How to Prescribe Colace (Docusate)
Based on current evidence, docusate (Colace) has limited efficacy for constipation and should not be a first-line agent—start with polyethylene glycol (MiraLAX) 17g daily or stimulant laxatives like senna instead. 1
Evidence Against Docusate as First-Line Therapy
The evidence for docusate is surprisingly weak despite its widespread use:
A systematic review found inadequate experimental evidence supporting docusate's effectiveness in chronically ill patients, with identified studies showing only small, non-significant trends toward increased stool frequency 2
In hospitalized cancer patients, a sennosides-only protocol was more effective than sennosides plus docusate (400-600 mg/day), with 62.5% achieving bowel movements >50% of days versus only 32% in the docusate combination group 3
In geriatric patients, docusate sodium (both once and twice daily) showed no significant improvement over placebo in a controlled trial, with mean stool frequency of 1.95-2.29 bowel movements per week versus 1.50-1.76 for placebo (P=NS) 4, 5
FDA-Approved Dosing (If You Choose to Use It)
If you decide to prescribe docusate despite limited evidence, the FDA labeling provides: 6
- Adults and children ≥12 years: 1-3 capsules (typically 100mg each) daily, taken as single or divided doses 6
- Children 2 to <12 years: 1 capsule daily 6
- Children <2 years: Consult physician 6
Recommended Alternative Approach
First-line therapy should be polyethylene glycol (MiraLAX) 17g once daily, which the AGA-ACG 2023 guidelines strongly recommend with moderate certainty of evidence, increasing complete spontaneous bowel movements by 2.90 per week versus placebo 1, 7
For patients requiring additional intervention: 1
- Add bisacodyl 10-15 mg daily to three times daily with goal of 1 non-forced bowel movement every 1-2 days 1
- Bisacodyl is recommended for short-term use (≤4 weeks) or rescue therapy, with starting dose of 5mg daily, maximum 10mg daily 1
For refractory cases after ruling out impaction/obstruction: 1, 7
- Increase PEG to twice daily (17g BID) for patients with months-to-weeks life expectancy 1, 7
- Consider adding senna 8.6-17.2 mg daily (up to 4 tablets twice daily), though long-term safety data are limited 1
When Docusate Might Be Considered
The NCCN Palliative Care guidelines mention docusate only in combination therapy: 1
- "Senna ± docusate, 2-3 tablets BID-TID" for dying patients (weeks-to-days life expectancy) with goal of 1 non-forced bowel movement every 1-2 days 1
- This represents its most appropriate use—as an adjunct to stimulant laxatives in end-of-life care, not as monotherapy 1
Critical Pitfalls to Avoid
- Do not use docusate as monotherapy for constipation prevention or treatment—the evidence does not support this practice despite its historical popularity 3, 2
- Do not assume "stool softener" means effective laxative—docusate's mechanism (reducing surface tension) does not reliably increase bowel movement frequency 4, 2
- Always rule out fecal impaction and mechanical obstruction before starting any laxative regimen, using physical exam and abdominal imaging if indicated 1, 7
- Discontinue non-essential constipating medications (opioids if possible, anticholinergics, calcium supplements) before escalating laxative therapy 1