Procedure performed by ___________________

THOMPSON PEAK GASTROENTEROLOGY AND HEPATOLOGY GAVIN LEVINTHAL M.D. & STUART TRIESTER M.D. INSTRUCTIONS FOR COLONOSCOPY – MIRALAX PREP Patient Name: ________________________________________________________________________ Facility:Thompson Peak Hospital main admittingDate: Check In: a.m/p.m. YOU MAY BE ASKED TO DISCONTINUE THE FOLLOWING MEDICATIONS FOR UP TO 7 DAYS PRIOR TO YOUR PROCEDURE: Supplements Including iron, vitamin E, and others. Multivitamins may be continued. Anti-inflammatory medications Including aspirin (Anacin, Excedrin), ibuprofen (Advil, Motrin), naproxen (Aleve, Anaprox, Naprosyn), diclofenac (Arthrotec, Voltaren, Cataflam), oxaprozin (Daypro), piroxicam (Feldene), indomethacin (Indocin), ketoprofen, ketorolac, etodolac (Lodine), meloxicam (Mobic), nabumetone (Relafen), salsalate, sulindac, celecoxib (Celebrex). Tylenol is fine to take. Medications to thin the blood Including warfarin (Coumadin), clopidogrel (Plavix), ticlopidine (Ticlid), dipyridamole (Persantine). ADDITIONAL INFORMATION REGARDING YOUR MEDICATIONS You may take your regular morning medications with a sip of water on the morning of the procedure (ex. blood pressure medications, thyroid medication). Morning medications for diabetes should NOT be taken the morning of the procedure unless instructed otherwise. If you have questions regarding any medication, please contact our office at least one week prior to the colonoscopy. PURCHASE FROM THE DRUG STORE (OTC/no prescription needed): Dulcolax (bisacodyl) 5mg tablets – 4 tablets MiraLAX Powder 8.3 oz (238gm) bottle 64 oz of Gatorade -- please choose a light colored or clear flavor (no red, blue or purple) Must follow a clear liquid diet. NO SOLID FOODS MAY BE EATEN. We recommend you drink plenty of fluids such as water, pulp-free juice, tea, coffee, clear soda, clear broth, Jell-O (no red), popsicles and Gatorade. Please do not consume milk, milk products, non-dairy creamer, red colored products or juices containing pulp. At 1 p.m. -- swallow 4 Dulcolax tablets. At 3 p.m. -- mix the bottle of MiraLAX powder into the 64 oz of Gatorade. Shake until the powder is dissolved. Drink an 8 oz glass of the Gatorade mixture every 10-15 minutes until gone. You may drink the Gatorade a little slower if you become nauseated. After finishing the Gatorade solution, please continue to drink plenty of approved fluids to keep you hydrated. You can drink clear liquids until midnight. DAY OF PROCEDURE: MORNING ARRIVAL: Do not take anything by mouth. Approved medications can be taken with a sip of water. You will be able to eat after the procedure. NOON OR LATER ARRIVAL: You may continue to drink clear liquids until a.m. on your procedure day. Nothing by mouth after this time. You will be able to eat after the procedure. You will be unable to drive yourself home. You MUST have a close friend/relative present so the physician can speak with them after the procedure and to make sure you arrive home safely. If you arrive on the day of the procedure without an appropriate escort, the procedure may be cancelled even though you have done the preparation. AFTERWARDS: You should experience little if any discomfort. You may have a full feeling that will be relieved by passing gas. After you get home, in most cases, you can resume your usual diet and light activities. For the remainder of the procedure day – you must not drive a car, make important decisions or operate machinery. At the time of discharge, your physician may request that you have someone stay with you the rest of the day. If you have a heart murmur or other condition that usually requires antibiotics prior to medical procedures, please contact our office. In most cases, antibiotics will not be required prior to your colonoscopy. ________ Please initial here acknowledging you have read and understand the above instructions.

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