Preparing for a colonoscopy, a procedure in which a doctor slides a flexible tube through the colon to get a camera look inside the organ, remains perhaps the biggest impediment to detection. So the approval last year of a much less disgusting preparation option for patients was good news.
Cleaning the colon beforehand is essential to identify and remove polyps, often precursors to cancer, during the procedure. Over the years, various next generation preparation solutions are available, each with advantages and disadvantages, and others, including in the form of flavored shakes and food bars — have been tested but not yet approved.
The solutions most patients drink cleanse 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, with half taken the day before and the rest several hours before the procedure.
“We tell people to chill it, sip it through a straw, hold their nose, chew gum in the middle, or suck on hard candy,” says Louis Korman, a semi-retired DC-area gastroenterologist. “Everyone hears the stories about how horrible the preparation is. The preparation is what everyone remembers and it represents a disincentive to get a colonoscopy.”
But last year, in what experts believe could end the fear that keeps many people from getting this important test, the Food and Drug Administration approved a regimen of pills, Sutab, that studies show works as well as 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.
Patients should still drink plenty of water, a total of 48 ounces the first day and another 48 ounces the next day. But at least pure water is tasteless.
“The great thing about Sutab is that it takes away the taste problem,” says Douglas K. Rex, distinguished professor of medicine emeritus at Indiana University School of Medicine. “You’re still going to have to sit on the toilet, but not having to drink something that tastes horrible is a big plus.”
Oncologist Arif Kamal, an 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 chief patient officer at the American Cancer Society. He also points to simpler alternatives to full colonoscopies for patients who are at average risk of colon cancer, including home screening tests for blood and altered DNA suggestive of cancer.
“The pros: It’s more convenient to do it at home,” says Kamal. “The cons: he has yet to taste his own fecal matter. In addition, the frequency is more frequent, every two or three years”, compared to an interval of seven to ten years for colonoscopies. Most insurance plans, including Medicare, cover them.
“Virtual” colonoscopies are also available, though patients still must do the prep, and certain “flat” polyps are more easily seen on conventional colonoscopies, experts say. Virtual colonoscopies are not home procedures as they involve imaging the colon and insurance coverage is patchy. They are covered only in special circumstances, such as when a conventional colonoscopy cannot be completed for any reason.
The American Cancer Society now recommends that people age 45 and older with an average risk for colon cancer get screened. This is a change from previous guidelines that recommended screening only for people over age 50 with normal risk.
Excluding skin cancers, colorectal cancer it is the third most common cancer in the United States, according to the American Cancer Society, which projects an estimated 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 current on colonoscopy exam, according to the Centers for Disease Control and Prevention. Experts believe that avoiding preparation is probably one of the main reasons that the rest do not do it.
The new pills could change that, but they have a downside.
Many insurance drug plans won’t cover them, and your out-of-pocket 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 got from Sebela Pharmaceuticals.)
“For people who won’t have a colonoscopy because of the unpleasant preparation, it could be a game changer, if they can afford it,” says gastroenterologist Clement Boland, a retired professor of medicine at the University of California, San Francisco School of Medicine. 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 proven to be an advance over less expensive alternatives. “An insurance company will say, ‘Well, if it’s equivalent, we’ll just cover the cheapest,’” says Kamal.
Many gastroenterologists faced with reluctance to prepare the patient consider this to be hindsight. “Insurance companies go to great lengths to force people to use generic products, which are not very well tolerated,” says Rex. “When it comes to preparation, efficiency is not the issue. From the patient’s perspective, it’s tolerability. That’s really important for 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.
However, since others don’t, it’s probably a good idea to check with your own individual plan to determine if the pills are covered.
For those without insurance or whose plans don’t cover the pills, McGowan suggests checking out sutab.com/savings on your company website to find ways to save. In addition, the company offers free samples and discount coupons to doctors for patients who can’t afford the pills, she says.
He acknowledges that cost may be a barrier for some patients. However, “in the event that a patient is unable to adequately complete the liquid prep, a repeat colonoscopy should be done, in which case the additional upfront out-of-pocket costs of Sutab would be worth it,” she says.
The newer pills should not be confused with the older tablets, made primarily of sodium phosphate, which the FDA found in 2006 caused serious kidney damage in some patients. While they’re still on the market, the old pills are rarely used today, experts say.
“The newer ones have sodium sulfate and are safe,” says Rex, stressing that patients should still drink the recommended amounts of water to avoid dehydration. “You don’t want to drink the stuff that tastes bad, but you have to drink something,” he says.
Di Palma, who conducted the Sutab study, says he tried all the preparations and used them for his own colonoscopies.
“I’ve had five colonoscopies, and Sutab was the easiest one yet,” he says.