Efficacy of a multifactorial strategy for bowel preparation in diabetic patients undergoing colonoscopy: a randomized trial

Background and study aims: Previous studies have reported that diabetes mellitus is an independent risk factor for inadequate bowel preparation. Current guidelines do not recommend a specific preparation for this patient population. The aims of this study were to assess the efficacy, safety, and tolerability of an adapted preparation protocol for colon cleansing in patients with type 2 diabetes mellitus.

Patients and methods: This randomized, single-blind, parallel group, superiority trial compared a conventional bowel preparation protocol (CBP) with a diabetes-specific preparation protocol (DSP). The CBP included a low-fiber diet for 3 days followed by a clear liquid diet for 24 hours before colonoscopy. The DSP included a multifactorial strategy combining an educational intervention, a low-fiber diet, and adjustment of blood glucose-lowering agents. All patients received 4 L of a polyethylene glycol solution in a split-dose regimen. The endoscopists were blinded to the preparation protocol. The primary outcome measure was inadequate bowel preparation according to the Boston Bowel Preparation Scale. Secondary outcome measures included hypoglycemic events, tolerability, and acceptability.

Results: A total of 150 patients were included in the study (74 CBP and 76 DSP). Both groups were comparable in terms of baseline characteristics. Inadequate bowel cleansing was more frequent following CBP than DSP (20 % vs. 7 %, P = 0.014; risk ratio 3.1, 95 % confidence interval 1.2 – 8). Only CBP and performance status were independently associated with inadequate bowel preparation. Both preparations were equally tolerated and accepted by patients, and side-effects were similar between the groups.

Conclusions: A multifactorial strategy for bowel preparation in patients with diabetes undergoing colonoscopy showed a threefold reduction in the rate of inadequate bowel preparation, with no differences in safety and tolerability compared with conventional preparation.

Trial registration: ClinicalTrials.gov (NCT02300779).

• References

• 1 Sun L, Yu S. Diabetes mellitus is an independent risk factor for colorectal cancer. Dig Dis Sci 2012; 57: 1586-1597
• 2 Taylor C, Schubert ML. Decreased efficacy of polyethylene glycol lavage solution (golytely) in the preparation of diabetic patients for outpatient colonoscopy: a prospective and blinded study. Am J Gastroenterol 2001; 96: 710-714
• 3 Ozturk NA, Gokturk HS, Demir M et al. The effect of autonomous neuropathy on bowel preparation in type 2 diabetes mellitus. Int J Colorectal Dis 2009; 24: 1407-1412
• 4 Dik VK, Moons LMG, Hüyük M et al. Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: Development and validation of a prediction score. Gastrointest Endosc 2015; 81: 665-672
• 5 Froehlich F, Wietlisbach V, Gonvers J-J et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005; 61: 378-384
• 6 Oken MM, Creech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5: 649-655
• 7 Charlson ME, Pompei P, Ales KL et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
• 8 Ozturk NA, Gokturk HS, Demir M et al. Efficacy and safety of sodium phosphate for colon cleansing in type 2 diabetes mellitus. South Med J 2010; 103: 1097-1102
• 9 Hayes A, Buffum M, Hughes J. Diabetic colon preparation comparison study. Gastroenterol Nurs 2011; 34: 377-382
• 10 Grigg E, Schubert MC, Hall J et al. Lubiprostone used with polyethylene glycol in diabetic patients enhances colonoscopy preparation quality. World J Gastrointest Endosc 2010; 2: 263-267
• 11 Johnson DA, Barkun AN, Cohen LB et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2014; 109: 1528-1545
• 12 Battle WM, Snape WJ, Alavi A et al. Colonic dysfunction in diabetes mellitus. Gastroenterology 1980; 79: 1217-1221
• 13 Sims MA, Hasler WL, Chey WD et al. Hyperglycemia inhibits mechanoreceptor-mediated gastrocolonic responses and colonic peristaltic reflexes in healthy humans. Gastroenterology 1995; 108: 350-359
• 14 Reilly T, Walker G. Reasons for poor colonic preparation with inpatients. Gastroenterol Nurs 2004; 27: 115-117
• 15 Jung YS, Seok HS, Park DI et al. A clear liquid diet is not mandatory for polyethylene glycol-based bowel preparation for afternoon colonoscopy in healthy outpatients. Gut Liver 2013; 7: 681-687
• 16 Park DI, Park SH, Lee SK et al. Efficacy of prepackaged, low residual test meals with 4L polyethylene glycol versus a clear liquid diet with 4L polyethylene glycol bowel preparation: a randomized trial. J Gastroenterol Hepatol 2009; 24: 988-991
• 17 Sipe BW, Fischer M, Baluyut AR et al. A low-residue diet improved patient satisfaction with split-dose oral sulfate solution without impairing colonic preparation. Gastrointest Endosc 2013; 77: 932-936
• 18 Soweid AM, Kobeissy AA, Jamali FR et al. A randomized single-blind trial of standard diet versus fiber-free diet with polyethylene glycol electrolyte solution for colonoscopy preparation. Endoscopy 2010; 42: 633-638
• 19 Joshi GP, Chung F, Vann MA et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg 2010; 111: 1378-1387
• 20 Ko CW, Riffle S, Shapiro JA et al. Incidence of minor complications and time lost from normal activities after screening or surveillance colonoscopy. Gastrointest Endosc 2007; 65: 648-656
• 21 Abuksis G, Mor M, Segal N et al. A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department. Am J Gastroenterol 2001; 96: 1786-1790
• 22 Tae JW, Lee JC, Hong SJ et al. Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy. Gastrointest Endosc 2012; 76: 804-811
• 23 Spiegel BMR, Talley J, Shekelle P et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Am J Gastroenterol 2011; 106: 875-883
• 24 Liu X, Luo H, Zhang L et al. Telephone-based re-education on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomised, controlled study. Gut 2014; 63: 125-130
• 25 Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58: 76-79
• 26 Jover R, Zapater P, Polanía E et al. Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. Gastrointest Endosc 2013; 77: 381-389.e1
• 27 Calderwood AH, Jacobson BC. Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010; 72: 686-692