Potentially ineffective laxatives frequently prescribed in hospitals

Last Updated: 2016-06-27

By Reuters Staff

NEW YORK (Reuters Health) - Laxatives are widely prescribed to inpatients, more than half of whom also receive exit prescriptions for stool softeners, a new single-center study shows.

Two-thirds of laxatives prescribed in the hospital - and half of those prescribed for discharged patients - were docusate-based softeners, which have not been shown to be efficacious in treating or preventing constipation, Dr. Todd C. Lee and colleagues from McGill University in Montreal, Canada, found. Their findings appeared online June 20 in JAMA Internal Medicine.

"These medications contribute to inpatient pill burden, which is particularly troublesome in cases of polypharmacy or in patients who have difficulty swallowing," Dr. Lee and his team write. "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."

Constipation develops in 43% of inpatients during hospitalization, and laxatives are frequently prescribed, the researchers note.

"While relatively inexpensive themselves, the indirect cost of laxatives include: pharmacy inventory management and distribution; nursing administration time; a contribution to polypharmacy, and downstream investigations (e.g., Clostridium difficile testing) in the case of laxative-induced diarrhea," they add.

To investigate these indirect costs, the researchers looked at pharmacy distribution data for the 832-bed McGill University Health Center. They estimated nursing time at 45 seconds for each administration.

In total, in excess of 258,000 laxative doses were administered to medical and surgical inpatients in fiscal 2015, requiring more than 3,200 nursing hours, for a total cost of nearly 96 million Canadian dollars.

Almost two-thirds of laxatives administered in the hospital were docusate products. Half of discharged patients received a docusate product prescription, 11% sennosides, and 9.6% lactulose.

"While seemingly trivial, the routine use of docusate products in a constrained health care system is wasteful," Dr. Lee and his team write. "Perhaps it is time for a trial to address the efficacy and clinical benefit of inpatient laxative use so that we might avoid flushing good money down the toilet."

In an accompanying invited commentary on the findings, Dr. Kanako McKee and Dr. Eric Widera of the University of California, San Francisco, note that there are many downsides to docusates.

For example, patients must take a large dose in capsule or solution form several times a day, and the medications have an "unpalatable taste and lingering aftertaste." What's more, the researchers add, using docusates delays more effective constipation treatments.

"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," they state. "These adverse effects are not trivial."

They conclude: "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. We guarantee that prescribing practices for medications like docusate will change quickly afterwards."

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/28Y2cks and http://bit.ly/29fONFM

JAMA Intern Med 2016.