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Invited Commentary
Less Is More
August 2016

Habitual Prescribing of Laxatives—It’s Time to Flush Outdated Protocols Down the Drain

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Division of Geriatrics, Department of Medicine, University of California, San Francisco
  • 3Department of Veterans Affairs Medical Center, San Francisco, California
JAMA Intern Med. 2016;176(8):1217-1219. doi:10.1001/jamainternmed.2016.2780

Constipation is a common and distressing symptom among those who are ill. In addition to adequate fluid intake and mobilization, the mainstay of constipation treatment has traditionally been the “bowel regimen,” a stimulant laxative such as sennosides combined with the stool softener docusate. Years ago, as trainees fatigued by endless pages alerting us to constipated patients, we too routinely ordered sennosides and docusate for every patient admitted to the hospital. Only after tasting various laxatives—and memorably, gagging on liquid docusate—did we feel compelled to change this practice. 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.

A fundamental responsibility of a health care provider prescribing any treatment to a patient is to consider efficacy and/or benefit, adverse effects, and on some level, cost. This means stopping ourselves from prescribing medications on autopilot mode, and looking beyond the prescription to imagine what life is like for the patient who is going to be under “doctor’s orders” to take the medication. Let us consider these questions using docusate as a case example.

Does It Work?

Docusate has not been proven effective in any well-designed or placebo-controlled trials. A systematic review2 published in 2000 concluded that the evidence base for docusate use was inadequate, noting that the available randomized controlled trials were of low quality with flawed study designs and clinical heterogeneity precluding pooled data analysis. The call for better evidence was met by Tarumi et al1 in 2013, with their publication of the results from a randomized, double-blind, placebo-controlled trial—the highest-quality evidence to date—showing that docusate is no more 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.3

What Are the Harms?

Many physicians are surprised to hear that there are downsides to docusate use. In fact, 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. Docusate may affect the absorption of other medications, 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. These adverse effects are not trivial.

What Are the Costs?

In the current issue of JAMA Internal Medicine, Lee et al4 describe their analysis of oral laxative use and associated costs at McGill University Health Centre in Montreal, Canada, during the year 2015. They found that docusate products were most commonly prescribed, accounting for 165 000 doses (64%), requiring over 2000 nursing hours for administration. More than 258 000 total doses of laxatives were dispensed, requiring an estimated 3233 nursing hours. Of 1480 discharged patients, 738 (49.9%) received prescriptions for docusate, 163 (11%) sennosides, and 142 (9.6%) lactulose. Extrapolating to a societal scale, they conclude that health care spending on docusate products in North America likely amounts to hundreds of million dollars per year being “flushed down the toilet.”

What Needs to Change?

Stopping the use of ineffective treatments such as docusate is an important issue for quality of care, safety, and cost. Yet, old habits die hard, which is why physicians continue to prescribe docusate 3 years after a clinical trial showed it to be ineffective, and hospital formularies continue to support them. Nonbeneficial medications like docusate should be eliminated from hospital formularies so that patients can receive effective treatments in a more timely fashion. Similarly, other practice habits that may be wasteful and harmful to patients include “magic mouthwash” for cancer treatment-induced mucositis,5 statins in hospice patients, and aggressive use of insulin to achieve tight glucose control in patients with poor prognosis. For treatments with insufficient evidence or guidelines, such as constipation prophylaxis with sennosides for hospitalized patients or nursing home residents, admission orders should be thoughtful and individualized, rather than reflexive and habitual. For example, a standing order for sennosides is reasonable for patients admitted with preexisting constipation6 or for those on standing opioid pain medications. However, treatment efficacy and the need for continued therapy should be frequently reassessed, including at the time of discharge. Reduction of inappropriate polypharmacy should be 1 key goal every time we perform medication reconciliation. It’s time to put ourselves in our patients’ shoes, and consider gathering our colleagues together for taste tests of medications like laxatives on our formulary.7 We guarantee that prescribing practices for medications like docusate will change quickly afterwards.

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Article Information

Corresponding Author: Kanako Y. McKee, MD, Hospice and Palliative Medicine Fellow, Department of Medicine, University of California, San Francisco, 533 Parnassus Ave, Ste 109, PO Box 0131, San Francisco, CA 94143-0131 (kanako.mckee@ucsf.edu).

Published Online: June 20, 2016. doi:10.1001/jamainternmed.2016.2780.

Conflict of Interest Disclosures: None reported.

References
1.
Tarumi  Y, Wilson  MP, Szafran  O, Spooner  GR.  Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients.  J Pain Symptom Manage. 2013;45(1):2-13.PubMedGoogle ScholarCrossref
2.
Hurdon  V, Viola  R, Schroder  C.  How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill.  J Pain Symptom Manage. 2000;19(2):130-136.PubMedGoogle ScholarCrossref
3.
Hawley  PH, Byeon  JJ.  A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer.  J Palliat Med. 2008;11(4):575-581.PubMedGoogle ScholarCrossref
4.
Lee  TC, McDonald  EG, Bonnici  A, Tamblyn  R.  Pattern of inpatient laxative use: waste not, want not  [published online June 20, 2016].  JAMA Intern Med. doi:10.1001/jamainternmed.2016.2775.Google Scholar
6.
Staller  K, Khalili  H, Kuo  B.  Constipation prophylaxis reduces length of stay in elderly hospitalized heart failure patients with home laxative use.  J Gastroenterol Hepatol. 2015;30(11):1596-1602.PubMedGoogle ScholarCrossref
7.
Widera  E. (2009, September 27). GeriPal Taste Test Part I: Liquid Bowel Medications. Retrieved from http://www.geripal.org/2009/09/geripal-taste-test-part-i-liquid-bowel.html.
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