Hello AF support community

About a year ago I had an AF that took weeks and weeks to heal. Finally through trial and error I managed to find some magic combination of dietary intervention, supplements, and OTC stool softener. After it healed I continued using docusate sodium (100mg each night), magnesium citrate (200mg each night) and fiber supplements (1 tbs inulin in the morning and 1 tbs Benefiber in the morning) plus lots of fluids and 15-20 grams of fiber each day through food. That seemed to keep me healthy for about a year, with a few minor or near-AF situations developing. But I just seem super prone to hard stool, especially in the morning. And if I have a hard stool, the chances are very high that I will get an AF.

About a week ago I had a major tear occur. I'm feeling so low about it because the things that worked last time don't seem to be working this time around. I'm wondering if maybe the reason my stool got hard again and caused a tear is that I've developed a higher tolerance for docusate sodium and magnesium citrate. So my first question is:

Can you become more tolerant of docusate sodium so that in order to get the same softening effects you have to keep increasing the dosage? I know that it isn't dependency forming, like stimulant laxatives, but that doesn't rule out tolerance increasing.

My next question concerns something I was thinking to try: a quarter or half dose of Miralax. I'm nervous to add a full dose to my healing regimen because of fear of developing a dependency. My question is whether Miralax must be taken at a full dose to be effective, or whether one might get some good effects from a lower than recommended dose?

Any insight would be much appreciated. I've been in pain and bleeding every day for the past two weeks.

Thank you!

My experience with docusate sodium is that you do build up a tolerance, but not 100%. In other words, it helps most at first, but after a week or so it only helps somewhat from then on (maybe one-third or half as effective). I find that it helps to split the dose into 50mg in the morning and 50mg in the afternoon. If I have a harder-than-normal stool day, I'll take an extra 50mg in the morning just for that day. The 50mg capsules are harder to find, unfortunately. I get mine at CVS.

Miralax is not considered to be something that causes dependency since it's not a stimulating laxative. I find that staying between 3/4 to 1 cap produces the best results. If BMs get too soft then I cut back to 1/2 cap. I hope this was helpful.

William2 wrote:My experience with docusate sodium is that you do build up a tolerance, but not 100%. In other words, it helps most at first, but after a week or so it only helps somewhat from then on (maybe one-third or half as effective). I find that it helps to split the dose into 50mg in the morning and 50mg in the afternoon. If I have a harder-than-normal stool day, I'll take an extra 50mg in the morning just for that day. The 50mg capsules are harder to find, unfortunately. I get mine at CVS.

Thanks for your reply. I do think I may have built up a tolerance. I had been taking 100mg before bed to prevent hard stool in the morning. That seemed to work for about a year after my first fissure healed. Now I'm trying to heal from this second fissure and have found that not even 250mg is enough to soften my stool to a point in the morning where I don't have the dreaded hard tip problem. Today I'm going to try a new approach to see if that helps: taking 50mg at noon, 50mg at 4pm, and then 200mg before bed. And yes, the 50mg dose sure is hard to find! I found them at CVS and Walgreen's. I guess Colace makes 50mg too, but that brand is so expensive.

patience_and_healing wrote:Miralax is not considered to be something that causes dependency since it's not a stimulating laxative. I find that staying between 3/4 to 1 cap produces the best results. If BMs get too soft then I cut back to 1/2 cap. I hope this was helpful.

Thanks! It's helpful to hear that 1/2 cap could do some good, too. For the most part I've been experimenting with upping the docusate sodium. The Miralax seems to make me go more often, but I still have the hard tipped stool issue. It's weird how challenging it is to overcome that, and it seems like healing, at least in my case, completely depends on making that possible.

Regarding dependency and Miralax, I may have read somewhere that even osmotic laxatives can be dependency forming even as they're gentler than stimulants. The dependency that's possible has something to do with whether your body can draw water into the colon all on its own if we use osmotic laxatives for long stretches. I'm really unclear on what level of risk there is here though!

Unfortunately I have no idea how to avoid hard BM beginnings. I've read on this forum that using a bulb enema beforehand could help with that, and I tried it but found it too messy.

If you could point me to the information about miralax that would be great. I take a couple of medications that cause constipation so I can't stop taking the miralax. I would hate to develop a dependency on it though.

Hi guys, I haven't had the plug effect as they call it for a few months now after I started drinking a 16 oz cup of warm water first thing in the morning. But don't chug it, instead sup it slowly. The temperature, the time of consumption and the way of consumption allows the water to enter the digestive system and hydrate that portion of the stool that is still in process and will be coming out first thing the following day.

patience_and_healing wrote:Unfortunately I have no idea how to avoid hard BM beginnings. I've read on this forum that using a bulb enema beforehand could help with that, and I tried it but found it too messy.

If you could point me to the information about miralax that would be great. I take a couple of medications that cause constipation so I can't stop taking the miralax. I would hate to develop a dependency on it though.

Hi there. I've only ever seen the claim that Miralax is dependency forming from informal forum discussions (e.g., like this one: http://www.ibsgroup.org/forums/topic/42 ... od-to-use/, but eventually someone cites studies that seem to suggest it isn't dependency causing), not when researching empirical studies through GoogleScholar, for example.

I have my first GI appointment at the end of February and plan to ask about this to deepen my understanding. I'll report back if I hear anything helpful!

As for the bulb enema, I'm pretty sure it'd be too messy for me too. I'm also afraid of the rigid tube insertion.

Thanks for your reply!

P.S. This website by the Gastrointestinal Society of Canada has some very well-organized and useful information for chronic constipation, laxative use, and many other topics relevant to our health issues. Just thought I'd share:

https://www.badgut.org/information-cent ... pics/#c-en