Wednesday, October 12, 2016

A New "Lytic" Controversy: This One Isn't Full of Sh*t. Docusate As a Ceruminolytic

In my opinion, pharmacist "interventions" are a bad thing. While there are many reasons behind this, but I prefer creating a culture of open, prospective discussion rather than reactive drug policing. If I approach a prescriber in the ED, I'm greeted with "What did I do now?" I'm doing something wrong.

Discussing new papers, institutional protocols, sharing interesting patient cases, or you know, general human-to-human conversations are great opportunities for taking about drug therapy approaches, new ideas, or suggestions for improved patient care. Often, these interactions become more fruitful than chasing down problems after they occur. So much experience can be shared in these interactions, and open avenues to different approaches to known (or unknown) problems.

Docusate otic administration for cerumen impaction. I wish I could have been a part of the discussion the first time someone tried this.

"I've had a kid last night with a gnarly cerumen impaction."
"Saline irrigation not cutting it?"
"Not really. Any ideas on how to soften it in the future?"
"Docusate: works for poop, maybe it'll work for cerumen."

As it turns out, docusate may be useful as a ceruminolytic. While the literature describing this therapy is limited in numerous areas, it appears to be a reasonable alternative strategy to saline irrigation or triethanolamine polypeptide (no longer available in the US).(1,2) The most commonly cited study was conducted by Singer et. al, who conduced a prospective, randomized, controlled, double-blinded trial on a convenience sample of adult and pediatric patients in their ED who required removal of cerumen for tympanic membrane visualization.(1) If the physician determined the TM was partially or totally obstructed, patients were randomized to receive intra-aural docusate, or triethanolamine polypeptide, then the patient was positioned with the obstructed ear facing upward for 10-15 minutes.  Afterwards, the ceruminolytic was allowed to drain at which point the physician then determined whether the TM was totally, partially obstructed, or completely visualized.

There were 22 (82%) patients who received docusate with or without 100 mL saline irrigation and had complete visualization versus only 8 (35%) patients who received triethanolamine polypeptide with or without irrigation (95% CI 22.3 to 71.1).  Among patients younger than 5 years old, 8 (90%) achieved complete visualization of TM after receiving docusate with or without irrigation versus 0 (0%) patients who received triethanolamine polypeptide with or without irrigation (95% CI 50.5 to 100). No adverse events were reported by the investigators.

The authors concluded that docusate is a more effective ceruminolytic than triethanolamine, allowing for TM visualization in most patients.

From the literature, it is difficult to determine what dose was used. In the above study, 1 mL of docusate was used. I assume this was from the capsule, not the oral liquid. Cutting the tip of the capsule with trauma shears seems to be the best method of opening vs attempting to aspirate with a needle. Plus this would avoid any potential, accidental IV administrations, since cutting then squeezing wouldn't require a syringe.

Putting this to practice, can present some operational obstacles.  Particularly if CPOE exists at your institution since one may not be able to change the route of administration of docusate to "otic." If you're lucky enough to have EPIC as well as pharmacists dedicated to IT (here we do), an order screen can be created in a few hours or less.  Creating a user-friendly, orderable item is a vital step that will compliment thorough communication with all involved with the care of the patient involved. Even if the dose was administered PO, rather than otic, an error is an error.  It's not sexy pharmacy operations, but it is key.

Ref
1) Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000;36:228–32

2) Whatley VN, Dodds CL, Paul RI. Randomized clinical trial of docusate, triethanolamine polypeptide, and irrigation in cerumen removal in children. Arch Pediatr Adolesc Med. 2003;157:1181–3

3) Walling AD. Alternatives to Ear Syringing for Removal of Earwax. Am Fam Physician. 2004 Apr 15;69(8):1860-1863

See also GlobalRPh, and Ped EM Morsels for a nice discussion.

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