What are the recommendations for using stool softeners, such as docusate sodium, to treat constipation?

Stool Softeners for Constipation: Evidence-Based Recommendations

Stool softeners like docusate sodium should NOT be used as first-line treatment for chronic constipation, as they lack evidence of efficacy and are notably absent from the most recent 2023 AGA-ACG guidelines on pharmacological management of chronic idiopathic constipation. 1

What the Guidelines Actually Recommend

The 2023 AGA-ACG joint guideline conducted systematic reviews of multiple agents for chronic constipation but conspicuously did not include docusate sodium in their evidence review, examining only: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). 1

Strong Recommendations (First-Line Options):

• Polyethylene glycol (PEG) - 17g mixed in 8 ounces of water once daily 2
• Sodium picosulfate 1
• Linaclotide 1
• Plecanatide 1
• Prucalopride 1

Conditional Recommendations (Alternative Options):

• Fiber (psyllium with 8-10 ounces of fluid) 2
• Lactulose 1
• Senna 1
• Magnesium oxide 1
• Lubiprostone 1

The Evidence Against Docusate

Direct comparative trials show docusate is inferior to other treatments. A randomized controlled trial demonstrated that psyllium was superior to docusate sodium for softening stools (psyllium increased stool water content by 2.33% vs. docusate 0.01%, P=0.007) and had greater overall laxative efficacy. 3

In hospice patients, docusate showed no benefit. A randomized, double-blind, placebo-controlled trial found no significant differences between docusate plus sennosides versus placebo plus sennosides in stool frequency, volume, consistency, or patient-reported outcomes. 4

Limited Context Where Docusate Appears

Docusate only appears in older guidelines for specific situations:

• Opioid-induced constipation prophylaxis: The 2010 NCCN cancer pain guidelines mention "stool softener, stimulant laxative (senna, docusate, 2 tablets every morning)" as prophylactic measures when starting opioids. 1
• Older general practice recommendations: A 2015 review suggested docusate as a step after osmotic laxatives, but this predates the comprehensive 2023 guidelines. 5

Recommended Treatment Algorithm for Constipation

For Acute Constipation (1 week duration):

1. Start with PEG 17g daily (first-line pharmacological treatment) 2
2. Add stimulant laxative (bisacodyl) if insufficient response after 3-5 days 2
3. Consider suppositories or enemas if still inadequate response 2
4. Rule out impaction and obstruction if constipation persists 2

Supportive Measures (All Patients):

• Increase fluid intake, particularly if baseline consumption is low 2
• Increase dietary fiber if adequate fluid intake and physical activity present 2
• Exercise if feasible 2

Critical Pitfalls to Avoid

Do not use magnesium-based products in patients with renal insufficiency due to risk of hypermagnesemia. 2

Ensure adequate hydration when using fiber supplements (8-10 ounces of fluid) to prevent worsening constipation. 2

Stimulant laxatives should not be used for more than one week without medical supervision according to AGA recommendations. 2

Clinical Bottom Line

If you are considering docusate sodium, use PEG instead. The evidence strongly favors polyethylene glycol as first-line therapy with a strong recommendation from the most recent and highest quality guideline. 1, 2 Docusate's mechanism as a "stool softener" sounds appealing but lacks clinical efficacy data, which is why it was excluded from systematic review in the 2023 guidelines. 1

The only reasonable contemporary use of docusate is as prophylaxis when initiating opioid therapy, combined with a stimulant laxative, based on older cancer pain management protocols. 1 Even in this context, however, more effective agents exist and should be preferentially used. 1