Comparing the Real-World Effectiveness of Competing Colonoscopy Bowel Preparations on Bowel Cleansing and Adenoma Detection: Results of a Large Prospective Trial

Abstract

Introduction: Diagnostic accuracy of colonoscopy depends on reliably emptying the colon of fecal matter for better visualization. Currently there is no standardized consensus regarding different commercially available preparations prior to performing colonoscopy for screening, surveillance, and/or diagnostic purposes. This is due to lack of head-to-head studies comparing the effectiveness of various bowel preparations. Most randomized controlled trials studied 2-3 preps at a time and were performed in controlled settings that may not reflect real practice. Thus, we conducted a prospective, naturalistic, comparative study looking at effectiveness of various bowel preparations in regard to adenoma detection rate. Methods: We included patients ≥50 years old who presented for an outpatient colonoscopy between 8/4/2016-1/31/2018 at Cedars-Sinai Medical Center. The center is affiliated with 70 endoscopists who are free to prescribe the prep of their choice. The primary and secondary outcomes were adenoma detection rate (ADR; i.e., at least 1 adenoma found during exam) and bowel cleansing as measured by the Boston Bowel Prep Scale (BBPS), respectively. We performed regression models on ADR and bowel cleansing outcomes, adjusted by patient- (e.g., age, gender, body mass index, etc.), prep- (e.g., type of prep, prep dosing, etc.), and procedural-factors (e.g., performing endoscopist, cecal intubation, withdrawal time, etc.) to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI). Results: There were 2348 colonoscopies performed by 70 endoscopists. Table 1 lists the study cohort’s demographics and prescribed bowel preps. Overall, 91% of colonoscopies had adequate cleansing (i.e., BBPS ≥6). Miralax with Gatorade (BBPS 7.15±1.64; adjusted p(Table 2). Male gender, BMI ≥30, age ≥65 years, higher BBPS, and surveillance indication were associated with higher ADR. Conversely, no cecum intubation and additional procedures had lower ADR. Conclusion: In this prospective, comparative effectiveness study, we found that Miralax with Gatorade, Suprep, and MoviPrep significantly improved bowel cleansing when compared to GoLYTELY. They were also associated with numerically higher ADRs, which was likely driven by improved cleansing. This study also provides further evidence validating cecal intubation and ≥6-minute withdrawal time as colonoscopic quality indicators.127_A Figure 1. Demographic characteristics of the study cohort (N=2348)127_B Figure 2. Logistic odds ratios on adenoma detection rate