I am looking for some feedback here. How would you manage this case?
A patient in her early 30s states that she has taken a Dulcolax tablet daily for over ten years. She states she spent most of that time in correctional facilities but never had any problem receiving an order for daily Dulcolax. She was out of jail for a time and continued to take OTC Dulcolax. She reports no abdominal work ups. Her only surgery was an appendectomy. Her only other medical problem is episodic asthma. Her physical exam is normal.
She now has arrived at one of my jails and wants me to continue her daily Dulcolax prescription. Should I? Here is my thought process:
My problem with this is that this is not optimal medical care. I’m sure that she is having problems with having a BM since her Dulcolax stopped–Dulcolax is habituating. But is the answer to continue to give her Dulcolax every day for the rest of her life?
If I prescribe the Dulcolax, will she really never ever have a bowel problem again? I doubt this. My sense is that those who take chronic laxatives have more ongoing bowel complaints, not fewer. Those of us not habituated to Dulcolax experience occasional constipation issues–from not eating enough fiber to getting sick and having transient gut slowing. Taking daily Dulcolax will not change this–those habituated to laxatives need the laxative to be at “baseline,” but still will have normal bowel fluctuations like the rest of us. In fact, my sense is that these fluctuations are more severe in those taking chronic laxatives–or, at least, they complain about them more.
Plus, this is a young patient. My wife’s grandmother used to purchase Milk of Magnesia by the case (no exaggeration!) but she was in her 90s. I would think twice about withdrawing chronic laxatives from a 90-year-old–is that really in her best interest? But in a healthy young woman? The best medical care I can provide to her would be to return her to normal bowel health.
Also, there is the Principle of Fairness to consider. If I prescribe Dulcolax to this patient based on her verbal history of constipation, I should fairly prescribe it to any inmate who states that he or she is constipated and wants Dulcolax. I guarantee that would be popular! I would get lots of requests!
In the end, I finally decided not to continue the ongoing Dulcolax prescription. However, I recognize that those with longstanding dependence on laxatives will have problems adjusting and will benefit from short-term use of a different laxative agent, preferably from a different class. My choice is polyethylene glycol (Miralax). My plan is to make this available to her for a couple of weeks during the transition phase.
However, obviously other doctors would approach this patient much differently. What would you do?