming is Everything

• Patient driven factors (AM better tolerated)– Less interference with day prior work

– Lower incidence of prep related symptoms

– Superior sleep quality

– Dietary restriction?

• Prep Options– PM only-No!

– Split Dosing (PM/AM) or AM only superior• Start: within 8 hrs. of colonoscopy

• End: >2 hrs prior to colonoscopy

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“Good” (Ottawa <2) prep

% p

atie

nts

Varughese S et al. Am J Gastroenterol 2010;105:2368-74

Morning Only Prep for PM Colonoscopy

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PM/AM Split-Dosing: PM/AM Split-Dosing: What are the Barriers? What are the Barriers?

• Patient acceptance of sleep disturbance?Patient acceptance of sleep disturbance?– 85% surveyed willing to get up at night to take 285% surveyed willing to get up at night to take 2ndnd dose dose

– 78% complied78% complied

• Bowel activity in transit to procedure Bowel activity in transit to procedure ““pit stoppit stop””??– No difference taken PM or SD PM/AM (5-15%)No difference taken PM or SD PM/AM (5-15%)

• Non-compliance with preprocedure fasting guidelines (increased risk of Non-compliance with preprocedure fasting guidelines (increased risk of aspiration)?aspiration)?– ASA guideline: clears OK 2 hours prior

Unger RZ, Rex DK, et al. Dig Dis Sci 2010;55:2030-34Unger RZ, Rex DK, et al. Dig Dis Sci 2010;55:2030-34

American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting and American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting and Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2011;114:495-Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2011;114:495-511511

Parra-Blanco A et al. World J Gastroenterol 2006;12:6161-6Parra-Blanco A et al. World J Gastroenterol 2006;12:6161-6Khan MA et al. Gastrointest Endosc 2008;67(suppl):AB246Khan MA et al. Gastrointest Endosc 2008;67(suppl):AB246

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A.M. versus P.M. Procedures

• Adenoma Detection Rate (ADR) has been reported higher for morning compared to afternoon colonoscopy– ADR 29.3% in morning vs. 25.3% in afternoon– By multivariate analysis OR 1.2 (95% CI 1.06-1.4,p=0.008)

• Afternoon colonoscopies have higher failure rates than morning procedures– Incomplete procedure (6.5% vs. 4.1%, OR 1.64, CI 1.11-2.44;p=0.01)

– Inadequate prep (15.4% AM vs. 19.7% PM, OR 1.35, CI 1.08-1.69;p=0.01)

Sanaka MR et al. Am J Gastroenterol 2006;101:2726-30; Sanaka MR et al. Am J Gastroenterol 2009;104:1659-64 17

Fatigue? Confounders?

• Queue position (i.e. absolute numbers of cases prior) inversely associated with ADR

• When accounting for full-day vs. half-day blocks, full-day blocks have lower ADRs

• Adjustment for confounders (e.g. endoscopist, withdrawal time) may account for these observations

• Regardless, this is measurable and modifiable

Lee A, et al. Am J Gastroenterol 2011;106:1457-65;Gurudu SR, et al. Am J Gastroenterol 2011;106:1466-71; Do A, et al. DDW 2012 18

Diet

Is Dietary Restriction Necessary?Meta-analysis of Split-dosing

Kilgore TW et al. Gastrointest Endosc. 2011;73:1240-45

Take Home Message: Optimal preprocedure diet with split-dose

regimen not well-defined. Most would consider a clear liquid diet as

standard of care.20

High vs. Low Residue Diet

• Prospective cohort study in Taiwan asked about diet 2 days prior to colonoscopy

• Low residue = well-cooked meats, eggs, white bread, white rice, pasta, no skins

• Higher-residue diets were associated with worse bowel preparations

• Only 44% adhered to low-residue diet

Wu et al. Dis Colon Rectum 2011;54:107-1221

How To Predict a Bad Prep: Patient Characteristics

• Inpatient vs. outpatient (Froehlich et al)• Elderly (Froehlich et al)• Obesity• Lower education• History of constipation• Use of antidepressants• Noncompliance

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How To Deal with a Bad Prep

• No studies to provide evidence-based guidance• Navigator and patient education• Extend period of diet modification from 24 to 48h• Increase total volume of PEG ( 2 to 4 L, or 4 to 6L)• Split dosing• Adequate hydration• Add Magnesium citrate• Add oral bisacodyl or senna

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Bowel Prep is a Quality Indicator

• High-quality practice should monitor prep quality as a quality indicator

• Target: < 10% preps inadequate to detect lesions > 5 mm.

• Consider practice level interventions if > 10% preps inadequate (e.g., patient education, use of split-dose regimens)

Lieberman et al. Gastrointest Endoscopy 2007;65:757-6624

Medications

Preprocedure: Anticoagulation

Risk of Thromboembolism

High Low

Anticoagulation(e.g., warfarin, dabigratran [Pradaxa])

Discontinue warfarin 5 days or dabigratran 1-2 days prior;

Consider bridging therapy with heparin or LMWH

Discontinue warfarin 5 days or dabigatran 1-2 days prior;

Re-institute warfarin after procedure

Antiplatelet therapy(e.g., ticlodipine, clopidrogel)

Consider discontinuing for 7-10 days prior

Discontinue 7-10 days prior

Aspirin/NSAIDs ContinueConsider discontinuing 5-7 days prior

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Preprocedure: Diabetic medications

Oral Hypoglycemic

AgentsInsulin

Day prior to procedure ? Discontinue

• Take ½ AM dose of isophane insulin (NPH),

Lente, Novolin 70/30 or insulin Glargine

• No regular or insulin lispro

Day of procedure Discontinue

• Take ½ AM dose of isophane insulin (NPH),

Lente, Novolin 70/30 or insulin Glargine

Sifri R, et al. Ca Cancer J Clin 2010;60:40-49.27

Preprocedure: Antibiotic prophylaxis

• Colonoscopy ± polypectomy = low risk procedure

• Risk of bacteremia < routine daily activities

• Revised AHA guideline (Wilson W, et al. Circulation 2007:116:1736-54).

“Antibiotic prophylaxis to solely prevent infective endocarditis is not

recommended for GU or GI procedures”

• Not recommended for synthetic vascular grafts or orthopedic prostheses. (ASGE. Gastrointest Endosc 2008:67:791-8)

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Preprocedure: Miscellaneous Medications

Iron Discontinue 7-10 days prior

Opiod analgesicsContinue

Increase fluid consumption for 1-2 days prior

Sifri R, et al. Ca Cancer J Clin 2010;60:40-49.

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Preprocedure: Cardiac Devices

• Determine the type of cardiac device, indication for the device, the patient’s underlying cardiac rhythm, and degree of pacemaker-dependence before endoscopy

• Use continuous electrocardiographic rhythm monitoring in addition to pulse oximetry during the procedure.

• Most patients with cardiac pacemakers may undergo routine uses of electrocautery (eg, polypectomy, hemostasis) with no alterations in management.

• For patients who are pacemaker dependent and in whom prolonged electrocautery is anticipated consider reprogramming the pacemaker to an asynchronous mode via application of a magnet over the pulse generator during the use of electrocautery.

• For patients with an implantable cardioverter-defibrillators (ICD) in whom the use of any electrocautery may be anticipated, consultation with a cardiologist or a heart-rhythm specialist is recommended. Deactivation of the ICD function by qualified personnel should be considered.

GIE 2007;65;561-8 30