The FDA has approved Suflave (Sebela/Braintree), a low-volume polyethylene glycol (PEG)- and sulfate-based product for cleansing of the colon prior to colonoscopy in adults. Other oral colonoscopy preparations available in the US are listed in Table 2. Suflave is marketed as tasting better than other products.

The FDA has approved an oral tablet formulation of sodium sulfate, magnesium sulfate, and potassium chloride (Sutab – Braintree) for colon cleansing prior to colonoscopy in adults. A sodium sulfate-based oral solution (Suprep) has been available in the US since 2010. Sutab is the second tablet formulation to be approved for bowel cleansing prior to colonoscopy; a sodium phosphate-based tablet (OsmoPrep) was approved earlier.

In our article in issue 1564 on Plenvu for colonoscopy preparation (Med Lett Drugs Ther 2019; 61:11), the comparator drug in the DAYB trial was not Prepopik, but rather Citrafleet, a similar sodium picosulfate-based preparation that is not available in the US. Also, we said that Plenvu can be taken as a single- or split-dose regimen; we should have said that it can be taken as two doses in a single day or split over two days.

Most colorectal cancers arise from localized adenomatous polyps in a process that may take 10 years or more. Early detection and removal of a precancerous colonic lesion (polyp) can prevent cancer from developing.

The FDA has approved Plenvu (Salix), a polyethylene glycol (PEG)-containing oral powder for reconstitution, for colon cleansing prior to colonoscopy in adults. Plenvu is the first PEG-containing colonoscopy preparation that requires only 1 L of water for dissolution and ingestion of 1 L of clear fluid in addition.

The FDA has approved Clenpiq (Ferring), a low-volume oral solution that contains sodium picosulfate, magnesium oxide, and anhydrous citric acid, for colon cleansing prior to colonoscopy in adults. The ready-to-drink solution contains the same ingredients as Prepopik, which is supplied as a powder for reconstitution.

The FDA has approved Cologuard (Exact Sciences), a stool DNA test, to screen average-risk adults ≥50 years old for colorectal cancer.

Colonoscopy remains the preferred method of colorectal cancer screening. Many patients consider cleansing the bowel in preparation for colonoscopy the most unpleasant part of the procedure, but inadequate bowel preparation significantly lowers the diagnostic yield.

Use of screening tests to identify cancers before they cause symptoms can lead to earlier therapy and may improve outcomes. Screening tests for some common cancers are reviewed below.

A reader has asked us to review the use of propofol (Diprivan, and others) as a sedative agent for brief procedures, such as colonoscopy.

First marketed more than 20 years ago,1 propofol has a rapid onset of action (patients usually lose consciousness in less then one minute) and a short duration of action with a rapid recovery (3-5 minutes) that makes it highly suitable for brief ambulatory procedures. Propofol is now the most commonly used parenteral anesthetic in the US.2 The main problems with its use have been pain on injection and bacterial contamination, both related to its lipid emulsion formulation; fospropofol (Lusedra) is a water-soluble prodrug of propofol that acts similarly without pain on IV injection or a significant potential for contamination.3,4 Both propofol and fospropofol have a narrow therapeutic window; overdosing can readily induce states of deep sedation and general anesthesia, which could result in respiratory depression and loss of protective airway reflexes.

After years of use by emergency physicians and nurses, nurse anesthetists and gastroenterologists, among others, the Centers for Medicare and Medicaid Services (CMS) issued a memo in 2010 (soon after the propofol-related death of Michael Jackson) that has generally been interpreted as limiting the use of propofol for procedural sedation to anesthesiologists. This CMS guideline for Medicare and Medicaid patients has had a ripple effect on hospital emergency departments, where propofol has been widely used for intubation, and on endoscopy suites; patients who may have had endoscopies for years without receiving bills from anesthesiologists are receiving them now.

The mortality rate associated with brief use of propofol is so low that few data are available comparing the safety of use by non-anesthesiologists with that of use by anesthesiologists.5,6

1. Propofol. Med Lett Drugs Ther 1990; 32:22.

2. PM Patel et al in LL Brunton et al, eds, Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 12th ed., New York: McGraw-Hill 2011, p. 536.

3. LB Cohen et al. A randomized, double-blind, phase 3 study of fospropofol disodium for sedation during colonoscopy. J Clin Gastroenterol 2010; 44:345.

4. TJ Gan et al. Safety evaluation of fospropofol for sedation during minor surgical procedures. J Clin Anesth 2010; 22:260.

5. DK Rex et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137:1229.

6. H Singh et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; 4:CD006268.

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(Med Lett Drugs Ther 2008; 50:94) In Table 1, "Invasive" should be "less" and "more" rather than "no" and "yes" for CT colonography and colonoscopy, respectively. In the conclusion, CT colonography should be changed to "less invasive" rather than "noninvasive".

(Med Lett Drugs Ther 2008; 50:94) In table 1, "Invasive" should be "less" and "more" rather than "no" and "yes" for CT colonography and colonoscopy, respectively.

Options in screening for colon cancer include fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, computed tomography (CT) colonography and fecal DNA tests. Since the last Medical Letter article on this subject, more data have become available on colonography.

Last year, a Medical Letter article reviewing colonoscopy preparations warned that oral sodium phosphate preparations, such as Fleet Phospho-Soda solution and Visicol tablets, could cause significant electrolyte disturbances and, rarely, renal failure (Med Lett Drugs Ther 2005; 47:53). A subsequent report documented acute phosphate nephropathy and renal failure in 21 patients who had used sodium phosphate before colonoscopy (GS Markowitz et al. J Am Soc Nephrol 2005; 16:3389). Seventeen of these patients were women and 14 were taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). The FDA recently issued an alert advising against use of oral sodium phosphate in patients with kidney disease or uncorrected electrolyte abnormalities and urges caution in patients taking drugs that may affect renal function such as diuretics, NSAIDs, ACE inhibitors or ARBs.

Since the publication of our article on colonoscopy preparations,1 which compared polyethylene glycol electrolyte solutions (GoLytely, and others) with sodium phosphate (Fleet Phospho-Soda, and others), some readers have told us that we should have included a combination of a magnesium citrate solution with bisacodyl tablets (Evac-QKwik, and others) as an alternative. In one study, such a preparation offered better cleansing and patient tolerance than a sodium phosphate regimen.2

1. Colonoscopy preparations. Med Lett Drugs Ther 2005; 47:53.

2. M Delegge and R Kaplan. Efficacy of bowel preparation with the use of a prepackaged, low fibre diet with a low sodium, magnesium citrate cathartic vs. a clear liquid diet with a standard sodium phosphate cathartic. Aliment Pharmacol Ther 2005; 21:1491.

Use of screening tests to identify cancers before they cause symptoms can lead to earlier therapy and may improve outcomes. Screening tests for some common cancers are reviewed.

Many patients consider cleansing the bowel in preparation for colonoscopy the most unpleasant part of the procedure. Several methods are available.

Currently available techniques for colorectal cancer screening include fecal occult-blood testing, flexible sigmoidoscopy, double contrast barium enema (DCBE) and traditional optical colonoscopy. Optical colonoscopy requires bowel cleansing and sedation, and involves some risk, but is generally accepted as the best available method for detection of lesions and offers the advantage that polyps can be removed when they are identified. A less invasive screening tool, computed tomography (CT) colonography, also known as virtual colonoscopy (VC), offers an additional option.