While relatively inexpensive themselves, the indirect costs of laxatives include: pharmacy inventory management and distribution; nursing administration time; a contribution to polypharmacy; and downstream investigations (eg, Clostridium difficile testing) in the case of laxative-induced diarrhea. Evidence supporting the efficacy of certain laxatives is lacking, particularly docusate sodium/calcium.
These medications contribute to inpatient pill burden, which is particularly troublesome in cases of polypharmacy or in patients who have difficulty swallowing. Moreover, docusate use was perpetuated into the community in nearly 50% of patients. Since all medications are usually given equal urgency on most exit prescriptions, the pill burden caused by docusate products may increase the chance of nonadherence to other more important medications. Furthermore, some of these patients will become long-term users. While this may seem like a minor issue, the societal costs are striking, when taking into account the frequency of outpatient laxative use. Among the 2.8 million governmentally-insured beneficiaries in the province of Ontario (population 13.6 million), spending on laxatives exceeded $28 million Canadian dollars (CAD) in 20126 with nearly $9.7 million (CAD) spent on stool softeners, including docusate. A loose extrapolation to North America would suggest spending on docusate products is easily hundreds of millions of dollars.
There is now evidence demonstrating
that docusate is ineffective
for the treatment of
It is time to stop a habitual practice that is wasteful
and harmful to patients.
Docusate has not been proven effective in any
well-designed or placebo-controlled trials.
Docusate is nomore effective
than placebo when added to sennosides for the
management of constipation in hospice patients. As for the
commonly-held belief that docusate reduces the incidence of
cramps in the treatment of constipation, a study of hospitalized
patients diagnosed with cancer treated using a protocol
of sennosides alone vs a protocol of sennosides plus docusate
(with an initial docusate-only phase) found no difference
between the 2 protocols in the incidence of cramps.
It is a burdensome
medication for many patients—especially those who are
ill and already suffering from dysphagia, nausea, poor appetite,
polypharmacy, or confusion regarding their medications.
Docusate comes as a large capsule or solution, and a
therapeutic dose requires patients to take multiple capsules
per day. The common workaround of mixing the medication
into juice or applesauce does not work with docusate because
of its unpalatable taste and lingering aftertaste. Docusatemay
affect the absorption of othermedications, and is best
taken 2 hours away from other medications. The most important
unintended downstream consequence of docusate is that
it delays more effective interventions to relieve constipation.
In addition, other consequences include patient refusal of other
medications owing to pill burden, decreased appetite and oral
intake owing to the persistent aftertaste, and activities curtailed
owing to the need for frequent medication administration.
Tiré de JAMA Internal Medecine