Senna

Scientific Name(s): Cassia acutifolia Delile, Cassia angustifolia Vahl
Common Name(s): Senna

Medically reviewed by Drugs.com. Last updated on Jul 13, 2023.

Clinical Overview

Use

Senna is most commonly used as a stimulant laxative.

Dosing

Senna leaves and 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. A bitter tea can be made containing senna 0.5 to 2 g (0.5 to 1 teaspoon). Senna should not be used at high 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.

Pregnancy/Lactation

Use with caution in pregnancy until more definitive information is accumulated. Some data suggest endometrial stimulation, as well as mutagenic and genotoxic effects. No effects on stools in infants or on lactation have been reported with short-term use during lactation, although small amounts of senna do cross into breast milk.

Interactions

Avoid use of senna with drugs known to deplete potassium.

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 laxative dependence. Children, particularly those wearing diapers, may experience severe diaper rash, blister formation, and skin sloughing.

Toxicology

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

Scientific Family

• Fabaceae (bean/pea)

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 senna (Cassia hebecarpa Fern. and Cassia marilandica L.) grow on moist banks and in wooded areas in the eastern United States. This plant should not be confused with cassia, a common name for cinnamon. Senna is a low-branching shrub that grows to about 1 m tall. It has a straight, woody stem and yellow flowers. The top parts are harvested, dried, and graded. Tinnevelly senna is hand-collected, while Alexandria senna is harvested and graded mechanically. There are more than 400 known species of Cassia.Chevalier 2001, Duke 2002 A synonym is Cassia senna L.

History

Senna was first used medicinally by Arabian physicians in the 9th century AD.Chevalier 2001 The plant's name is derived from the Arabic word sena and the Hebrew word cassia, which means "peeled back," a reference to its peelable bark. Senna has long been used in traditional Arabian and 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 active ingredients in the tea, its effects may be unpredictable. Standardized commercial dosage forms have been developed and are available as liquids, powders, and nonprescription tablets in over-the-counter laxatives.Blumenthal 2000, Ulbricht 2011

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 appear to contribute to senna’s laxative effect. The plant also contains free anthraquinones in small amounts, including rhein, aloe-emodin, chrysophanol, and their glycosides. Senna pods 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. Other carbohydrates include mannose, fructose, glucose, pinitol, and sucrose. Senna’s flavonols include isorhamnetin and kaempferol. Glycosides 6-hydroxymusizin and tinnevellin are also present.

Other constituents in senna include chrysophanic acid, salicylic acid, saponin, resin, mannitol, sodium potassium tartrate, and trace amounts of volatile oil.Bisset 1994, Duke 2002, Newall 1996

Uses and Pharmacology

Laxative

Clinical data

Quality clinical trials evaluating the efficacy and safety of senna in the treatment of constipation, as well as comparative trials comparing senna with other laxatives, are generally lacking.Candy 2011, Gordon 2012, Ramkumar 2005, Ulbricht 2011 However, a 2014 double-blind, randomized, active-comparator trial (N = 56 intent-to-treat; n = 43 protocol) found senna (2 capsules daily for 6 days) to be as effective as lubiprostone (Amitiza) for improving constipation-related symptoms and quality of life in adults who experienced opioid-induced constipation following orthopedic surgery.Marciniak 2014

Widespread use of senna and older clinical studies have led to the acceptance of senna as an effective laxative in adult populations for the treatment of chronic constipation, constipation due to other medicines (such as opioids), and in preparing the bowel for diagnostic procedures, although alternative laxatives may be safer and more effective.Ramkumar 2005, Ulbricht 2011, WGO 2010 Data from 173 inpatients in a 2017 randomized, controlled study also suggested a benefit of adding senna (3 g 3 times daily for 3 days) to a mannitol-saline-simethicone bowel cleansing regimen in preparation for diagnostic procedures. Cleanliness of the whole, proximal, and distal small bowel were significantly improved in the senna group compared to the mannitol-saline regimens with and without simethicone. However, unlike the other test groups, the senna group also fasted for 3 days, so extrapolating results to senna per se warrants caution.Chen 2017

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.Blumenthal 2000, Ulbricht 2011 A bitter tea can be made containing senna 0.5 to 2 g (0.5 to 1 teaspoon). Senna should not be used at high doses or for extended periods of time.

Senna may be standardized according to sennoside content and is available in multiple forms commercially, as well as in combination with other laxatives.Ulbricht 2011

Senna should not be used at high doses or for extended periods of time,Blumenthal 2000, Ulbricht 2011 and should not be used in children younger than 2 years without consulting a health care provider. In children younger than 12 years and in elderly patients, alternative laxatives may be more effective.Ulbricht 2011

Pregnancy / Lactation

Category C. The use of senna during pregnancy is controversial. Because of the minimal absorption of senna glycosides by the intestines, a teratogenic effect is not expected. Some data suggest endometrial stimulation, as well as mutagenic and genotoxic effects with senna use.Ernst 2002, Ulbricht 2011 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.Acs 2009

No effects on stools in infants or on lactation have been reported with short-term use during lactation, although small amounts of senna do cross into breast milk.AAP 2001, Ulbricht 2011

Interactions

Additive potassium depletion with concomitant medicines such as diuretics may occur.(Ramkumar 2005, Ulbricht 2011)

Dichlorphenamide: Laxatives may enhance the hypokalemic effect of dichlorphenamide. Monitor therapy.(Cohen 2019, Keveyis November 2019)

Digoxin: Senna may enhance the adverse/toxic effect of digoxin. Monitor therapy.(Wang 2011)

Sodium sulfate: Laxatives (stimulant) may enhance the adverse/toxic effect of sodium sulfate. Specifically, the risk of mucosal ulceration or ischemic colitis may be increased. Avoid combination.(Suclear January 2013, Suprep July 2020, Sutab November 2020)

Polyethylene glycol-electrolyte solution: Senna may enhance the adverse/toxic effect of polyethylene glycol-electrolyte solution. Monitor therapy.(Plenvu May 2018)

Adverse Reactions

Senna may cause loss of fluids, hypokalemia, diarrhea, and abdominal pain and cramping. Prolonged use may alter electrolyte levels, increasing the risk for cardiovascular complications.Ramkumar 2005, Soyuncu 2008, Ulbricht 2011

Patients with intestinal obstruction should avoid senna, and it should be used with caution in patients with hemorrhoids or inflammatory bowel conditions.Ulbricht 2011

Long-term use of any laxative, particularly stimulant laxatives such as senna, may result in laxative dependency, characterized by poor gastric motility in the absence of repeated laxative administration.Ulbricht 2011

Several case reports exist of severe diaper rash, blister formation, and skin sloughing with senna use in young children.Smith 2012, Spiller 2003

Allergies, including occupational asthma, have been reported.Ulbricht 2011

The European Association for the Study of the Liver (EASL) clinical practice guideline for drug-induced liver injury (2019) recommends physicians consider herbal and dietary supplements as potential causative agents associated with liver injury (Level 4; Grade C), including senna, which has a fair level of evidence supporting hepatotoxicity.EASL 2019

Toxicology

Long-term use of senna and its anthraquinone glycosides has been associated with pigmentation of the colon (melanosis coli). Case reports exist of reversible finger clubbing (enlargement of the ends of the fingers and toes) following long-term abuse of senna-containing laxatives.Armstrong 1981, FitzGerald 1983, Levine 1981, Lim 2008, Malmquist 1980, Prior 1978, Surh 2012

Senna abuse has been associated with the development of cachexia and reduced serum globulin levels after long-term ingestion.Levine 1981

Renal toxicity and hepatotoxicity have been demonstrated in rodent studies.Surh 2012 Hepatotoxicity has been reported in humans following long-term senna use.Seybold 2004, Sonmez 2005, Ulbricht 2011, Vanderperren 2005

An association between long-term laxative use and colon cancer has been reported. In vitro and animal studies regarding the genotoxicity of senna extracts have produced conflicting data.Borrelli 2006, Levine 1981, Morales 2009, Silva 2008, Ulbricht 2011, Vitalone 2011

Index Terms

• Cassia hebecarpa Fern.
• Cassia marilandica L.
• Cassia senna L.

References

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This information relates to an herbal, vitamin, mineral or other dietary supplement. This product has not been reviewed by the FDA to determine whether it is safe or effective and is not subject to the quality standards and safety information collection standards that are applicable to most prescription drugs. This information should not be used to decide whether or not to take this product. This information does not endorse this product as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this product. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this product. This information is not specific medical advice and does not replace information you receive from your health care provider. You should talk with your health care provider for complete information about the risks and benefits of using this product.

This product may adversely interact with certain health and medical conditions, other prescription and over-the-counter drugs, foods, or other dietary supplements. This product may be unsafe when used before surgery or other medical procedures. It is important to fully inform your doctor about the herbal, vitamins, mineral or any other supplements you are taking before any kind of surgery or medical procedure. With the exception of certain products that are generally recognized as safe in normal quantities, including use of folic acid and prenatal vitamins during pregnancy, this product has not been sufficiently studied to determine whether it is safe to use during pregnancy or nursing or by persons younger than 2 years of age.

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