What are the risks associated with daily use of stool softeners (e.g. docusate)?

From the Guidelines

Daily use of stool softeners is not recommended due to the risk of dependency and electrolyte imbalances, and instead, patients should focus on increasing fiber intake, adequate hydration, and regular physical activity to manage constipation. The use of stool softeners like docusate sodium or docusate calcium can lead to dependency, where the bowels become less effective at functioning normally without medication 1. Additionally, these medications can cause electrolyte imbalances with prolonged use, particularly affecting potassium, sodium, and magnesium levels. Some users may experience side effects including abdominal cramping, diarrhea, or nausea.

According to the American Gastroenterological Association-American College of Gastroenterology clinical practice guideline, the use of fiber supplementation is recommended as first-line therapy for chronic idiopathic constipation, particularly for individuals with low dietary fiber intake 1. The guideline suggests that among the evaluated fiber supplements, only psyllium appears to be effective. Furthermore, the guideline recommends the use of polyethylene glycol (PEG) as an osmotic laxative, which has been shown to be effective in improving stool consistency and frequency.

The American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation also recommends the use of laxatives as first-line agents, with a strong recommendation for the use of stimulant laxatives like bisacodyl or sodium picosulfate for short-term use or as rescue therapy 1. However, the guideline notes that there is limited evidence to support the use of stool softeners like docusate, and instead recommends the use of other agents like PEG or stimulant laxatives.

In terms of natural alternatives, adding a tablespoon of ground flaxseed to the diet or consuming prunes can effectively soften stool without the risks of medication dependence. If constipation persists requiring daily medication, it is essential to consult with a healthcare provider to rule out underlying conditions and develop a safer long-term management plan. Key considerations for managing constipation include:

• Increasing fiber intake to 25-30g daily
• Adequate hydration with 6-8 glasses of water daily
• Regular physical activity
• Avoiding long-term use of stool softeners
• Considering natural alternatives like ground flaxseed or prunes
• Consulting with a healthcare provider to rule out underlying conditions and develop a safer long-term management plan.

From the Research

Daily Stool Softener Risks

• The use of daily stool softeners, such as docusate sodium, has been studied in various clinical trials to assess their efficacy and safety in treating chronic constipation 2, 3, 4, 5, 6.
• A study published in 1998 found that psyllium was superior to docusate sodium in increasing stool water content and overall laxative efficacy in subjects with chronic idiopathic constipation 2.
• Another study published in 2018 found that senna and lactulose were the most studied laxatives in long-term care patients, and senna was found to be superior to or as effective as other laxatives, including docusate sodium 3.
• A systematic review published in 2005 found that there was a paucity of quality data regarding many commonly used agents, including stool softeners, and that psyllium and lactulose had moderate evidence to support their use in treating chronic constipation 4.
• A review published in 2010 found that the quality of evidence for the use of faecal softeners, including docusate, was low, and that there was limited data to support their use in adults with idiopathic chronic constipation 5.
• A study published in 2021 found that docusate did not show any benefits for constipation when compared with placebo or psyllium or sennosides, and that psyllium and sennosides were more effective compared with docusate 6.

Risks and Side Effects

• The use of daily stool softeners, such as docusate sodium, may be associated with risks and side effects, including gastrointestinal upset, diarrhea, and abdominal cramps 2, 3, 4, 5, 6.
• A study published in 2018 found that the frequency and severity of adverse drug reactions were similar between the arms of the studies, and that no serious adverse drug reactions were reported 3.
• Another study published in 2021 found that there was a lack of data to support the use of docusate for constipation, and that pharmacists and healthcare providers should reassess and reconsider whether to use it in the older adult population 6.

Efficacy and Safety

• The efficacy and safety of daily stool softeners, such as docusate sodium, have been studied in various clinical trials, and the results suggest that they may not be effective in treating chronic constipation 2, 3, 4, 5, 6.
• A study published in 1998 found that psyllium was superior to docusate sodium in increasing stool water content and overall laxative efficacy in subjects with chronic idiopathic constipation 2.
• Another study published in 2018 found that senna and lactulose were the most studied laxatives in long-term care patients, and that senna was found to be superior to or as effective as other laxatives, including docusate sodium 3.