Skip to Content

Senna

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

Clinical Overview

See also: Amitiza

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.

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.1, 2 A synonym is Cassia senna L.

History

Senna was first used medicinally by Arabian physicians in the 9th century AD.1 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.3, 4

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.2, 5, 6

Uses and Pharmacology

Laxative

Animal data

Senna has been studied for laxative effects in rats, although the widespread use and acceptance of senna make data from animal studies irrelevant.7

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.3, 8, 9, 10 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.33

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.3, 8, 11

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.3, 4 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.3

Senna should not be used at high doses or for extended periods of time,3, 4 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.3

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.3, 12 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.13

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.3, 14

Interactions

Additive potassium depletion with concomitant medicines such as diuretics may occur.3, 8, 14

As an increased risk of bleeding may exist, although case reports are lacking, senna should be used with caution in patients taking anticoagulant or antiplatelet medication.3, 15

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.3, 8, 16

Patients with intestinal obstruction should avoid senna, and it should be used with caution in patients with hemorrhoids or inflammatory bowel conditions.3

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.3

Several case reports exist of severe diaper rash, blister formation, and skin sloughing with senna use in young children.17, 18

Allergies, including occupational asthma, have been reported.3

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.19, 20, 21, 22, 23, 24, 25

Senna abuse has been associated with the development of cachexia and reduced serum globulin levels after long-term ingestion.24

Renal toxicity and hepatotoxicity have been demonstrated in rodent studies.25 Hepatotoxicity has been reported in humans following long-term senna use.3, 26, 27, 28

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.3, 24, 29, 30, 31, 32

References

1. Chevalier A. The Encyclopedia of Medicinal Plants. New York, NY: DK Publishing; 2001.
2. Duke JA. Handbook of Medicinal Herbs. 2nd ed. Boca Raton, FL: CRC Press; 2002.
3. Ulbricht C, Conquer J, Costa D, et al. An evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration. J Diet Suppl. 2011;8(2):189-238.22432689
4. Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000.
5. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London, England: The Pharmaceutical Press;1996:243-244.
6. Bisset NG. Herbal Drugs and Phytopharmaceuticals. Stuttgart, Germany: Medpharm Scientific Publishers and Boca Raton, FL: CRC Press Inc; 1994;463-466.
7. Lemli J. Metabolism of sennosides—an overview. Pharmacology. 1988;36(suppl 1):126-128.3368510
8. Ramkumar D, Rao SS. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol. 2005;100(4):936-971.15784043
9. Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448. 21249653
10. Gordon M, Naidoo K, Akobeng AK, Thomas AG. Osmotic and stimulant laxatives for the management of childhood constipation. Cochrane Database Syst Rev. 2012;7:CD009118.22786523
11. World Gastroenterology Organisation. Global Guidelines. Constipation: A Global Perspective. November 2010. http://www.worldgastroenterology.org/assets/export/userfiles/05_constipation.pdf.
12. Ernst E. Herbal medicinal products during pregnancy: are they safe? BJOG. 2002;109(3):227-235. 11950176
13. Acs N, Bánhidy F, Puhó EH, Czeizel AE. Senna treatment in pregnant women and congenital abnormalities in their offspring—a population-based case-control study. Reprod Toxicol. 2009;28(1):100-104. 19491001
14. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-789.11533352
15. Kittisupamongkol W, Nilaratanakul V, Kulwichit W. Near-fatal bleeding, senna, and the opposite of lettuce. Lancet. 2008;371(9614):784.18313506
16. Soyuncu S, Cete Y, Nokay AE. Portal vein thrombosis related to Cassia angustifolia. Clin Toxicol (Phila). 2008;46(8):774-777.19238740
17. 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):636-639.12708936
18. Smith WA, Taintor AR, Kos L, Drolet B. Senna-containing laxative inducing blistering dermatitis in toddlers. Arch Dermatol. 2012;148(3):402-404.22431792
19. Prior J, White I. Tetany and clubbing in patient who ingested large quantities of senna. Lancet. 1978;2(8096):947.81966
20. Malmquist J, Ericsson B, Hultén-Nosslin MB, Jeppsson JO, Ljungberg O. Finger clubbing and aspartylglucosamine excretion in a laxative-abusing patient. Postgrad Med J. 1980;56(662):862-864.7267500
21. Armstrong RD, Crisp AJ, Grahame R, Woolf DL. Hypertrophic osteoarthropathy and purgative abuse. Br Med J (Clin Res Ed). 1981;282(6279):1836.6786643
22. FitzGerald O, Redmond J. Anthraquinone-induced clubbing associated with laxative abuse. Ir J Med Sci. 1983:152(6):246-247.6874294
23. Lim AK, Hooke DH, Kerr PG. Anorexia nervosa and senna misuse: nephrocalcinosis, digital clubbing and hypertrophic osteoarthropathy. Med J Aust. 2008;188(2):121-122.18205591
24. Levine D, Goode AW, Wingate DL. Purgative abuse associated with reversible cachexia, hypogammaglobulinemia, and finger clubbing. Lancet. 1981;1(8226):919-920. 6112328
25. Surh I, Brix A, French JE, et al. Toxicology and carcinogenesis study of senna in C3B6.129F1-Trp53tm1Brd N12 haploinsufficient mice. Toxicol Pathol. 2012;41(5):770-780.23125117
26. Vanderperren B, Rizzo M, Angenot L, Haufroid V, Jadoul M, Hantson P. Acute liver failure with renal impairment related to the abuse of senna anthraquinone glycosides. Ann Pharmacother. 2005;39(7-8):1353-1357.15956233
27. 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. 16268429
28. Seybold U, Landauer N, Hillebrand S, Goebel FD. Senna-induced hepatitis in a poor metabolizer. Ann Intern Med. 2004;141(8):650-651.15492352
29. Borrelli F, Aviello G, Capasso R, Capasso F. Senna: a laxative devoid of carcinogenic effects. Arch Toxicol. 2006;80(12):873.17063369
30. Morales MA, Hernández D, Bustamante S, Bachiller I, Rojas A. Is senna laxative use associated to cathartic colon, genotoxicty, or carcinogenicity? J Toxicol. 2009;2009:287247.20107583
31. Vitalone A, Di Giacomo S, Di Sotto A, et al. Cassia angustifolia extract is not hepatotoxic in an in vitro and in vivo study. Pharmacology. 2011;88(5-6):252-259.21997710
32. Silva CR, Monteiro MR, Rocha HM, et al. Assessment of antimutagenic and genotoxic potential of senna (Cassia angustifolia Vahl.) aqueous extract using in vitro assays. Toxicol In Vitro. 2008;22(1):212-218.17826029
33. Marciniak CM, Toledo S, Lee J, et al. Lubiprostone vs senna in postoperative orthopedic surgery patients with opioid-induced constipation: a double-blind, active-comparator trial. World J Gastroenterol. 2014;20(43):16323-16333.25473191

Disclaimer

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.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Hide