Failure to deprescribe docusate common on hospital discharge

Last Updated: 2016-05-17

By Scott Baltic

NEW YORK (Reuters Health) - The stool softener docusate sodium is frequently prescribed to treat constipation, although there is little evidence that it works, and it is often not deprescribed on hospital discharge, Canadian researchers have found.

This was particularly surprising given the availability of effective alternatives, they note in the American Journal of Medicine, online May 3. The team also highlighted the risk of constipation among this inpatient population, some of whom had been newly prescribed opioids.

"There is considerable research showing that polypharmacy is a widespread problem, and our study is consistent with the literature, as the patients in our study were prescribed a median of 10 medications at the time of hospital discharge," corresponding author Dr. Thomas E. MacMillan from the University of Toronto and University Health Network told Reuters Health by email.

"While research on deprescribing is more limited," he added, "rates of deprescription appear to be low in other settings, suggesting that this problem is also widespread and difficult to tackle. From that perspective, our study may offer a useful 'snapshot' of the problem."

The study encompassed two groups of patients admitted to internal medicine at two large academic hospitals in Toronto from December 2013 through November 2014. One comprised all patients who received at least one dose of docusate (1,169 of 7,581 total admissions), and the second was a random sample of 452 patients from the first group, among whom laxative and opioid medication use were evaluated.

A systematic review of constipation treatments in the American Journal of Gastroenterology in 2005 summarized the evidence regarding docusate as "poor quality" and "insufficient to provide a recommendation for or against use," the authors note.

One-third of patients not receiving docusate before admission were prescribed the stool softener at discharge, potentially exacerbating polypharmacy.

Among patients already receiving docusate, 80% had it continued upon discharge, indicating "significant missed opportunities for deprescribing."

They contend that deprescription rates for ineffective medications such as docusate should be around 90% to 100%.

In the smaller, random sample, 53% had received docusate prior to admission, and only 13% of them had docusate deprescribed. Among patients not receiving docusate before admission, 33.2% (71/214) received a new prescription for docusate on discharge.

More than a quarter (28%) of patients receiving opioids were prescribed no laxatives or given docusate monotherapy, the researchers also found.

Beyond the issue of polypharmacy, the authors write, their findings are worthy of attention because patients receiving docusate might suffer from inadequate treatment of their constipation.

"Given the availability of effective therapies for constipation," the report concludes, "our results suggest quality improvement initiatives are needed to promote evidence-based laxative use in hospitalized patients, and discourage the use of less effective medications such as docusate sodium."

Among this study's strengths is the large representative sample of the hospitals investigated, according to Dr. Sarah N. Hilmer, an expert in geriatric pharmacology at the University of Sydney and Royal North Shore Hospital, St. Leonards, Australia.

One of the limitations, she told Reuters Health by email, is a lack of clinical outcome data (that is, bowel habit) to help assess the appropriateness of the docusate prescriptions.

Beyond that, Dr. Hilmer said the paper highlights a number of issues in deprescription and polypharmacy, such as how differences of hospital versus community settings might affect prescribing decisions.

"Patient bowel habit is affected by dehydration, immobility and other medicines used during acute care," she said. "Therefore we often need to prescribe more or less aperients in hospital than we would on discharge. Similar issues exist with diabetes and blood pressure management in hospital."

Dr. Hilmer also pointed to the lack of priority given to addressing polypharmacy in inpatients: "The pressures of managing the acute illness, short length of stay in hospital, lack of knowledge about the patient's detailed medical and medication history, and lack of expertise on assessing polypharmacy and deprescribing amongst most hospital staff all contribute to failure to address polypharmacy."

The HoPingKong Centre for Excellence in Education and Practice at the University Health Network, Toronto Western Hospital, partially supported this research. The authors made no disclosures.

SOURCE: http://bit.ly/201drgb

Am J Med 2016.