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Senna

Senna

Scientific Name(s): Cassia acutifolia Delile, syn. with Cassia senna L. Also includes references to C. angustifolia Vahl. Family: Fabaceae (beans)

Common Name(s): Senna

Uses of Senna

Senna is most commonly used as a laxative.

Senna Dosing

Senna leaves or pods have been used as a stimulant laxative at dosages of 0.6 to 2 g/day, with a daily dose of sennoside B from 20 to 30 mg. The brand Senokot is available in 8.6 and 17.2 mg tablets. A bitter tea can be made containing senna 0.5 to 2 g (ie, ½ to 1 teaspoon). Senna should not be used at higher doses or for extended periods of time.

Contraindications

Senna is contraindicated in patients with intestinal obstruction, ulcerative colitis, appendicitis, and Crohn disease. Senna is not recommended for children younger than 2 years of age.

Pregnancy/Lactation

Category C . Use with caution until more definitive information is known. Some data suggest endometrial stimulation and mutagenic and genotoxic effects with senna usage. Other sources suggest it is the laxative drug of choice in pregnancy.

Senna Interactions

Use of senna with drugs known to deplete potassium, such as diuretics, should be limited or avoided. Because senna may cause diarrhea, caution is warranted in patients receiving warfarin, because diarrhea can reduce the absorption of vitamin K and increase the risk of bleeding.

Senna Adverse Reactions

Senna may cause diarrhea, loss of fluids, hypokalemia, and abdominal pain/cramping. The long-term use of senna has resulted in pigmentation of the colon, reversible finger clubbing, cachexia, and dependency on the laxative. Children, particularly those wearing diapers, may experience severe diaper rash, blister formation, and skin sloughing. Case reports indicate a possible association between long-term administration of senna and hepatotoxicity.

Toxicology

Various case reports of senna toxicity are available and include coma and neuropathy after ingestion of a senna-combination laxative, as well as hepatitis after long-term use of the plant.

Botany

C. acutifolia is native to Egypt and the Sudan while C. angustifolia is native to Somalia, the Middle East, and India. Plants known as wild sennas ( C. hebecarpa Fern. and C. marilandica L.) grow on moist banks and in woods in the eastern United States. This plant should not be confused with cassia, a common name for cinnamon. Senna is a low branching shrub, growing to about 1 m in height. It has a straight woody stem and yellow flowers. 1 The top parts are harvested, dried, and graded. Tinnevally senna is hand-collected, while Alexandria senna is harvested and graded mechanically. There are over 400 known species of Cassia . 1 , 2

History

Senna was first used medicinally by Arabian physicians in the 9th century A.D. 1 The plant derives its name from the Arabic sena and from the Hebrew word cassia , which means “peeled back,” a reference to its peelable bark. It has long been used in traditional Arabic as well as European medicine, primarily as a cathartic. The leaves were brewed into a tea and administered as a strong laxative. Because it is often difficult to control the concentration of the active ingredients in the tea, an unpredictable effect may be obtained. Therefore, standardized commercial dosage forms have been developed, and these concentrates are available as liquids, powders, and nonprescription tablets in over-the-counter laxatives.

Chemistry

Senna contains anthraquinones, including dianthrone glycosides (1.5% to 3%), sennosides A and B (rhein dianthrones), and sennosides C and D (rhein aloe-emodin heterodianthrones). Numerous minor sennosides have been identified, and all appear to contribute to the laxative effect. The plant also contains free anthroquinones in small amounts including rhein, aloe-emodin, chrysophanol, and their glycosides. 3 , 4

Senna pods also contain the same rhein dianthrone glycosides as the leaves.

Carbohydrates in the plant include 2% polysaccharides and approximately 10% mucilage consisting of galactose, arabinose, rhamnose, and galacturonic acid. 3 , 4 Other carbohydrates include mannose, fructose, glucose, pinitol, and sucrose. 3

Flavonols present include isorhamnetin and kaempferol. Glycosides 6-hydroxymusizin and tinnevellin are also found.

Other constituents in senna include chrysophanic acid, salicylic acid, saponin, resin, mannitol, sodium potassium tartrate, and trace amounts of volatile oil. 3 , 5

Senna Uses and Pharmacology

Senna is a potent laxative. Its cathartic effects can be obtained from a tea prepared from 1 or 2 teaspoons of dried leaves or standardized commercial dosage forms. Senna’s use in treating constipation is well documented. It is one of the most popular laxatives, especially in elderly patients. 6

Approximately 90% of sennosides are excreted in the feces as polymers. Only 3% to 6% of the metabolites of sennosides are excreted in urine. 7

An in vitro study using Caco-2 monolayers as a model of the human intestinal mucosal barrier suggests that sennosides A and B are transported in a concentration-dependent manner. Transport was higher in the secretory direction compared with the absorptive direction, suggesting the involvement of efflux pumps in the intestine. 8

Laxative

Animal data

Senna has also been studied for long-term laxative treatment in rats. 9 Perivascular nerve stimulation caused a vasconstrictive effect on the mesenteric vascular bed. However, it is thought that myenteric neurons in the rat colon are not destroyed by sennosides, as had been previously suggested. 10 , 11 , 12 , 13 Anthraquinone purgatives in excess were said to have caused degeneration of neurons.

Sennosides exert their cathartic effect through alterations in colonic motility, which occurs indirectly by damage to the epithelial cells. They also change colonic absorption and secretion to cause fluid accumulation. Enhanced permeability is the result of disruption of the tight junctions between the colonic epithelial cells. 14

Metabolism of anthranoid laxatives 15 , 16 and sennosides 17 , 18 , 19 have been reported.

Clinical data

Many reports are available discussing senna’s role in constipation 20 , 21 ; its use in elderly patients, 22 , 23 , 24 , 25 , 26 psychiatric patients, 27 and spinal cord injury patients 28 ; and in pregnancy, in which it is the stimulant laxative of choice. 29 In cancer treatment protocols, senna has also been noted to reverse the constipating effects of narcotics, and may prevent constipation if given with the narcotic. 30 However, it may cause more adverse effects than other laxatives, primarily abdominal pain. 31 In terminally ill patients with cancer, it has also demonstrated efficacy in preventing constipation, which may not only be attributable to opioids but potentially due to administration of tricyclic antidepressants or phenothiazines, physical inactivity, deficient nutrition, and/or inadequate fluid intake. 32 Senna has also been studied in long-term constipation. 33 Castor oil was superior to senna for long-term constipation sufferers in another report. 34 In a study of children younger than 15 years of age with constipation, the efficacy and adverse effects of senna were compared with lactulose. Lactulose use resulted in patients passing more normal stools than on the corresponding day of the senna week. Additionally, senna was associated with more adverse effects with greater frequency compared with lactulose. 35

Patients who underwent reconstructive pelvic surgery were randomized to receive senna 8.6 mg/docusate 50 mg or placebo following the surgery. There was a significant difference in time to first bowel movement (3 ± 1.5 vs 4.05 ± 1.5 days; P < 0.002) for patients receiving senna and docusate compared with placebo. Additionally, significantly more patients receiving placebo required magnesium citrate ( P < 0.001). 36 Senna may influence intestinal transit time. 37 , 38 , 39 Its effectiveness as part of a cleansing regimen to evacuate the bowels in preparation for colonoscopies or barium enemas is documented. 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 Results from these studies include reduced ingestion of commercial Golytely solution and simethicone when given with senna 45 and more effective colon cleansing with senna in combination with polyethylene glycol electrolyte lavage solution compared with the solution alone. 46 However, a study comparing the efficacy of PEG 2 L and senna syrup 120 mg with PEG 4 L found that the combination therapy was not as effective as the larger quantity of PEG, though it was better tolerated (ie, 38% could not finish the PEG 4 L compared with 6% receiving combination therapy). 53

A study of 345 patients undergoing colonoscopies assessed the efficacy of magnesium citrate combined with senna versus magnesium citrate alone. In patients receiving magnesium citrate only, 6.9% of the patients had to reschedule the colonoscopy due to inadequate bowel evacuation. In those patients receiving combination therapy, 4.4% required rescheduling ( P = 0.44). Adequate visualization during the colonoscopy occurred in 81.3% of patients receiving combination therapy compared with 67.5% receiving magnesium citrate alone ( P = 0.004). 51 When senna 180 mg was compared with 95 mL of sodium phosphate solution for bowel evacuation prior to colonoscopy, senna was not equivalent to sodium phosphate. However, senna was better accepted compared with sodium phosphate based on taste, and was associated with less nausea and vomiting. 54

Capsule endoscopies are useful for assessing obscure GI bleeding, suspected small-bowel Crohn disease, celiac disease, polyposis syndromes, and small-bowel tumor detection. Compared with standard preparation (ie, restriction to clear fluids, fasting, simethicone), the addition of purgatives, such as magnesium citrate and senna, did not improve completion rates or view quality and were associated with less patient acceptance. 55

Because sennosides are water-soluble polar molecules with a high molecular weight, they are not resorbed in the small intestine. Specifically, the beta-glycosidic bond provides protection against acid digestion and to alpha-glucosidase activity. Instead, they act as prodrugs as they pass through the small intestine. They are later converted in the large intestine by gut bacteria to the active metabolite, rheinanthrone, which increases colonic motility and fluid secretion. 1 , 7 , 56 , 57

Prostaglandins may also be involved in the laxative actions. 3 The kinetics of senna constituents rhein and aloe-emodin have been investigated in humans. 58

Other uses

The senna constituents, aloe-emodin and beta-sitosterol, possess inhibitory activity against cancer cells in mice. 2 , 9

Senna did not have antidiabetic activity when tested in diabetic mice. 59

Senna extract was not found to be cytotoxic or mutagenic against strains of Escherichia coli . However, senna was able to induce single and double-strand breaks in plasmid DNA, suggesting senna may only be toxic to DNA in cell-free systems. 60

Dosage

Senna leaves or pods have been used as a cathartic laxative at dosages of 0.6 to 2 g/day, with a daily dose of sennoside B from 20 to 30 mg. The brand Senokot is available in 8.6 and 17.2 mg tablets. 61 Effects usually occur within 8 to 12 hours of administration and may last up to 24 hours. 62 A bitter tea can be made containing 0.5 to 2 g (ie, ½ to 1 teaspoon) of senna. 2 Senna should not be used at higher doses or for extended periods of time. 63

Pregnancy/Lactation

Category C . The use of senna during pregnancy is controversial. Due to minimal absorption of senna glycosides by the intestines, a teratogenic effect would not be expected. However, prolonged use may cause fluid and electrolyte imbalances. 62

Some data suggest endometrial stimulation and mutagenic and genotoxic effects with senna usage. 64 , 65 Other sources suggest it is the laxative of choice during pregnancy. In a 2009 case-control epidemiological study, the use of senna was not associated with a higher risk of congenital abnormalities in the offspring of pregnant women with constipation. 62 However, until more definitive information is known, use with caution. 14

Interactions

Use of senna with drugs known to deplete potassium levels, such as diuretics, should be limited or avoided. Patients may be at an increased risk of cardiac complications. 63 Because senna may cause diarrhea, caution is warranted in patients receiving warfarin, because diarrhea can reduce the absorption of vitamin K and increase the risk of bleeding. In a case report, a woman 45 years of age with an aortic valve taking warfarin presented with abdominal pain. She had been taking senna once to twice per week; however, she took “many” tablets (unspecified) to relieve 2 days of constipation when her abdominal pain started. She reported 3 watery stools and 3 bloody stools. At the time of admission, she was hypotensive, tachycardic, and had a distended abdomen. A computed tomography of the abdomen revealed hematomas in the pelvic, paracolic, and subhepatic regions. Her international normalized ratio (INR), which was therapeutic 25 days prior to admission, was 11.9. She was given vitamin K, fresh frozen plasma, and packed red cells, and her INR eventually returned to the target range. 66

Adverse Reactions

Senna may cause loss of fluids, hypokalemia, diarrhea, and abdominal pain and cramping. 14 Prolonged use may alter electrolytes and thereby increase the risk for cardiac complications. Patients with intestinal obstruction should avoid senna. 3

Long-term use of any laxative, in particular irritant laxatives such as senna, often results in laxative dependency syndrome, characterized by poor gastric motility in the absence of repeated laxative administration. Other reports of laxative abuse include laxative-induced diarrhea 67 , 68 and osteomalacia and arthropathy associated with prolonged use of the product. 69

The long-term use of anthroquinone glycosides has been associated with pigmentation of the colon (melanosis coli). Several cases of reversible finger clubbing (enlargement of the ends of the fingers and toes) have been reported following long-term abuse of senna-containing laxatives. 70 , 71 , 72 One report described a woman who developed finger clubbing following ingestion of 4 to 40 Senokot tablets per day for approximately 15 years. 73 Clubbing reversed after the laxative was discontinued. The mechanism has been postulated to be related to either increased vascularity of the nail beds or a systemic metabolic abnormality secondary to long-term laxative ingestion. A case report describes a patient with anorexia nervosa using 50 to 100 tablets of senna daily for weight loss. She developed nephrocalcinosis, finger clubbing, and hypertrophic osteoarthropathy. Nephrocalcinosis was likely due to long-term ingestion of calcium (each senna tablet contained calcium 12.5 mg) in the presence of dehydration, resulting in low calcium excretion. This, in addition to a low body mass index, contributes to calcium phosphate retention. 74

Senna abuse has been associated with the development of cachexia and reduced serum globulin levels after long-term ingestion. 75

Case reports include occupational asthma and rhinoconjunctivitis from a factory worker exposed to senna-containing hair dyes 76 and asthma and allergy symptoms from workers in a bulk laxative manufacturing facility. 77 Another report describes urticaria, rhinoconjunctivitis, and wheezing occurring within 2 hours of an occupational exposure to airborne senna despite wearing a protective suit and respirator. 78

Senna may cause hepatotoxicity. This may be attributed to the exposure of the liver to high amounts of toxic metabolites of anthraquinone glycosides. 7

In a case report, a woman 42 years of age who boiled dried senna leaves and consumed 200 mL of the product each day for 2 years presented with a 5-day history of epigastric pain, vomiting, anorexia, fever, mildly elevated liver function tests, and iron deficiency anemia. She was diagnosed with portal vein thrombosis based on Doppler findings. Additionally, fluid loss and dehydration associated with long-term use of senna may have exerted negative effects on coagulation. 14

Another case report describes the development of subacute cholestatic hepatitis in a man 77 years of age who used senna 15 to 30 mg/day for 3 months. Discontinuation of the product resulted in a progressive decline in liver enzymes and bilirubin levels. 79

Children, particularly those wearing diapers, may experience severe diaper rash, blister formation, and skin sloughing. In a study of 88 exposures to senna, 33% displayed severe diaper rash, which was significantly worse for those wearing diapers ( P < 0.05). The presence of blisters and skin sloughing was also worse in children wearing diapers ( P < 0.05). Diarrhea occurred 5 to 6 hours after ingestion of senna, with skin lesion appearing 14 to 15 hours following ingestion. Thus, the dermatologic manifestations could be attributed to prolonged skin contact with stool or senna being present in later stools, causing an irritant effect on the skin. 80

Patients who are homozygous for the CYP2D6∗4 variant, and thus poor metabolizers for phase 1 hepatic detoxification reactions, may be at risk of hepatitis. The CYP2D6∗4 variant is common in approximately 10% of white people. 81

Toxicology

Concerns regarding the carcinogenicity of anthranoid laxatives have been raised. In a 2-year study, rats receiving senna dosages of 25, 100, and 300 mg/kg/day did not show any changes in several assessments, including hematology measures, tissue histology, and mortality ratio, when compared with the control rats. High doses of senna were associated with increases in water consumption, electrolyte changes, and increases in tubular basophilia and tubular pigment deposits in the kidneys. In fact, other animal data suggest that senna may have anticancer action. 56 , 82 , 83

An analysis of the literature from 2009 suggests: (1) senna is not associated with structural and/or functional changes in the enteric nerves, (2) long-term administration of senna is not associated with GI tumors or any other type in rats, (3) when dosed up to 300 mg/kg in rats for 2 years, senna was not carcinogenic, and (4) evidence does not show an increased risk of genotoxicity in patients treated with senna. 13

Risk assessment for senna’s use during pregnancy has been addressed. 84 One review suggests senna to be the stimulant laxative of choice during pregnancy and lactation. 29 Uterine motility was not stimulated by sennosides in one report in pregnant ewes. 85 None of the breast-fed infants experienced abnormal stool consistency from their mothers’ ingestion of senna laxatives. The constituent rhein, taken from milk samples, varied in concentration from 0 to 27 mg/mL, with between 89% and 94% of values no more than 10 mg/mL. 86 , 87 Nonstandardized laxatives are not recommended during pregnancy. 3

Toxicity studies separating toxic components of senna’s anthraquinone derivatives have been performed. 88

Various case reports of senna toxicity are available and include coma and neuropathy after ingestion of a senna-combination laxative 89 and hepatitis after long- term use of the plant. 90

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73. FitzGerald O, Redmond J. Anthraquinone-induced clubbing associated with laxative abuse. Ir J Med Sci . 1983:152(6):246-247.

74. Lim AK, Hooke DH, Kerr PG. Anorexia nervosa and senna misuse: nephrocalcinosis, digital clubbing and hypertrophic osteoarthropathy. Med J Aust . 2008;188(2):121-122.

75. Levine D, Goode AW, Wingate DL. Purgative abuse associated with reversible cachexia, hypogammaglobulinemia, and finger clubbing. Lancet . 1981;1(8226):919-920.

76. Helin T, Mäkinen-Kiljunen S. Occupational asthma and rhinoconjunctivitis caused by senna. Allergy . 1996;51(3):181-184.

77. Marks GB, Salome CM, Woolcock AJ. Asthma and allergy associated with occupational exposure to ispaghula and senna products in a pharmaceutical work force. Am Rev Respir Dis . 1991;144(5):1065-1069.

78. Wong CG, Jakubovic H, Betschel SD. Senna: drug hypersensitivity following occupational exposure: case report. Reactions . 2009;1(1240):37.

79. Sonmez A, Yilmaz MI, Mas R, et al. Subacute cholestatic hepatitis likely related to the use of senna for chronic constipation. Acta Gastroenterol Belg . 2005;68(3):385-387.

80. Spiller HA, Winter ML, Weber JA, Krenzelok EP, Anderson DL, Ryan ML. Skin breakdown and blisters from senna-containing laxatives in young children. Ann Pharmacother . 2003;37(5):636-639.

81. Seybold U, Landauer N, Hillebrand S, Goebel FD. Senna-induced hepatitis in a poor metabolizer. Ann Intern Med . 2004;141(8):650-651.

82. Borrelli F, Aviello G, Capasso R, Capasso F. Senna: a laxative devoid of carcinogenic effects. Arch Toxicol . 2006;80(12):873.

83. Mascolo N, Mereto E, Borrelli F, et al. Does senna extract promote growth of aberrant crypt foci and malignant tumors in rat colon? Dig Dis Sci . 1999;44(11):2226-2230.

84. Risk assessment for senna during pregnancy. Pharmacology . 1992;44(suppl 1):20-22.

85. Garcia-Villar R. Evaluation of the effects of sennosides on uterine motility in the pregnant ewe. Pharmacology . 1988;36(suppl 1):203-211.

86. Faber P, Strenge-Hesse A. Relevance of rhein excretion into breast milk. Pharmacology . 1988;36(suppl 1):212-220.

87. Faber P, Strenge-Hesse A. Senna-containing laxatives: excretion in the breast milk? [in German]. Geburtshilfe Frauenheilkd . 1989;49(11):958-962.

88. Hietala P, Marvola M, Parviainen T, Lainonen H. Laxative potency and acute toxicity of some anthraquinone derivatives, senna extracts, and fractions of senna extracts. Pharmacol Toxicol . 1987;61(2):153-156.

89. Dobb GJ, Edis RH. Coma and neuropathy after ingestion of herbal laxative containing podophyllin. Med J Aust . 1984;140(8):495-496.

90. Beuers U, Spengler U, Pape GR. Hepatitis after chronic abuse of senna. Lancet . 1991;337(8737):372-373.

Copyright © 2009 Wolters Kluwer Health

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Senna

Senna

Pronunciation Generic Name: senna (SEN nah)

Brand Name: Black Draught, Dr Caldwell Laxative, Ex-Lax Chocolated, Ex-Lax Maximum Relief Formula, Ex-Lax Regular Strength Pills, Fletchers Castoria, Innerclean, Little Tummys Laxative Drops, Pedia-Lax, Perdiem Overnight, Senexon, Senna, Senna Lax, Senna Smooth, Senna-gen, Senokot, Senokot Extra, Senokot To Go, SenokotXTRA, SenoSol, SenoSol-X

OverviewSide EffectsInteractionsFor ProfessionalsMore…

What is senna?

Senna is also known as Cassia senna, tinnevelly senna, Indian senna, Alexandrian senna, and Khartoum senna.

Senna has been used in alternative medicine as an aid to treat constipation.

Not all uses for senna have been approved by the FDA. Senna should not be used in place of medication prescribed for you by your doctor.

Senna is often sold as an herbal supplement. There are no regulated manufacturing standards in place for many herbal compounds and some marketed supplements have been found to be contaminated with toxic metals or other drugs. Herbal/health supplements should be purchased from a reliable source to minimize the risk of contamination.

Senna may also be used for purposes not listed in this product guide.

What is the most important information I should know about senna?

Not all uses for senna have been approved by the FDA. Senna should not be used in place of medication prescribed for you by your doctor.

Senna is often sold as an herbal supplement. There are no regulated manufacturing standards in place for many herbal compounds and some marketed supplements have been found to be contaminated with toxic metals or other drugs. Herbal/health supplements should be purchased from a reliable source to minimize the risk of contamination.

Use senna as directed on the label, or as your healthcare provider has prescribed. Do not use this product in larger amounts or for longer than recommended.

Call your healthcare provider if your symptoms do not improve, or if they get worse while using senna. Do not use this product for longer than 1 week without the advice of a healthcare provider.

What should I discuss with my health care provider before taking senna?

Ask a doctor, pharmacist, herbalist, or other healthcare provider if it is safe for you to use this product if you have:

  • a bowel disorder such as Crohn’s disease or ulcerative colitis;

  • heart disease; or
  • stomach pain, nausea, or vomiting.

It is not known whether senna will harm an unborn baby. Do not use this product without medical advice if you are pregnant.

It is not known whether senna passes into breast milk or if it could harm a nursing baby. Do not use this product without medical advice if you are breast-feeding a baby.

Some forms of senna are made for use by children. Do not give any herbal/health supplement to a child without the advice of a doctor.

How should I take senna?

When considering the use of herbal supplements, seek the advice of your doctor. You may also consider consulting a practitioner who is trained in the use of herbal/health supplements.

If you choose to use senna, use it as directed on the package or as directed by your doctor, pharmacist, or other healthcare provider. Do not use more of this product than is recommended on the label.

Senna is usually taken before bed to produce a bowel movement 6 to 12 hours later when you wake up.

Measure liquid medicine with a special dose-measuring spoon or medicine cup, not with a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one.

Do not use different formulations of senna (such as tablets and liquid) at the same time without medical advice. Using different formulations together increases the risk of an overdose of senna.

Call your healthcare provider if your symptoms do not improve, or if they get worse while using senna. Do not use this product for longer than 1 week without the advice of a healthcare provider.

Store at room temperature away from moisture, heat, and light.

What happens if I miss a dose?

Skip the missed dose if it is almost time for your next scheduled dose. Do not use extra medicine to make up the missed dose.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

What should I avoid while taking senna?

Follow your healthcare provider’s instructions about any restrictions on food, beverages, or activity.

Senna side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your healthcare provider at once if you have a serious side effect such as:

  • severe stomach pain, severe diarrhea, watery diarrhea;

  • weight loss;
  • worsening constipation after you stop taking senna;
  • enlargement of your fingers and toes;
  • low potassium (confusion, uneven heart rate, extreme thirst, increased urination, leg discomfort, muscle weakness or limp feeling); or
  • nausea, upper stomach pain, itching, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

Less serious side effects may include:

  • stomach cramps, bloating, gas, mild diarrhea;

  • numbness or tingly feeling;
  • joint pain; or
  • discolored urine.

This is not a complete list of side effects and others may occur. Tell your doctor, pharmacist, herbalist, or other healthcare provider about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088.

See also: Senna side effects (in more detail)

What other drugs will affect senna?

Do not take senna without the advice of a healthcare provider if you are using any of the following medications:

  • digoxin (Lanoxin);

  • a diuretic (water pill); or
  • a blood thinner such as warfarin (Coumadin, Jantoven).

This list is not complete and other drugs may interact with senna. Tell your healthcare provider about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

Next Page → Side Effects

More Senna resources

  • Side Effects
  • Pregnancy Warnings
  • Drug Images
  • Drug Interactions
  • Support Group
  • 8 Reviews - Add your own review/rating

Compare Senna with other medications

  • Bowel Preparation
  • Constipation

Where can I get more information?

  • Consult with a licensed healthcare professional before using any herbal/health supplement. Whether you are treated by a medical doctor or a practitioner trained in the use of natural medicines/supplements, make sure all your healthcare providers know about all of your medical conditions and treatments.

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Senna

Senna

Pronunciation Class: Cathartics and Laxatives

ATC Class: A06AB06

VA Class: GA204

CAS Number: 8013-11-4

Brands: Black Draught, Dr. Caldwell, Dr. Edwards’ Olive, Evac-U-Gen, Ex-Lax, Fletcher’s, Perdiem, Peri-Colace, Senexon, Senna-S, Senokot, Senokot S

For ProfessionalsSide EffectsInteractionsMore…

Introduction

Stimulant laxative; hydroxymethylanthraquinone derivative occurring naturally in plants as glycosides.a

Uses for Senna

Constipation

Used to relieve occasional constipation.b

Mildest of the stimulant laxatives; less pronounced laxative effect than bisacodyl or the violent purgation produced by castor oil.b

Use of stimulant laxatives for simple constipation is seldom necessary or desirable.b

If a stimulant laxative is used, senna derivatives may be preferred.b

Used to treat constipation that occurs following prolonged bed rest or hospitalization.b

Has been used to treat constipation during pregnancy or the puerperium; bulk-forming laxatives or stool softeners preferred.b

Because senna may be distributed into milk, other laxatives usually are preferred for postpartum constipation.b

Also has been used to treat constipation resulting from diminished colonic motor response in geriatric patients but, because this type of constipation frequently is due to psychological or physical laxative dependence, bulk-forming laxatives preferred.b

Used to treat constipation occurring secondary to idiopathic slowing of transit time, to constipating drugs, or to irritable bowel or spastic colon syndrome.b

Also has been used to treat constipation in patients with neurologic constipation.b

Colonic Evacuation

Used orally to empty the bowel prior to surgery or radiologic, proctoscopic, or endoscopic (e.g., sigmoidoscopic, proctoscopic) procedures.b

Usually supplemented with administration of rectal evacuants (e.g., saline, stimulant, or soapsuds enemas) immediately before radiologic procedures.b

Senna Dosage and Administration

Administration

Oral Administration

Administer orally, in conjunction with adequate fluid intake.b

May be administered 1–2 times daily; however, usually administered as a single dose at bedtime.a

Oral Solution

Shake well before use.c d

Tablets

Swallow tablets with a glass of water;f h i do not crush, break, or chew.h i

Chewable Tablets or Pieces

Chew tablets or allow to dissolve in mouth before swallowing.e

Chew piece(s) before swallowing.g

Dosage

Available as sennosides, standardized senna concentrate, and standardized senna fruit extract; dosage expressed in terms of sennosides.a

Administer as infrequently as possible at the lowest effective dosage level.b Do not use for >1 week unless directed by prescriber.c d

Senna fluidextract: 33.3 mg/mL senna concentrate contains 3 mg sennosides A & B per mL.a m

Pediatric Patients

Constipation

Stimulant laxatives generally avoided in children <6 years of age.b

Oral (Standardized Senna Concentrate)

Children 2–6 years of age: 4.3 mg once daily; maximum 8.6 mg twice daily.j

Children 6–11 years of age: Usually, 8.6–15 mg 1–2 times daily.f g h i j May increase to a maximum 17.2 mg twice daily.j

Alternatively, for children 6–11 years of age: 25 mg (1 maximum strength tablet) 1–2 times daily.i

Alternatively, for children ≥6 years of age: 10 mg as chewable tablet 1–2 times daily.e

Children ≥12 years of age: Usually, 17.2–30 mg 1–2 times daily.e f h j May increase to a maximum 34.4 mg twice daily.j

Alternatively, for children ≥12 years of age: 50 mg (2 maximum strength tablets) 1–2 times daily.i

Oral (Senna Fluidextract Oral Solution)

Children 2–5 years of age: 15–30 mg (5–10 mL) 1–2 times daily.c Do not give concentrate containing alcohol to children <6 years of age unless otherwise directed by prescriber.d

Children 6–15 years of age: 30–45 mg (10–15 mL) 1–2 times daily.c

Children ≥12 years of age: Alternatively, 45–90 mg (15–30 mL) of oral solution (with alcohol) may be administered before or after meals or at bedtime.d May repeat in 6–8 hours if needed.d

Oral (Standardized Senna Fruit Extract Oral Solution)

Children 2–5 years of age: 4.4–6.6 mg (2.5–3.75 mL) once daily.n May increase to a maximum 6.6 mg (3.75 mL) twice daily.n

Children 6–11 years of age: 8.8–13.2 mg (5–7.5 mL) 1–2 times daily.n May increase to a maximum 13.2 mg (7.5 mL) twice daily.n

Children ≥12 years of age: 17.6–26.4 mg (10–15 mL) once daily.n May increase to a maximum 26.4 mg (15 mL) twice daily.n

Oral (Sennosides and Docusate Fixed Combination)

Children 2–5 years of age: 4.3 mg of sennosides and 25 mg of docusate sodium once daily.k May increase to a maximum 8.6 mg of sennosides and 50 mg of docusate sodium twice daily.k

Children 6–11 years of age: 8.6 mg of sennosides and 50 mg of docusate sodium once daily.k May increase to a maximum 17.2 mg of sennosides and 100 mg of docusate sodium twice daily.k

Children ≥12 years of age: 17.2 mg of sennosides and 100 mg of docusate sodium once daily.k May increase to a maximum 34.4 mg of sennosides and 200 mg of docusate sodium twice daily.k

Adults

Constipation
Oral (Standardized Senna Concentrate)

Usually, 17.2–30 mg 1–2 times daily.e f g h j May increase to a maximum 34.4 mg twice daily.j

Alternatively, 50 mg (2 maximum strength tablets) 1–2 times daily.i

Oral (Senna Fluidextract Oral Solution)

45–90 mg (15–30 mL) before or after meals or at bedtime.d May repeat in 6–8 hours if needed.d

Oral (Standardized Senna Fruit Extract Oral Solution)

17.6–26.4 mg (10–15 mL) once daily.n May increase to a maximum 26.4 mg (15 mL) twice daily.n

Oral (Sennosides and Docusate Fixed Combination)

17.2 mg of sennosides and 100 mg of docusate sodium once daily.k May increase to a maximum 34.4 mg of sennosides and 200 mg of docusate sodium twice daily.k

Colonic Evacuation

To prepare for colonic surgery or radiologic, sigmoidoscopic, or proctoscopic procedures, patient should receive a residue-free diet 1 day before the surgery or procedure.a Castor oil may be administered 16 hours before surgery or procedure; and a cleansing rectal enema (e.g., tap water, soap suds, saline laxative, bisacodyl tannex enema) administered on the day of surgery or procedure.a

Oral (Standardized Senna Fruit Extract or Standardized Senna Concentrate)

05–157.5 mg as a single dose 12–14 hours before surgery or procedure.a

Prescribing Limits

Pediatric Patients

Constipation

Do not use for >1 week unless directed by prescriber.c d

Oral (Standardized Senna Concentrate)

Children 2–6 years of age: Maximum 8.6 mg twice daily.j

Children 6–11 years of age: Maximum 17.2 mg twice daily.j

Alternatively, for children 6–11 years of age: Maximum 25 mg (1 maximum strength tablet) 2 times daily.i

Children ≥12 years of age: Maximum 34.4 mg twice daily.j

Alternatively, for children ≥12 years of age: 50 mg (2 maximum strength tablets) 2 times daily.i

Oral (Standardized Senna Fruit Extract Oral Solution)

Children ≥12 years of age: Maximum 26.4 mg (15 mL) twice daily.n

Oral (Sennosides and Docusate Fixed Combination)

Children 2–5 years of age: Maximum 8.6 mg of sennosides and 50 mg of docusate sodium twice daily.k

Children 6–11 years of age: Maximum 17.2 mg of sennosides and 100 mg of docusate sodium twice daily.k

Children ≥12 years of age: Maximum 34.4 mg of sennosides and 200 mg of docusate sodium twice daily.k

Adults

Constipation

Do not use for >1 week unless directed by prescriber.c d

Oral (Standardized Senna Concentrate)

Maximum 34.4 mg twice daily.j

Oral (Standardized Senna Fruit Extract Oral Solution)

Maximum 26.4 mg (15 mL) twice daily.n

Oral (Sennosides and Docusate Fixed Combination)

Maximum 34.4 mg of sennosides and 200 mg of docusate sodium twice daily.k

Special Populations

No special population dosage recommendations at this time.

Cautions for Senna

Contraindications

  • Acute abdominal pain, nausea, vomiting,b c d f j k or other symptoms of appendicitis or undiagnosed abdominal pain.b

  • Intestinal obstruction.b

Warnings/Precautions

Warnings

Laxative Dependence

Habit-forming.b

Potentially serious toxicity with chronic use.b (See Chronic Use or Overdosage under Cautions.)

Chronic Use or Overdosage of Laxatives

Chronic use or overdosage of laxatives may produce persistent diarrhea, hypokalemia, loss of essential nutritional factors, and dehydration.b

Laxative dependence, chronic constipation, and loss of normal bowel function may occur during long-term use.b

Electrolyte disturbances (including hypokalemia, hypocalcemia, metabolic acidosis or alkalosis), abdominal pain, diarrhea, malabsorption, weight loss, and protein-losing enteropathy may occur.b

Electrolyte disturbances may produce vomiting and muscle weakness; rarely, osteomalacia, secondary aldosteronism, and tetany.b

Chronic use may cause pathologic changes including structural damage to the myenteric plexus, severe and permanent interference with colonic motility, and hypertrophy of the muscularis mucosae.b

“Cathartic colon” with atony and dilation of the colon, especially of the right side, has occurred with habitual use (often for several years); often resembles ulcerative colitis.b

Change in Bowel Habits

If a sudden change in bowel habits occurs that last >2 weeks, consult a clinician before using.c e h i g j k

General Precautions

Discoloration of Urine and Colonic Mucosa

May discolor colonic mucosa (melanosis coli); innocuous and reversible.b

May discolor urine pink to red or brown to black.b

Diabetes Mellitus

Standardized senna fruit extract contains large amounts of sugar; consider caloric value in patients with diabetes mellitus.b

Use of Fixed Combinations

When senna is used in fixed combination with docusate sodium, consider the cautions, precautions, and contraindications associated with docusate sodium.

Specific Populations

Pregnancy

Category C.l

Lactation

May be distributed into milk.a b Unlikely to appear in sufficient amounts to affect nursing infants.a b

AAP considers senna compatible with breast-feeding.l

Pediatric Use

Safety and efficacy not established in children <2 years of age.c Avoid use of laxatives in infants and children.b

Common Adverse Effects

Abdominal discomfort, nausea, mild cramps, griping, faintness.b

Interactions for Senna

GI Drug Absorption

By increasing intestinal motility, can potentially decrease transit time of concomitantly administered oral drugs and thereby decrease their absorption.b

Specific Drugs and Laboratory Tests

Drugs and Laboratory Tests

Interaction

Phenolsulfonphthalein (PSP)

Discolors urine; possible apparent increase in urinary excretion of PSPb

Test for estrogen (Kober procedure)

Possible false-positive resultsb

Test for urinary urobilinogen

Possible false-positive resultsb

Senna Pharmacokinetics

Absorption

Bioavailability

Minimal absorption following oral administration.a

Onset

Following oral administration, laxation usually occurs within 6–12 hours; may take 24 hours.a c d e f g h i j k

Distribution

Extent

Distribution not fully characterized; may be distributed into bile, saliva, and colonic mucosa.a

Elimination

Metabolism

Absorbed drug metabolized in the liver.a

Elimination Route

Absorbed drug and its metabolites eliminated in feces via biliary excretion and/or in urine.a

Stability

Storage

Oral

Tablets and Chewable Pieces

20–25°C (may be exposed to 15–30°C);f g h i j protect from moisture.f

Solution

Tight, light-resistant container at ≤40°C.a

Actions

  • Stimulant laxative; primary active cathartic principles are the stereoisomeric glucosides, sennosides A and B.a

  • Precise mechanism of action not known.b
  • Commonly thought that the stimulant laxatives induce defecation by stimulating propulsive peristaltic activity of the intestine through local irritation of the mucosa or through a more selective action on the intramural nerve plexus of intestinal smooth muscle, thus increasing motility.b
  • More recent evidence shows that stimulant laxatives alter fluid and electrolyte absorption, producing net intestinal fluid accumulation and laxation.b
  • Increases concentrations of cyclic 3′,5′-adenosine monophosphate (cAMP) in colonic mucosal cells and may alter the permeability of these cells and mediate active ion secretion, producing net fluid accumulation and laxative action.b
  • Mainly promotes evacuation of the colon.b

Advice to Patients

  • Importance of informing clinicians before use if abdominal pain, nausea, or vomiting is present or if there has been a sudden change in bowel habits that persists over a period of 2 weeks.b c d e f g h i k

  • Importance of discontinuing use and informing clinician if a bowel movement does not occur or rectal bleeding occurs after use.b c d e f g h i j k
  • Importance of not using laxative products for a period longer than 1 week unless directed by a clinician.c d f g h i j k
  • Importance of taking with a glass of water.f h i
  • Advise about risk of laxative abuse and potential serious consequences.b (See Chronic Use or Overdosage under Cautions.)
  • Importance of advising clinicians of preexisting diabetes mellitus since some preparations contain sugar (e.g., standardized senna fruit extract).b
  • Advise patients of a potential discoloration in urine.b
  • Importance of taking 2 hours before or 2 hours after taking other medications.f g h i
  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses, including intestinal obstruction.b f g h i
  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.c d e f g h i j k
  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Senna Leaf
Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Powder*

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Senna Concentrate, Standardized
Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets, chewable

10 mg Sennosides

Black Draught

Lee

Evac-U-Gen

Lee

Pieces, chewable

15 mg Sennosides

Ex-Lax Chocolated

Novartis

Tablets

8.6 mg Sennosides*

Dr. Edwards’ Olive

Oakhurst

Senexon

Watson

Senna-Gen

Teva

Sennatural

G&W

Senokot

Purdue Frederick

15 mg Sennosides

Ex-Lax Regular Strength

Novartis

Perdiem

Novartis

17 mg Sennosides

SenokotXTRA

Purdue Frederick

25 mg Sennosides

Ex-Lax Maximum Strength

Novartis

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Senna Concentrate, Standardized Combinations
Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Tablets*

8.6 mg Sennosides with Docusate Sodium 50 mg

Peri-Colace

Purdue

Senna-S

Teva

Senokot S

Purdue Frederick

Senna Fluidextract
Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Solution

3 mg Sennosides per mL (33.3 mg Senna Concentrate per mL)

Dr. Caldwell Senna Laxative (with alcohol 4.9%)

Denison

Fletcher’s (with parabens; alcohol-free)

Mentholatum Company

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Senna Fruit Extract, Standardized
Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Solution*

8.8 mg Sennosides per 5 mL

Senexon Liquid (with parabens)

Watson

Disclaimer

This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.

The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug’s actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.

AHFS Drug Information. © Copyright, 1959-2013, Selected Revisions January 1, 2008. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

a. AHFS drug information 2007. McEvoy GK, ed. Anthraquinones. Bethesda, MD: American Society of Health-System Pharmacists; 2007:2923-4.

b. AHFS drug information 2007. McEvoy GK, ed. Cathartics and laxatives general statement. Bethesda, MD: American Society of Health-System Pharmacists; 2007:2919-23.

c. The Mentholatum Co., Inc. Fletcher’s laxative for kids patient information. Orchard Park, NY. Undated.

d. Denison. Dr. Caldwell senna laxative patient information. From website: . Accessed 2007 May 28.

e. Lee Pharmaceuticals, Inc. Black draught laxative tablets patient information. From website: . Accessed 2007 June 24.

f. Novartis Consumer Health, Inc. Perdiem overnight relief patient information. From website: . Accessed 2007 May 28.

h. Novartis Consumer Health, Inc. ex-lax regular strength patient information. From website: . Accessed 2007 May 28.

g. Novartis Consumer Health, Inc. ex-lax regular strength chocolate patient information. From website: . Accessed 2007 May 28.

i. Novartis Consumer Health, Inc. ex-lax maximum strength patient information. From website: . Accessed 2007 May 28.

j. Purdue Products L.P. Senokot tablets patient information. From website: . Accessed 2007 May 28.

k. Purdue Products L.P. Senokot-S tablets patient information. From website: . Accessed 2007 May 28.

l. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 7th ed. Phildelphia, PA: Lippincott Williams & Wilkins; 2005:1452-3.

m. Esford J (The Mentholatum Co., Inc., Orchard Park, NY): Personal communication; 2007 June 27.

n. Rugby Laboratories. Senexon Liquid patient information. Duluth, GA: 2005 Sept.

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Senna

Senna

Pronunciation Pronunciation: SEN-ah

Class: Laxative

For ProfessionalsSide EffectsInteractionsMore…

Trade Names

Agoral

– Liquid 25 mg

Black Draught

– Granules 20 mg/5 mL

– Tablets 6 mg

ex•lax

– Tablets 15 mg

ex•lax chocolate

– Tablets 15 mg

Fletcher Castoria

– Liquid 33.3 mg/mL

Senexon

– Tablets 8.5 mg

Senna-Gen

– Tablets 8.6 mg

Senokot

– Granules 15 mg/5 mL

– Syrup 8.8 mg/5 mL

– Tablets 8.6 mg

SenokotXTRA

– Tablets 17 mg

Senna Laxative Pills Extra Strength Peristaltic Stimulant (Canada)

Senna Laxative Pills Regular Strength Peristaltic Stimulant (Canada)

Senna Tablets Peristaltic Stimulant (Canada)

Pharmacology

Directly acts on intestinal mucosa by altering water and electrolyte secretion, inducing peristalsis and defecation.

Indications and Usage

Short-term treatment of constipation; preoperative and preradiographic bowel evacuation for procedures involving GI tract.

Contraindications

Nausea, vomiting, or other symptoms of appendicitis; acute surgical abdomen; fecal impaction; intestinal obstruction; undiagnosed abdominal pain.

Dosage and Administration

Adults PO 2 tablets, 5 mL of granules or 10 to 15 mL of syrup, usually at bedtime (max, 15 mL twice daily of syrup).

PR 1 suppository at bedtime; may repeat in 2 h.

Children 6 to 12 y of age PO 1 tablet or 2.5 mL granules, or 5 to 7.5 mL of syrup once daily, usually at bedtime (max, 7.5 mL twice daily of syrup).

PR ½ suppository at bedtime.

2 to younger than 6 y PO 2.5 to 3.75 mL of syrup once daily, usually at bedtime (max, 3.75 mL twice daily of syrup).

General Advice

  • Administer at bedtime on empty stomach.
  • Shake liquid solution before administering.
  • Dissolve granules before administering.
  • Give oral dosages with full glass of water or juice.
  • Administer suppository with patient lying on left side.

Storage/Stability

Store between 59° and 86° F.

Drug Interactions

None well documented.

Adverse Reactions

Cardiovascular

Palpitations.

CNS

Dizziness, fainting.

GI

Abdominal cramping, bloating, excessive bowel activity (eg, griping, diarrhea, nausea, vomiting), flatulence, perianal irritation.

Miscellaneous

Sweating, weakness.

Precautions

Monitor

Assess bowel function, including normal frequency, type, last bowel movement, bowel sounds, abdominal distention.

Pregnancy

Category C .

Lactation

Undetermined.

Abuse/dependency

Long-term use may lead to laxative dependency, which may result in fluid and electrolyte imbalances, steatorrhea, osteomalacia, and vitamin and mineral deficiencies. Cathartic colon, a poorly functioning colon, results from long-term abuse. Pathologic presentation may resemble ulcerative colitis.

Discoloration of acidic urine

May result in yellow-brown urine.

Discoloration of alkaline urine

May result in pink to red urine.

Fluid and electrolyte imbalance

Excessive laxative use may lead to significant fluid and electrolyte imbalance.

Melanosis Coli

Darkened pigmentation of colonic mucosa may occur after long-term use, usually resolving within 5 to 11 mo of discontinuation.

Rectal bleeding or failure to respond

May indicate serious condition requiring further attention.

Overdosage

Symptoms

Gripping pain, diarrhea.

Patient Information

  • Explain potential hazards (eg, dependence) associated with long-term laxative use.
  • Advise that senna may result in discolored yellow-brown or reddish urine.
  • Explain that bowel patterns are very individual.
  • Identify measures to improve bowel function (ie, fluids, activity, dietary bulk).
  • Caution against taking laxatives in presence of acute abdominal pain or in presence of nausea or vomiting.

Copyright © 2009 Wolters Kluwer Health.

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