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Sunday, July 27, 2025

Docusate


Docusate is a stool softener classified as a surfactant laxative, used primarily to treat and prevent constipation by facilitating the easier passage of stool. It works by increasing the amount of water and fat absorbed into the stool, thereby softening it and making defecation less painful and more regular. Docusate is considered a gentle, non-stimulant option often recommended for patients who should avoid straining during bowel movements, such as those recovering from surgery, childbirth, or with cardiovascular conditions.

Pharmacological Classification

  • Therapeutic class: Laxative

  • Pharmacologic class: Surfactant (emollient) laxative

  • ATC Code: A06AA02

  • Legal status: Over-the-counter (OTC) in most countries

  • Forms available:

    • Docusate sodium (DSS) – most common

    • Docusate calcium

    • Docusate potassium (rare)

Brand Names

  • Colace (USA)

  • DulcoEase (UK)

  • Diocto, Soft-lax, Stool Softener, Regulex, Surfak

  • Many products combine docusate with senna (a stimulant), e.g., Senokot-S, Peri-Colace

Mechanism of Action

Docusate acts as a surface-active agent (surfactant), reducing surface tension in the stool. This allows water and lipids to penetrate the stool mass:

  • Hydrates and softens the fecal material

  • Eases stool passage through the colon and rectum

  • No effect on peristalsis or colonic motility

  • Works best when adequate fluid intake is maintained

It does not stimulate the bowel, which is why it is considered mild and gentle, especially for post-operative or cardiac patients.

Indications

Approved Uses

  • Relief of occasional constipation

  • Prevention of constipation in patients who should avoid straining:

    • Post-operative

    • Postpartum

    • Hemorrhoids

    • Cardiovascular diseases (e.g., post-MI)

  • Adjunct to opioid therapy to prevent opioid-induced constipation (OIC), though not preferred as monotherapy in OIC

  • Bowel prep before diagnostic procedures (in combination with other agents)

Dosage and Administration

Adults

  • Docusate sodium:

    • 50–300 mg daily in 1–4 divided doses

    • Common OTC dose: 100 mg once or twice daily

  • Docusate calcium:

    • Typically 240 mg once daily

  • Combination products: Senna + docusate: 8.6 mg senna / 50 mg docusate (1–2 tablets at bedtime)

Children

  • 6–12 years: 40–120 mg/day (divided doses)

  • 2–6 years: 20–60 mg/day

  • <2 years: Use only under medical supervision

Administration Notes

  • Take with a full glass of water

  • Best results with regular fluid intake

  • Onset of action: 12–72 hours (not immediate)

  • Rectal formulations (enemas or suppositories): 2–15 minutes onset

Contraindications

  • Hypersensitivity to docusate or its components

  • Nausea, vomiting, or abdominal pain of unknown cause

  • Intestinal obstruction or acute abdominal conditions

  • Concomitant use with mineral oil (see interaction section)

  • Prolonged use without medical supervision

Warnings and Precautions

  • Not for chronic constipation without clinical assessment

  • Should not be used for more than 7 days unless prescribed

  • Persistent constipation may indicate an underlying condition

  • Use with caution in patients with fluid/electrolyte imbalance, inflammatory bowel disease, or bowel obstruction

Adverse Effects

Common (1–10%)

  • Mild abdominal cramps

  • Nausea

  • Diarrhea (with higher doses)

  • Throat irritation (liquid form)

Rare (<1%)

  • Rash, pruritus, or allergic reactions

  • Rectal irritation (with suppository or enema use)

  • Electrolyte disturbances (if overused)

  • Dependence (rare if used as directed)

Drug Interactions

Contraindicated combinations:

  • Mineral oil: Docusate increases the absorption of mineral oil, which can lead to lipoid pneumonia when aspirated. Should never be used together.

  • Loop diuretics or corticosteroids: Long-term laxative use in combination may exacerbate hypokalemia

  • Stimulant laxatives (e.g., senna, bisacodyl): Combination increases risk of GI cramps, but frequently co-formulated for synergistic effect

  • Anticoagulants: Rare reports of altered absorption or effect when excessive diarrhea occurs

Use in Special Populations

Pregnancy

  • Considered safe (Category A in Australia)

  • Widely used to manage constipation during pregnancy

  • Preferred over stimulant laxatives

Breastfeeding

  • Compatible with lactation

  • No adverse effects on infants observed

Geriatric Use

  • Generally well tolerated

  • Useful in managing constipation due to immobility or opioid use

  • Excessive use may cause dehydration or electrolyte disturbances

Renal or Hepatic Impairment

  • No dose adjustment required

  • Monitor if used chronically with other medications affecting electrolytes

Comparative Insights (No Tables)

Docusate vs. Senna

  • Docusate is a stool softener – gentle, slow onset

  • Senna is a stimulant laxative – rapid and stronger action

  • Combination (e.g., Senokot-S) often used to balance softening with stimulation

Docusate vs. Lactulose

  • Lactulose is an osmotic laxative – draws water into colon

  • Slower acting but better for chronic constipation or hepatic encephalopathy

  • Docusate has fewer gas and bloating effects

Docusate vs. Polyethylene Glycol (PEG)

  • PEG (e.g., Movicol) is a first-line treatment for chronic constipation

  • Docusate is generally less effective in severe or chronic cases

  • PEG better supported in clinical trials

Clinical Guidelines

  • NICE (UK): Does not recommend docusate as first-line for chronic constipation; suggests osmotic laxatives (e.g., PEG)

  • American College of Gastroenterology (ACG): Limited efficacy of docusate in chronic constipation supported by evidence

  • British National Formulary (BNF): Lists docusate for occasional and mild constipation; emphasizes short-term use

Overdose and Toxicity

Symptoms

  • Diarrhea

  • Abdominal cramps

  • Electrolyte imbalances (rare)

  • Nausea, vomiting (in large doses)

Management

  • Discontinue drug

  • Maintain hydration

  • Monitor electrolytes

  • No specific antidote; symptomatic treatment only

Patient Counseling Points

  • Do not use for more than 7 days without consulting a doctor

  • Increase fluid intake, dietary fiber, and physical activity for best results

  • Do not take with mineral oil

  • May take 1–3 days to soften stool

  • Report persistent symptoms or rectal bleeding

  • Liquid form may taste unpleasant – mix with juice if needed

  • Do not double dose if one dose is missed

Special Use: Inducing Lactation (Uncommon)

  • Docusate has no role in inducing lactation, unlike domperidone

  • Any reports of its use for milk flow are anecdotal and unsupported




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