Thread by @TWDFNR

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Why is "Prescribing Docusate for Constipation in Hospitalized Adults" a #TWDFNR?

This thread is a complement to the recently published review of the same name, appearing in February 2019 issue of @JHospMedicine

journalofhospitalmedicine.com/jhospmed/artic…

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Before discussing the review by Robert Fakheri and Frank Volpicelli, let's gauge current practice.

How do you currently use docusate in hospitalized adults with constipation?

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If you use docusate, you're not alone.

One single-center study found that docusate accounted for 64% of laxative doses. The cost: $60,000/year.

ncbi.nlm.nih.gov/pubmed/27323235

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How did we get here?

Early data suggested docusate my work. One study, from 1957, gave 16 patients with atonic constipation a placebo. They didn't respond.

They then gave these patients plus another 19 docusate. 51% had an "excellent response."

ncbi.nlm.nih.gov/pubmed/13458167

5/
But, despite early promise, subsequent studies failed to consistently demonstrate any benefit.

The largest placebo-controlled study enrolled just 74 hospice patients and found no benefit with docusate added to sennosides.

ncbi.nlm.nih.gov/pubmed/22889861

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The studies are heterogeneous, small, and generally low quality. Result: meta-analyses have been difficult to perform.

This is remarkable given how commonly we use docusate.

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In light of the paucity of proven benefit, any harms make the risk/benefit ratio favor not using docusate.

As the authors of the #TWDFNR review note, there are both patient and system-level harms.

Here are their recommendations.

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What do you think? Are you going to change your practice?

9/
This thread only covers parts of the arguments made by Fakheri and Volpicelli in their review.

To read more, download their paper published this month in @JHospMedicine

journalofhospitalmedicine.com/jhospmed/artic…