Brian Jacobson, MD, MPH, is an associate professor of medicine at Harvard Medical School and director of program development for gastroenterology at Massachusetts General Hospital.

Colonoscopy’s Role in CRC Screening, The Importance of Adequate Bowel Preparation

 is the second leading cause of cancer-related death in the United States, a stark reality that underscores the need for effective screening and prevention.

Each March, Colorectal Cancer Awareness Month serves as a reminder of the importance of early detection to reduce colorectal cancer’s significant impact. Colonoscopy remains the gold-standard screening tool, but its effectiveness relies heavily on adequate bowel preparation. Inadequate preparation can lead to missed lesions, prolonged procedures, and the need for repeat exams, diminishing its preventive power.

New guidance from the US Multi-Society Task Force on Colorectal Cancer (USMSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, provides clinical recommendations to address challenges related to bowel preparation for colonoscopy, focusing specifically on outpatients at low risk for inadequate bowel preparation.

In the first segment of this 6-part HCPLive RX Review, Brian Jacobson, MD, MPH, and Joseph Anderson, MD, discuss their work as co-authors on the recent USMSTF consensus statements and explain why adequate bowel preparation is so important in the context of colonoscopy.

Anderson begins by emphasizing the continued importance of colonoscopy as a cornerstone of colorectal cancer screening and prevention, particularly in the context of evolving noninvasive screening modalities. He highlights the comprehensive nature of colonoscopy, noting its dual role in both detecting and preventing colorectal cancer through polypectomy. While acknowledging the utility of noninvasive tests, both experts agree that colonoscopy remains the gold standard, acknowledging that even with noninvasive testing, a colonoscopy will still be required following a positive result.

The conversation then shifts to the critical role of bowel preparation in ensuring effective and complete exams. Anderson notes that inadequate preparation can result in missed lesions, increased healthcare costs, and the need for repeat procedures, undermining the value of the screening itself. He emphasizes that proper bowel preparation safeguards the efficacy of colonoscopy and protects patients from potential morbidity associated with incomplete exams.

: Brian Jacobson, MD, MPH, an associate professor of medicine at Harvard Medical School and director of program development for gastroenterology at Massachusetts General Hospital

: Joseph Anderson, MD, a professor of medicine at Geisel School of Medicine at Dartmouth and a gastroenterologist at White River Junction VAMC

Editors’ note: Jacobson has relevant disclosures with Curis and Guardant Health. Anderson has no relevant disclosures.

Jacobson BC, Anderson JC, Burke CA, et al. Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer. 

The American Journal of Gastroenterology.

Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. 

In the opening segment of this 6-part RX Review, experts discuss new USMSTF guidance on bowel preparation for colonoscopy.

Brian Jacobson, MD, MPH

Christopher Parker, DO

Dr. Karp is the 84th president of the American College of Rheumatology. He is chief of the Rheumatic Diseases Division at UT Southwestern Medical Center, Dallas, a role he has held for the past 18 years.

For the past 15 years, Dr. Karp’s research has focused on systemic lupus erythe­matosus, including the of use of genomics and proteomics to help understand disease progression. He joined the ACR during his fellowship and has been involved as a volunteer for the past 17 years, serving in various committee roles, leading the Rheumatology Research Foundation and serving on the ACR Board of Directors’ Executive Committee.

David R. Karp, MD, PhD

Gregg C. Fonarow serves as Interim Chief of UCLA's Division of Cardiology, Director of the Ahmanson-UCLA Cardiomyopathy Center, and Co-director of UCLA's Preventative Cardiology Program.

Emerging research suggests that even blood glucose levels within the higher end of the “normal” range may increase 

 risk, prompting experts to reconsider current guidelines. In an editorial published in the American Heart Journal, Gregg C. Fonarow, MD, division of cardiology, Geffen School of Medicine at the University of California, Los Angeles, highlights studies showing a significant rise in cardiovascular events in individuals with fasting glucose levels between 95-99 mg/dL compared with those below 80 mg/dL.

, Fonarow proposes a revised classification system that stratifies glucose levels within the normal range to better determine CVD risk and guide clinical decision-making. He emphasizes that while lifestyle interventions—such as increased physical activity and dietary modifications—remain foundational, pharmacologic options like GLP-1 receptor agonists and SGLT2 inhibitors may be appropriate for certain high-risk individuals.

He also underscores the importance of shifting clinical perspectives to recognize the continuous nature of cardiovascular risk across biomarkers, much like LDL-C. By refining risk assessment strategies and implementing targeted interventions, Fonarow indicated clinicians may better prevent premature cardiovascular events and improve patient outcomes.

This transcript has been edited for clarity.

Your editorial highlights compelling evidence linking higher normal blood glucose levels to increased cardiovascular risk. Could you break down key highlights from those findings and what they revealed about that link?

Traditionally, there's been wide recognition that individuals with overt diabetes and blood sugar elevations into the range for which diabetes is diagnosed are at increased cardiovascular risk. In addition, it's been recognized that those individuals with fasting glucose levels of 100 to just below 126 mg/dL have fallen into a category of prediabetes. Those individuals have also been at increased risk for cardiovascular events, not quite to the degree of those with T2D, but with excess risk.

Those who have had fasting blood sugar levels below 100 mg/dL have been felt to be at lower cardiovascular risk. However, there have been recent studies that have suggested that those still falling within what is traditionally viewed as the normal range below 100 mg/dL, but on the higher end between 90 and 99 mg/dL, there are detectable increases in cardiovascular risk in those individuals. By virtue of this editorial viewpoint, we highlighted that increase in risk, proposed an actual potential staging system that integrates that risk increase, and importantly, highlighted how some of that risk comes about and that this increase in cardiovascular risk may be potentially modifiable.

It highlights how the higher range in fasting glucose levels that are still within what has traditionally been considered the normal range is associated with increased cardiovascular risk. Specifically, an increased risk of myocardial infarction and ischemic stroke.

You and your co-author proposed a revised classification of those glucose levels and how that new framework might better guide risk assessment or clinical decision-making. How does that compare with the current guidelines?

It's important to recognize that although this terminology is of glucose in the normal range, because it's below 100 mg/dL, there is still the potential for increased risk. Recognizing those individuals in that range, using a staging classification, and those falling into Stage Two may help with that assessment, along with other established cardiovascular risk factors, to identify a group of individuals for potential lifestyle modification. An increase in physical activity, focusing on a cardiovascular-healthy diet could be beneficial for those where their blood pressure is elevated, and more aggressive.

Lowering blood pressure by more intensive treatment of modifiable lipid risk factors. Recognizing this is imparting some additional cardiovascular risk makes this actionable in that having an appropriate lifestyle and potential medication modifications are beneficial and can be applied to those individuals now, together with their clinician recognizing that increase in cardiovascular risk.

You highlighted some lifestyle prevention steps, but what are the potential medical interventions and how do they address this for this patient population?

A lot of what is driving this increased risk is this marker for insulin resistance, so there are disruptions of circadian rhythm, but also things worsening, including insulin-resistant chronic inflammation and less favorable physical activity. Obesity is contributing and may be an additional factor by which an individual would decide on medication use, including GLP-1 RAs. An increase in cardiovascular risk associated with a glucose level in this high normal range may be a factor that goes into decision-making beyond lifestyle interventions. Adding a GLP-1 RA would be reasonable for that individual and that’s a medication that could be considered.

SGLT2 inhibitors are another class of medication used for overt diabetes, chronic kidney disease (CKD), and heart failure. Depending on the other indications that are present, it may favor the selection of an SGLT2 inhibitor in certain individuals with glucose in the high normal range, but not to where they're at overt pre-diabetes or T2D. Those are some examples of medications that may favorably improve both blood sugar levels and insulin resistance and help lower cardiovascular risk.

On a larger scale, with an increased focus on cardiovascular risk biomarkers like LP(a) or LDL-C, what would need to happen for this perspective on blood glucose level classification to influence clinical guidelines?

With a lot of guidance and guidelines, we tend to classify these continuous risk factors that influence the way they are or are not treated. We recognize that with LDL-C, there's a continuum in the difference in risk. For somebody with an LDL-C of 101 versus 99 mg/dL, the difference is small but categorically may make a big difference in whether the patient gets treated or not. The same thing applies to fasting blood sugar levels, and HbA1c, and there's really a continuum. This recognition of what we previously would categorize as normal would often take this out of the patient or clinician’s mind that it may still be imparting risk. That is true with regards to these continuous biomarkers, where this gradation in risk and all of this should be factored into the clinical decision-making.

It is very much analogous and looks at not just a single continuous risk factor, but a background of that individual's age, other risk factors, and continuous biomarkers of cardiovascular risk. This becomes very important, all the more so because cardiovascular disease remains the leading cause of death in both men and women. Much of those premature cardiovascular events are preventable should lifestyle modification together with appropriate pharmacologic therapy be applied and adhered to in individuals at risk. We need to aim to identify that risk, act on it, and translate that to meaningful clinical risk reduction.

We are constantly at the population level and individual level not adequately applying our knowledge base to where there are lots of individuals at increased risks that have not been offered appropriate therapies that could help lower their risk. As a consequence, there are large number of cardiovascular events that continue to occur that could have been prevented with more precise and personalized cardiovascular risk assessment and the deployment of patient-centered cardiovascular risk reduction strategies.

Fonarow reports relevant disclosures with Bayer, Cytokinetics, Edwards Life Sciences, Johnson & Johnson, Merck, Novartis, and others.

Ebrahimi M, Fonarow GC. Higher levels of glucose within the normal range and cardiovascular risk: A landscape beyond diabetes and prediabetes. Am Heart J. 2025;283:1-4. doi:10.1016/j.ahj.2025.01.008

Shaye K, Amir T, Shlomo S, Yechezkel S. Fasting glucose levels within the high normal range predict cardiovascular outcome. Am Heart J. 2012;164(1):111-116. doi:10.1016/j.ahj.2012.03.023

Emerging evidence indicates that blood glucose levels at the higher end of the normal range may elevate cardiovascular disease (CVD) risk, prompting a reevaluation of current guidelines. Studies show increased cardiovascular events in individuals with fasting glucose levels between 95-99 mg/dL compared to those below 80 mg/dL. A proposed classification system stratifies glucose levels within the normal range to better assess CVD risk and guide clinical decisions. Lifestyle interventions remain crucial, but pharmacologic options like GLP-1 receptor agonists and SGLT2 inhibitors may be suitable for high-risk individuals.

Fonarow describes a revised classification of glucose levels that breaks down the normal range into lower and higher levels of associated cardiovascular risk.

Reevaluating Blood Glucose Levels for CV Risk with Gregg C. Fonarow, MD

Gregg C. Fonarow, MD

Faricimab versus High-Dose Aflibercept for the Treatment of Neovascular AMD and DME

1:05 Overview of faricimab and high-dose aflibercept

3:48 clinical trials for faricimab and high-dose aflibercept

9:12 Comparing the matched dose phase results in clinical trials

12:30 Potential impacts of Ang-2 inhibition

14:40 Real-world experience with faricimab

24:00 Choosing between faricimab vs high-dose aflibercept

29:00 Perspectives on retreatment criteria in clinical trials

33:00 Label differences between faricimab and high-dose aflibercept

Retina specialists evaluate the effectiveness of the two new therapies for neovascular AMD and DME by analyzing their respective clinical trial methodologies and outcomes.

Faricimab Versus High-Dose Aflibercept for the Treatment of Neovascular AMD and DME

Jennifer Lim, MD, FARVO, FASRS

The panelists stress the significance of a comprehensive approach to patient care.

Cardiometabolic Medicine: Seeing the Patient as a Whole

The panelists stress the significance of a comprehensive approach to patient care, acknowledging the interconnected nature of cardiovascular, kidney, endocrine, and obesity-related benefits, and highlighting that addressing secondary diseases can minimize overall disease risk in patients.

Michael Blaha, MD

Experts discuss strategies for making dry eye care an appealing practice option for optometry students and supporting their success in this specialized field.

Fostering Next-Generation Expertise in Dry Eye Treatment

Fostering Next-Generation Expertise in Dry Eye

Mile Brujic, OD

Key Takeaways for Improving CKD Diagnosis and Treatment in Patients With Type 2 Diabetes

In closing, what are the key takeaways for improving CKD diagnosis and treatment in patients with type 2 diabetes?

Now that we have many options in CKD, how should we think about sequencing these products in different patient types, for instance, to address CV and renal risk, in patients with earlier, less advanced disease as well those with later, advanced stages?

Chronic kidney disease (CKD) in Type 2 Diabetes patients necessitates early detection to prevent progression and associated complications. Identifying at-risk patients involves considering factors such as hypertension, family history of kidney disease, and elevated blood glucose levels. Screening tests include estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). Early detection is crucial as it allows timely intervention, potentially slowing disease progression and reducing cardiovascular risks. CKD is a significant risk factor for heart failure, making early detection vital for comprehensive cardiovascular risk management.

Panelists discuss the key takeaways for improving chronic kidney disease (CKD) diagnosis and treatment in patients with type 2 diabetes, emphasizing how to effectively sequence treatment options based on patient types to address cardiovascular and renal risks in both early and advanced stages of the disease.

Rajiv Agarwal, MD

COVID-19 has obviously presented significant challenges in our clinical work, particularly in the evaluation, diagnosis, and treatment of patients with ADHD [attention-deficit/hyperactivity disorder] of all ages. What we’ve all done, of course, is acclimate to this, largely through the use of telemedicine, telepsychiatry for a lot of our patients. Although more recently, I’ve gone back to more of a hybrid model where I am seeing some patients live and some via telepsychiatry. 

There are significant challenges. Some of those challenges include the fact that it’s a little more difficult to do an evaluation and to collect all the nonverbal information that you might get from being in the room with a person. Part of the problem is you may be seeing only a portion of the patient’s body. You may not be seeing the lower half of the body if you’re on a virtual call. You might not see some of the fidgeting or hyperactivity, for instance.

Also, what I find is patients either do really well with virtual telepsychiatry or don’t. They have trouble focusing. They get distracted. It’s really important to try to individualize care for our patients. Some people try to do in-person meetings. Ideally, this may be helpful for the initial evaluation so we can collect as much information as possible. When you’re dealing with children, you’d like to have collateral information, so you’d like to have parents and caregivers involved. That can be a little harder too, although it can be done virtually.

As far as prescribing medications, that can present a challenge. Although now, states are going to e-prescribing. In Florida, we now have to e-prescribe all controlled substances. That makes it easier, not having to handwrite a prescription and somehow get it to the patient in a COVID-19 environment.

The other thing I find is that sometimes children do a little better in this virtual environment, but many with ADHD struggle more. There’s a lot more stress and difficulty in school. Obviously, there’s more isolation, so fewer social relationships, fewer extracurricular activities, and maybe less access to exercise, which has been shown to be very beneficial for ADHD. These are some of the challenges that we’re trying to negotiate in the era of COVID-19.

Tele-prescribing of stimulants presents some unique challenges in the era of COVID-19. Part of the challenge is making sure you can e-prescribe appropriately. Most of us have figured out how to do that. Also, you want to make sure the pharmacy is available and shows up on your e-prescribing software. It is required, when we prescribe stimulants, that we monitor certain things. This can be more challenging in this environment, particularly when assessing vital signs, height, and weight. Blood pressure, heart rate, height, and weight can be a challenge in the virtual environment. This is when I may sometimes have the patient come to the office, just for the vital signs and height and weight checks. Or the patient can get 1 of the home monitoring devices, which you can get at many pharmacies. These devices can monitor blood pressure and heart rate. Your patients can check those periodically and report the results to you. Or you can certainly have them email that to you or communicate electronically.

As far as monitoring for abuse and possibility of diversion, this is something we also need to keep our eyes on. We can do this in various ways, including by checking prescribing databases, which can certainly be done online.

As far as monitoring for other issues and problems, such as the emergence of psychotic or manic symptoms or the possibility of vasoconstriction or cardiovascular issues, this is where taking a very careful history and evaluation and trying to look at the patient and evaluate them as best you can on camera really seems to help.

It’s important to understand that when evaluating and treating ADHD, comorbidity is the rule. Three-quarters of patients with ADHD will have a least 1 other comorbid condition. This is important because sometimes our core treatments for ADHD can help alleviate these other conditions. For instance, secondary anxiety or secondary depression. Sometimes, however, we do have to institute specific treatment in addition to the ADHD treatment to address a comorbid condition.

Rakesh Jain, MD, MPH: When parents and their children first come to see me for an evaluation for ADHD, there’s often a lot of confusion. We have a lot of myths in our heads. “Is this bad parenting?” “Was this just because one of us got divorced?” Is it because I had too many Diet Cokes when I was pregnant?” 

My first job is to offer parents and children a combination of sympathy and encouragement. I offer sympathy for the suffering they have gone through and encouragement that, if we do the right thing, we can make a pretty significant difference in all the challenges your child is having and you’re having as parents and caregivers. I have found that injection of enthusiasm, support, and knowledge to be as useful as anything I do.

The second step is really a pretty quick but accurate increase in knowledge base about the disease. Most people are quite surprised to know that it is a neurobiologically active condition. It is an inherited condition. It is a brain-based condition. Even though behavior is what they might see, the child is not being a “bad” child. 

Finally, we need to give an explanation of why interventions work or why a combination of nonpharmacological and pharmacological interventions is best explained in the context of neurobiology. 

When I offer that whole package of information, from sympathy to increasing their enthusiasm and encouragement to disease-state knowledge and then finally medication and nonmedication knowledge, you can see the parents and the child breathe a sigh of relief. “I’ve got a direction. There’s something I can do. I feel empowered.” That is precious. As a clinician, once I see that, I know I have established a solid therapeutic relationship that will lead to good outcomes.

Optimizing care and managing challenges for patients with ADHD during the COVID-19 pandemic and advice for clinicians educating patients and families on disease management. 

Optimizing Care for ADHD During COVID-19 

Rakesh Jain, MD, MPH, Texas Tech University School of Medicine

Geoffrey Grammer, MD closes this series highlighting the administration options of esketamine, its safety profile, and the importance of monitoring patients using this treatment.

Authors