Practice Perfect 653
Opioid-Induced Constipation: A Movement Away from Docusate

For the majority of the time I’ve been in clinical practice, I’ve used docusate (Colace®) for my postoperative patients to prevent constipation – like many health-care providers. However, recent research has called this practice into question, and it turns out there are better options. Take a stool, have a seat, and let’s converse about constipation.

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Let’s converse about constipation

Etiology of Postoperative Constipation

Let’s first discuss the etiology of this problem, since it is quite different from chronic constipation. Let’s assume our postoperative patient population did not suffer from constipation before surgery. Constipation is generally broken up into two etiologies: consistency (hard stools) and altered defecation behavior (infrequency, evacuation difficulty, or straining).1 It’s also very important to understand that constipation is a symptom and not a diagnosis, because treatment will often depend on the cause.

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This issue may be due to several factors surrounding surgery:

  • Decreased mobility
  • Perioperative comorbidities
  • Dehydration
  • Increased age
  • Anesthetics
  • Certain medications (opioids being the major player here)

Docusate is the most commonly prescribed laxative, but its use is based on poor evidence. The most recent high-quality study demonstrated no difference in stool frequency, consistency or volume between docusate plus sennosides versus placebo plus sennosides3 and this is now being discouraged in favor of more effective methods.4 Unfortunately, there are no written consensus statements on management of constipation in postoperative patients, but we can extrapolate some reasonable practice methods from the research in the severely ill patient population5.

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The “Bottom” Line on Medications for Constipation

  • Bulking Agents (eg, psyllium) generally not recommended for bedridden patients due to need for increased hydration while taking. Avoid these.

  • Stimulant Laxatives
    • Sennosides 8.6mg, starting with 2 tabs PO QHS, titrating upward to a max of 4 tabs PO BID.
  • Osmotic Laxatives
    These medications may take 24-48 hours to take effect2 so may require a second medication to improve constipation quickly.
    • Lactulose 15-30mL PO daily to BID (max 60mL per day).
    • PEG 3350 oral powder, 1 capful (or 17g packet) dissolved in 4-8oz of liquid daily.
    • Magnesium Citrate 150mL PO divided daily to BID with max 300mL/day.
      Watch out! This one causes a reaction in 1-6 hours.

Reasonable Practice Policy on Postoperative Constipation Prevention

  1. Mobilize patients as soon as possible
  2. Encourage hydration
  3. Avoid drugs that cause constipation when possible but not at the expense of pain relief
  4. Prescribe a laxative to be taken at first administration of constipating medications
  5. Optimize toileting when possible (privacy, morning bowel movements, avoidance of bedpans)
  6. Osmotic laxatives, lactulose, and polyethylene glycol (PEG, MiraLAX®) are supported by higher levels of evidence
  7. Docusate is not recommended
  8. Use an enema or suppository if constipation persists (consider phosphate enemas in this case)

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These suggestions will keep your patients off the pot and on the way to recovery!

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Basson M. Constipation. Medscape. Updated March 28, 2017. Last accessed April 20, 2019.
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  2. Wald A. Management of chronic constipation in adults. UpToDate. Last updated March 5, 2019. Last accessed April 20, 2019.
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  3. 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 Jan;45(1):2-13.
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  4. Fakheri R and Volpicelli F. Things We Do for No Reason: Prescribing Docusate for Constipation in Hospitalized Patients. J Hosp Med. 2019 Feb;14(2):110-113.
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  5. Librach SL, Bouvette M, De Angeles C, et al. Consensus Recommendations for the Management of Constipation in Patients with Advanced, Progressive Illness. J Pain Symptom Manage. 2010 Nov;40(5):761-773.
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