30 octobre 2016

Le Colace est inefficace

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 constipation.1 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

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