title: Missed Opportunity to Deprescribe: Docusate for Constipation in Medical Inpatients.
abstract: BACKGROUND
  Hospital admissions provide an opportunity to deprescribe ineffective medications and reduce pill burden. Docusate sodium is a stool softener that is frequently prescribed to treat constipation despite poor evidence for efficacy, thus providing a good target for deprescription. The aims of this study were to characterize rates of use and discontinuation of docusate among internal medicine inpatients, as well as use of other laxatives.
  
  
  METHODS
  We conducted a retrospective observational study over 1 year on all patients admitted to internal medicine at 2 urban academic hospitals to determine rates of docusate use. We also evaluated laxative and opioid medication use on a random sample of 500 inpatients who received docusate to characterize patterns of prescription and deprescription.
  
  
  RESULTS
  Fifteen percent (1169/7581) of all admitted patients received 1 or more doses of docusate. Among our random sample, 53% (238/452) received docusate before admission, and only 13% (31/238) had docusate deprescribed. Among patients not receiving docusate before admission, 33.2% (71/214) received a new prescription for docusate on discharge. Patients receiving opioids were frequently prescribed no laxatives or given docusate monotherapy (28%, 51/185).
  
  
  CONCLUSIONS
  Docusate was frequently prescribed to medical inpatients despite its known ineffectiveness, with low deprescription and high numbers of new prescriptions. Docusate use was common even among patients at high risk of constipation. One third of patients not receiving docusate before admission were prescribed docusate on discharge, potentially exacerbating polypharmacy. Among patients already receiving docusate, 80% had it continued on discharge, indicating significant missed opportunities for deprescribing. Given the availability of effective alternatives, our results suggest that quality-improvement initiatives are needed to promote evidence-based laxative use in hospitalized patients.
authors.affiliation: Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Ontario, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada. Electronic address: tom.macmillan@uhn.ca.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: MacMillan
authors.affiliation: HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada.
authors.forename: Reza
authors.initials: R
authors.lastname: Kamali
authors.affiliation: Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Ontario, Canada; HoPingKong Centre for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada.
authors.forename: Rodrigo B
authors.initials: RB
authors.lastname: Cavalcanti
mesh_terms: D000368:Aged; D003248:Constipation / Q000188:drug therapy*; D000069340:Deprescriptions; D004143:Dioctyl Sulfosuccinic Acid / Q000627:therapeutic use*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D054368:Laxatives / Q000627:therapeutic use*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010351:Patient Discharge / Q000706:statistics & numerical data; D012189:Retrospective Studies
chemical_list: D054368:Laxatives; D004143:Dioctyl Sulfosuccinic Acid
keywords: Constipation; Deprescribing; Docusate; Inpatients; Polypharmacy