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Docusate is a medication utilized for managing and treating constipation. Belonging to the stool softener class of drugs, it reduces the surface tension of the oil and water interface within the stool, facilitating the passage of water and lipids into the stool mass. The goal is for the stool to become softer and move through the intestinal tract more easily. Docusate has no indications approved by the U.S. Food and Drug Administration (FDA). This activity aims to review the indications, mechanism of action, and contraindications of docusate in treating and managing constipation. This activity will highlight the adverse event profile and other crucial factors of docusate, including dosing, monitoring, and relevant interactions, pertinent to interprofessional team members involved in caring for patients with constipation and related conditions. Objectives: Identify the appropriate indications for docusate usage in managing constipation and differentiate it from other laxative options. Screen patients for contraindications and potential drug interactions before prescribing docusate to ensure safe and effective use. Assess the efficacy of docusate in managing constipation and improving bowel movements for each patient and adjust treatment plans accordingly. Communicate effectively with patients about docusate therapy, involving them in shared decision-making while discussing its indications, risks, and benefits. Access free multiple choice questions on this topic.

Docusate has a well-documented safety and tolerability profile and has been in use in the United States since the 1950s. Animal studies have demonstrated that docusate sodium ear drops can cause significant ototoxicity. Therefore, docusate ear drops should be avoided in patients with tympanic membrane perforation.[20] Although propylene glycol (PG) present in some docusate products is considered safe, it can cause toxicity in children when used in high doses or for extended periods. PG may cause various health problems, including central nervous system toxicity, hyperosmolarity, hemolysis, cardiac arrhythmia, and lactic acidosis.[39] Docusate is metabolized in the liver, where it undergoes significant first-pass metabolism, forming both active and inactive metabolites. Although docusate undergoes hepatic metabolism and has high plasma protein binding, there have been no reports of clinically apparent hepatoxicity.[40]

For effective constipation management, it is crucial to identify and treat the underlying etiology. Constipation can result from various disease states, such as chronic kidney disease, hypothyroidism, irritable bowel syndrome, diabetes, dementia, depression, colorectal cancer, autonomic neuropathy, hemorrhoids, hypercalcemia, hypokalemia, multiple sclerosis, Parkinson disease, and stroke. Mitigating the underlying cause can ameliorate constipation symptoms and enhance the overall quality of life. Furthermore, certain medications, including opioids, anticholinergics, iron supplements, and calcium channel blockers, may instigate constipation. For patients already using docusate, assessing their constipation status and communicating with the prescribing healthcare provider about discontinuing docusate when appropriate is recommended. Laxative therapy should be advised when suitable for those patients who require medication to manage their condition. This activity emphasizes that healthcare teams should collaborate to review and exclude docusate from the prescribing order if it appears in pre-printed forms or order sets. These measures can prevent unnecessary docusate prescribing and promote the adoption of evidence-based alternatives for constipation management. According to an article from the Choosing Wisely initiative in the Journal of Hospital Medicine, it is recommended to discontinue prescribing docusate for patients already taking the drug before being admitted to the hospital. The article also suggests removing the medication from the hospital formulary. Despite limited evidence supporting its efficacy, the recommendation stems from the everyday use of docusate for constipation treatment and prevention. Instead, the article suggests opting for more effective therapies such as polyethylene glycol, lactulose, psyllium, or sennosides to manage constipation.[31] An observational study revealed that despite its ineffectiveness, docusate is frequently prescribed to medical inpatients, including those at high risk of constipation. Furthermore, there is a notable rate of new prescriptions on discharge, which can potentially exacerbate polypharmacy. Surprisingly, among patients already receiving docusate, 80% of them are still prescribed the medication when they are discharged, which indicates that there are missed opportunities for deprescribing.[41]

An observational study revealed that despite its ineffectiveness, docusate is frequently prescribed to medical inpatients, including those at high risk of constipation. Furthermore, there is a notable rate of new prescriptions on discharge, which can potentially exacerbate polypharmacy. Surprisingly, among patients already receiving docusate, 80% of them are still prescribed the medication when they are discharged, which indicates that there are missed opportunities for deprescribing.[41] A team consisting of internal medicine resident physicians and pharmacists initiated a quality improvement project to tackle the concern of docusate use in hospitalized patients. The team devised and implemented 2 interventions, encompassing education for residents and pharmacists and introducing an additional process-related barrier. As a result of this strategy, there was a substantial decrease in docusate orders without any adverse impact on the length of hospital stay for patients. The successful collaboration among the interprofessional team highlights the efficacy of this approach in promoting evidence-based medicine.[42] Although a primary care physician or advanced practice practitioner typically manages most cases of constipation initially, referral to a subspecialist may be necessary depending on the underlying cause, as mentioned earlier. In some cases, the involvement of a surgeon, gastroenterologist, neurologist, psychiatrist, or endocrinologist may also be necessary for providing better care for patients dealing with constipation issues. A radiologist can provide valuable information through imaging studies about bowel pathology by collaborating with a physician or surgeon. A dietician is critical in modifying dietary risk factors. A pharmacist will verify that the patient is not taking any medications that could worsen constipation and recommend suitable alternatives if necessary. An otorhinolaryngologist can use docusate for cerumen impaction treatment. Nurses play a crucial role in the interprofessional team, providing direct patient care, education, and counseling in both outpatient and hospital settings. Their effective communication skills enable them to raise concerns and contribute significantly to patient care by alerting other clinicians. Ensuring patient education on the effectiveness of docusate is of utmost importance.

Although a primary care physician or advanced practice practitioner typically manages most cases of constipation initially, referral to a subspecialist may be necessary depending on the underlying cause, as mentioned earlier. In some cases, the involvement of a surgeon, gastroenterologist, neurologist, psychiatrist, or endocrinologist may also be necessary for providing better care for patients dealing with constipation issues. A radiologist can provide valuable information through imaging studies about bowel pathology by collaborating with a physician or surgeon. A dietician is critical in modifying dietary risk factors. A pharmacist will verify that the patient is not taking any medications that could worsen constipation and recommend suitable alternatives if necessary. An otorhinolaryngologist can use docusate for cerumen impaction treatment. Nurses play a crucial role in the interprofessional team, providing direct patient care, education, and counseling in both outpatient and hospital settings. Their effective communication skills enable them to raise concerns and contribute significantly to patient care by alerting other clinicians. Ensuring patient education on the effectiveness of docusate is of utmost importance. Adopting an interprofessional approach with effective communication and shared decision-making among prescribing physicians, advanced practice practitioners, nurses, pharmacists, specialists, and dieticians is crucial for enhancing patient experience and optimizing outcomes.