Deep sedation for colonoscopy might not be safe

The use of propofol is on the rise and could put you at risk of complications

Published: November 19, 2014 06:30 PM

Getting knocked out during a colonoscopy might seem like a good idea. After all, being awake as your doctor uses a long, flexible tube to get an inside view of your lower intestines doesn't sound very appealing. To avoid that problem, many doctors now routinely use the drug propofol (Diprivan) during colonoscopy to cause deep sedation in their patients.

But beware: That drug, which was reportedly given to Joan Rivers  soon before she died, might not be the healthiest choice and could put you at risk for some serious complications.

Don’t get the wrong idea: Colonoscopies are usually safe (about 3 out of every 1,000 people suffer a serious complication). And the procedure is proved to prevent colon cancer deaths. So if you’re ages 50 to 75, you should be screened (see our guide, "The Cancer Tests You Really Need," to find out how often you should be screened). 

But deep sedation isn't necessary. Colonoscopy can be done with no anesthesia (yes, some people actually do that) or using conscious sedation with a drug such as midazolam (Versed). “You should always try to aim for the lightest level of sedation that you need,” says Orly Avitzur, M.D., a  Consumer Reports medical adviser. “The trend toward deep sedation is worrisome because it increases risk.”

For example, propofol increases your risk of aspiration pneumonia (caused by inhaling particles such as vomit, mucus, or saliva) by almost 50 percent, according to a study by Gregory Cooper, M.D., (no relation to the writer of this article) in the journal JAMA Internal Medicine. And it can cause a host of other side effects, including confusion, seizures, irregular heart beats, and potentially deadly allergic reactions.  

“For the general population there’s not a lot of good data saying patients have a better outcome with propofol when there’s not a medical indication,” says Cooper, a professor of medicine at Case Western Reserve University in Cleveland. “It’s overkill.”

And propofol is expensive. Colonoscopies using anesthesia cost about 20 percent more than those done without, according to Cooper. And a 2013 research letter in JAMA Internal Medicine titled, "Propofol for screening colonoscopy: Are we paying too much?" said that the use of propofol typically added $600 to $2,000 to the price tag.

Screening colonoscopies are covered by insurance plans, thanks to the Affordable Care Act, although you might have to pay for part of the anesthesiologist’s fees, bowel prep kit, pathology costs, and a facility fee. But even so, “Somebody’s got to pay for it, whether it’s the insurance company or the patients,” Cooper says, adding that the current system provides a financial motivation for using more anesthesia.

But the rising tide of propofol use could be about to ebb. Beginning Jan. 1, 2015, Medicare is changing how it pays anesthesia professionals for colonoscopy care. Gastroenterologists will be paid a set amount that will cover the anesthesia cost, even if an anesthesiologist, for example, administers it. Doctors will then have to decide whether to recommend expensive anesthesia, which could include hiring a nurse anesthetist or anesthesiologist and pay them out of the same pot, or choose a less pricey option. “There may be a financial disincentive for Medicare doctors to recommend deep sedation,” Avitzur says.

We’ll have to wait to find out if commercial insurers follow Medicare’s lead. If they do, says Cooper, “There will be less cost to the health care system since there won’t be another bill from the anesthesiologist.”

Until then, if you’re gearing up to have a colonoscopy, make sure you discuss your anesthesia options with your doctor before the procedure.

—Lauren Cooper

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