Is Pericolace (docusate) safe for elderly patients with constipation?

Safety of Pericolace (Docusate) for Elderly Patients with Constipation

Pericolace (docusate) is not recommended as a first-line treatment for constipation in elderly patients due to limited evidence supporting its efficacy, despite its common use. 1

Efficacy and Safety Concerns

• Docusate has been shown to be ineffective for constipation management when compared to placebo, psyllium, or sennosides in clinical trials involving older adults 1
• The FDA label indicates docusate generally produces bowel movements within 12 to 72 hours, but this is for occasional constipation rather than chronic constipation common in elderly patients 2
• Studies specifically examining docusate in elderly populations have failed to demonstrate meaningful clinical benefits compared to other laxative options 1

Preferred Treatment Options for Elderly

First-Line Recommendations:

• Polyethylene glycol (PEG) at 17 g/day is recommended as a first-line pharmacological treatment for elderly patients with constipation due to its efficacy and good safety profile 3
• PEG has demonstrated better clinical efficacy compared to lactulose in elderly constipated patients with no clinically relevant changes in biochemical or nutritional parameters after six months of treatment 4
• Osmotic laxatives (PEG, lactulose) or stimulant laxatives (senna, cascara, bisacodyl, sodium picosulfate) are generally preferred over docusate 3

Important Considerations for Elderly Patients:

• Laxative selection must be individualized based on the elderly person's medical history, particularly cardiac and renal comorbidities, potential drug interactions, and adverse effects 3
• Regular monitoring is required for elderly patients with chronic kidney/heart failure, especially when concurrent treatment with diuretics or cardiac glycosides is prescribed due to risk of dehydration and electrolyte imbalances 3
• Saline laxatives containing magnesium (e.g., magnesium hydroxide) should be used cautiously in elderly patients due to risk of hypermagnesemia, particularly in those with renal impairment 3

Non-Pharmacological Approaches

• Before considering any medication, implement non-pharmacological measures including:
  • Ensuring adequate toilet access, especially for patients with decreased mobility 3
  • Providing dietetic support to address nutritional needs 3
  • Managing decreased food intake related to aging or chewing difficulties 3
  • Optimizing toileting habits by educating patients to attempt defecation twice daily, usually 30 minutes after meals, and to strain no more than 5 minutes 3
  • Encouraging increased fluid intake and physical activity within patient limitations 3

Cautions and Contraindications

• Avoid bulk-forming laxatives in non-ambulatory elderly patients with low fluid intake due to increased risk of mechanical obstruction 3
• Liquid paraffin should be avoided in bed-bound patients and those with swallowing disorders due to risk of aspiration lipoid pneumonia 3
• For patients with swallowing difficulties or repeated fecal impaction, rectal measures (suppositories or enemas) may be preferred, with isotonic saline enemas being safer than sodium phosphate enemas in elderly patients 3

Algorithm for Management

1. Start with non-pharmacological measures (increased fluid, physical activity, optimized toileting)
2. If ineffective, initiate PEG 17 g/day as first-line pharmacological treatment
3. For patients who cannot tolerate or do not respond to PEG, consider osmotic alternatives (lactulose) or stimulant laxatives (senna, bisacodyl)
4. Reserve docusate only for very specific situations where other options are contraindicated or unavailable
5. For patients with fecal impaction, consider rectal measures (suppositories or enemas)
6. Monitor regularly for adverse effects, particularly in patients with renal impairment