Darren Pasay, B.Sc.Pharm

Drug Stewardship Pharmacist (Central Zone)

darren.pasay@ahs.ca

Impact of a Drugs &

Therapeutics Backgrounder on

Docusate Utilization

I have no actual or potential conflict of interest in relation to

this topic or presentation.

Disclosure

• Drug Stewardship (DS) Team established in

2012

• “The shared responsibility of Drugs &

Therapeutics Committee (DTC), prescribers,

pharmacy and care units to ensure

medications are used in a manner that

maximizes the effectiveness, safety and

sustainability of care for our patients”

• Research and project support

Drug Stewardship in Alberta Health Services

Effectiveness

Safety

Sustainability

• Frontline staff wanted background and support on DTC/formulary

issues1

• One page document, meant to enhance conversations with

prescribers

• Supported by content experts, based upon DTC directions

• Published 6 times/year

• Followed by 2 interactive webinars for each edition

Drugs & Therapeutics Backgrounders

(DTBs)

1. Pasay Darren K, Chow Sheldon JS, Bresee Lauren C, Guirguis Micheal, Slobodan Jeremy. Assessment of current antimicrobial stewardship policies and

resources: a focus group project. Healthcare Infection 2015; 20: 7–15.

• Over-the-counter stool softener

• It is clear, based on published peer-reviewed

literature, that docusate is ineffective for the

prevention or treatment of constipation

• Open listed on AHS Provincial Drug

Formulary

• Limited coverage on Alberta Drug Benefit

List (palliative care only)

Docusate

• Influences o Engrained in practice

• Part of pharmacy, medicine,

nursing curriculums

• Order sets, Pre-printed care

orders (PPCO)

o Seen as innocuous, safe

• Preliminary work o ~ 2 million doses/year dispensed

o Some LTC sites have eliminated use already

• What are the costs of? o Procurement

o Processing, dispensing

o Medication administration

o Medication burden

Docusate DTB

BOTTOM LINE: Docusate is no more effective

than placebo for the prevention and treatment

of constipation.

CALL TO ACTION: Docusate may be stopped

with tapering or additional monitoring.

Patients already using docusate could have it

withdrawn without the need to replace it with

another laxative.

Synopsis of

evidence

Impact of use

HYPERLINK: Stool Softeners: WHY are they still used?

Meanwhile………….

• Order set revisions o Call to action in initial and follow up presentations to review/revise order

sets/PPCOs to remove docusate

o CPOE system in Calgary Zone

• Targeted communication to order set authors to remove docusate

• Therapeutic Interchanges o Removed docusate from Senekot-S interchange

Other interventions

• P – For sites in Alberta with measurable drug utilization data

• I – Did a multifaceted educational intervention to decrease docusate use

• C – Compared to other laxatives over time

• O – Result in fewer docusate DDD/1000 patient days dispensed

• Primary – Interrupted Time Series (ITS) analysis1,2

• Secondary – Proportional changes over time

Evaluation

1.Ramsay CR, Matowe L, Grilli R, Grimshaw JM, Thomas RE. “Interrupted time series designs in health technology assessment: lessons from two systematic reviews of behaviour change

strategies.” International Journal of Health technology Assessment in Health Care 2003; 19: 613-23

2.Use of Interrupted Time Series Analysis in Evaluating Health Care Quality Improvements Penfold, Robert B. et al. Academic Pediatrics , Volume 13 , Issue 6 , S38 - S44

• Dispended data obtained from each of 5 Zones

• Converted to defined daily doses (DDD) per 1000 patient days

• Utilization rates for the 6 months pre to and 3, 6, and 12 months post DTB

publication

• ITS o IBM SPSS 19 – ARIMA analysis

o Cochrane EPOC, ITS analysis

(https://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/21%20Interrupted%20time%20series%20anal

yses%202013%2008%2012_1.pdf)

• Proportional o Microsoft Excel

Methods

Drug Defined Daily Dose (DDD)

Docusate (capsule, liquid, syrup) sodium = 150 mg; calcium = 360 mg

PEG 3350 (powder) 17 grams

Lactulose (oral liquid) 6.7 grams (10 ml)

Magnesium hydroxide (MOM) 3 grams (30 ml)

Psyllium (capsule, powder) 7 grams

Study Medications

http://www.whocc.no/atc_ddd_index/

Results

* Statistically significant

Relative Change Confidence Interval

% p Low (%) High (%)

6 Months

Pre

Docusate -2.9 0.479 -12.5 6.6

Other Laxatives 2.4 0.554 -17.8 10.5

3 Months

Post

Docusate -19.6 0.025* -28.7 -1.2

Other Laxatives -5.0 0.339 -15.9 8.4

6 Months

Post

Docusate -25.9 0.027* -37.8 -1.2

Other Laxatives -6.2 0.376 -20.0 12.4

12 Months

Post

Docusate -33.0 0.091 -50.7 15.7

Other Laxatives -8.8 0.43 -28.2 23.7

Interrupted Time Series

Proportional

• Uncontrolled before/after design

• Multiple data sources/pharmacy systems

• Did not account for wastage or expired

• Non-constipation use included

• Did not include all known laxatives and cathartics

Limitations

• This project demonstrates that a multifaceted educational campaign with

clear messaging and a call to action can have significant impact on

medication use, while not inappropriately increasing the use of other agents.

• Two year data analysis (18 months post)

• Continued communication with order set/PPCO authors

• Intra-zone analysis

• Re-opening the delisting discussion

Conclusion & Future Directions

• DTB Review o AHS Drug Use Advisory Panel

• Interim report review o Gabrielle Zimmerman

• Co-authors: o Dr. Lauren Bresee

o Dr. Micheal Guirguis

o Jeremy Slobodan

• Project contributors o Caroline Ibrahim

o AHS Drug Use Evaluation

Acknowledgments

QUESTIONS

Contact Information:

Darren Pasay, B.Sc.Pharm.

Drug Stewardship Pharmacist, Alberta Health Services (Central Zone)

Email: darren.pasay@ahs.ca

Twitter: @RxDarrenP

Phone: 587-280-2307