Senna is an anthraquinone laxative similar to cascara. It is a plant derivative. Senna is used for relief of constipation in adult and pediatric patients 2 years and older. Senna is also used off-label, under a prescriber's direction only, for occasional relief of constipation in infants and children younger than 2 years of age. Senna is useful for constipation due to opiate analgesics; in adults, the American Gastroenterology Association (AGA) recommends the daily use of an osmotic laxative in combination with a stimulant laxative at least 2 to 3 times per week as first-line therapy in patients with opioid-induced constipation (OIC). Senna-containing products have been marketed since the late 1930s. Concerns over a risk for carcinogenicity due to stimulant laxatives prompted the FDA to review the status of senna. Data were submitted to the FDA regarding senna's safety and efficacy as a non-prescription (OTC) laxative, and experts note that there is little evidence that routine use of stimulant laxatives such as senna is harmful to the colon. Many products formerly containing stimulant laxative ingredients like cascara or casanthranol, which were removed from the market due to concerns over tumorigenicity, were reformulated to contain senna instead.
General Administration Information
For storage information, see the specific product information within the How Supplied section.
Route-Specific Administration
Oral Administration
-Senna is administered orally.
Oral Solid Formulations
-It is suggested to administer at bedtime with a full glass of water. However, the products may be given one or two times daily; see the product directions.
-Some marketed tablets are chewable; follow the directions on the product label for the specific product chosen.
-The products usually produce a bowel movement 6 to 12 hours later.
Oral Liquid Formulations
Oral solutions, syrups or suspensions:
-Shake well prior to each administration.
-To ensure accurate dosage, use a calibrated oral measuring device to measure each dose.
-The solution or syrup may be administered with milk or juice to mask taste.
-It is suggested to administer at bedtime with a full glass of water. However, the products may be given one or two times daily; follow the directions on the specific product label.
-The products usually produce a bowel movement in 6 to 12 hours.
Senna is relatively free from adverse effects if used occasionally and for short periods, or used appropriately as directed for longer periods. Stimulant laxatives like senna, by the nature of their effect, may cause mild abdominal pain, discomfort, or cramping, at rates higher than placebo. Bloating, flatulence and fecal urgency have also been reported with the use of senna. Abuse of stimulant laxatives can cause abdominal pain, diarrhea, nausea, vomiting, or hypokalemia; however, when used as directed, prospective studies have not found an increase in these events with the appropriate use of senna for up to 1 year. There is no addictive potential of senna, though misuse occurs primarily in psychiatric patients or those who abuse the drug to produce diarrhea with the misguided belief that this aids weight loss (use or abuse insignificantly affects dry weight). A long-term effect noted with the use of some anthraquinone laxatives is the development of 'melanosis coli', pigmentation of the colon mucosa; the cause of the pigmentation is not clear but is not considered to be of functional significance. Senna-containing products have been marketed since the late 1930s. Concerns over risk for carcinogenicity due to certain stimulant laxatives prompted the FDA to review the status of senna. Data were submitted to the FDA regarding senna's safety and efficacy as a non-prescription (OTC) laxative, and experts note that there is little evidence that routine use of stimulant laxatives such as senna is harmful to the colon. Laxative tolerance does not appear to occur in most users of senna. Prolonged use of stimulant laxatives has been thought to result in physiological dependence on the laxative ('cathartic colon'), leading to reduced normal bowel function and constipation after therapy is discontinued; however, tolerance and physiologic dependence is rare except in patients with slow colonic motility disorders who benefit from the stimulant laxative action to have regular, normal bowel movement frequency.
Senna is relatively free from adverse effects if used occasionally and for short periods of time. Urine discoloration can occur during senna administration, varying from red-pink in alkaline urine to yellow-brown in acidic urine. Senna suppositories may irritate the rectal area.
Respiratory and hypersensitivity-type reactions may occur with senna preparations. Wheezing or asthma, anaphylactoid reactions, rash (unspecified), and rhinoconjunctivitis have been reported.
Senna or sennosides should not be used in patients with a previous hypersensitivity to senna, sennosides, or any ingredients in the particular product formulation chosen.
Advise patients to consult their healthcare professional before taking senna if they have nausea, vomiting, abdominal pain or if they have notice a sudden change in their bowel habits that lasts for more than 2 weeks. Patients with serious GI disease, such as inflammatory bowel disease, should consult their health care provider prior to nonprescription use. Senna should not be used in patients with undiagnosed abdominal pain. Use of stimulant laxatives is generally contraindicated in patients with bowel or other GI obstruction. Patients should discontinue self-medication and consult their health care provider if they experience diarrhea, rectal GI bleeding or if they fail to have a bowel movement after senna administration; these may be signs of a more serious condition.
Systemic absorption of the sennosides is minimal and there have been no reports of teratogenicity or an increased risk of congenital anomalies due to senna use during pregnancy. The intermittent use of senna should be limited to use under the advice of a qualified health care professional and after safer agents have failed to produce intended results. The safest first-line treatments to use for constipation during pregnancy are those that are not absorbed systemically (e.g., fiber, bulk-forming laxatives, stool softeners such as docusate) in order to minimize drug exposure to the fetus. Polyethylene glycol 3350 has minimal systemic absorption and is also considered a first-line option for chronic constipation during pregnancy.
Senna is considered compatible for use during breast-feeding. Senna is not excreted into human milk, but it is a prodrug which is metabolized in vivo to the sennosides. Sennosides are glucosides of rhein, and the sennosides are essentially undetectable in human milk. Rhein appears to be excreted only in minimal amounts. There is a lack of reported adverse events in nursing infants whose mothers ingested sennosides during lactation. Agents that are non-absorbed or poorly absorbed (e.g., bulk-forming laxatives or stool softeners such as docusate) are often the preferred drugs for first-line use in the lactating female when such therapy is necessary. Other agents that may be considered based on lack of systemic effect or lack of reported adverse effects in nursing infants include magnesium hydroxide, polyethylene glycol 3350, and bisacodyl.
The federal Omnibus Budget Reconciliation Act (OBRA) regulates the use of medications in residents (e.g., geriatric adults) of long-term care facilities. The OBRA guidelines caution that laxatives may cause flatulence, bloating, and abdominal pain in debilitated or elderly patients.
Some senna oral solutions or syrups have added sodium; patients who are on a sodium restriction (e.g., low salt diet) should check with their health care professional prior to use.
Nonprescription use of senna is not recommended in infants. Most nonprescription products may be used in children 2 years and older; the literature describes off-label use of senna for occasional constipation or for bowel preparation in infants as young as 1 month of age, under a prescriber's advice and observation. Most senna liquids are not formulated for infants, some contain alcohol, propylene glycol, or benzyl alcohol that may be toxic to neonates or young infants.
General Dosing information
-The active ingredients of senna products are expressed as either senna or sennosides. There are a number of preparations available all of which contain different amounts of senna.
-1 mg sennosides = 21.7 mg standardized senna concentrate.
For the treatment of constipation:
Oral dosage (tablets with 8.6 mg sennosides per tablet):
Adults: 1 to 2 tablets (8.6 to 17.2 mg sennosides) PO twice daily. Max dose: 4 tablets (34.4 mg sennosides) PO twice daily.
Children and Adolescents 12 to 17 years: 1 to 2 tablets (8.6 to 17.2 mg sennosides) PO twice daily. Max dose: 4 tablets (34.4 mg sennosides) PO twice daily.
Children 6 to 11 years: 1 tablet (8.6 mg sennosides) PO at bedtime. Max: 2 tablets (17.2 mg sennosides) PO twice daily.
Children 2 to 5 years: One-half tablet (4.3 mg sennosides) PO once daily at bedtime. Max: 1 tablet (8.6 mg sennosides) PO twice daily.
Oral dosage (softgel capsules with 8.6 mg sennosides per capsule):
Adults: 2 softgel capsules (17.2 mg sennosides) PO at bedtime. Max dose: 4 softgel capsules (34.4 mg sennosides) PO twice daily.
Children and Adolescents 12 to 17 years: 2 softgel capsules (17.2 mg sennosides) PO at bedtime. Max dose: 4 softgel capsules (34.4 mg sennosides) PO twice daily.
Children 6 to 11 years: 1 softgel capsule (8.6 mg sennosides) PO at bedtime. Max: 2 softgel capsules (17.2 mg sennosides) PO twice daily.
Oral dosage (solution or syrup containing 8.8 mg sennosides per 5 mL):
Adults: 10 to 15 mL (17.6 to 26.4 mg sennosides) PO at bedtime. Max: 15 mL (26.4 mg sennosides) PO twice daily.
Children and Adolescents 12 to 17 years: 10 to 15 mL (17.6 to 26.4 mg sennosides) PO at bedtime. Max: 15 mL (26.4 mg sennosides) PO twice daily.
Children 6 to 11 years: 5 to 7.5 mL (8.8 to 13.2 mg sennosides) PO at bedtime. Max: 7.5 mL (13.2 mg sennosides) PO twice daily.
Children 2 to 5 years: 2.5 to 3.75 mL (4.4 to 6.6 mg sennosides) PO at bedtime. Max: 3.75 mL (6.6 mg sennosides) PO once daily.
Oral dosage (maximum strength oral solution with 25 mg sennosides per 15 mL):
Adults: 15 mL to 30 mL (25 mg to 50 mg sennosides) PO once daily. Max: 30 mL (50 mg sennosides) PO twice daily.
Children and Adolescents 12 to 17 years: 15 mL to 30 mL (25 mg to 50 mg sennosides) PO once daily. Max: 30 mL (50 mg sennosides) PO twice daily.
Maximum Dosage Limits:
-Adults
68.8 mg/day PO of sennosides for capsules and tablets; 52.8 mg/day PO of sennosides for oral solution; 100 mg/day PO of sennosides for maximum strength oral solution.
-Geriatric
68.8 mg/day PO of sennosides for capsules and tablets; 52.8 mg/day PO of sennosides for oral solution; 100 mg/day PO of sennosides for maximum strength oral solution.
-Adolescents
68.8 mg/day PO of sennosides for capsules and tablets; 52.8 mg/day PO of sennosides for oral solution; 100 mg/day PO of sennosides for maximum strength oral solution.
-Children
12 years: 68.8 mg/day PO of sennosides for capsules and tablets; 52.8 mg/day PO of sennosides for oral solution; 100 mg/day PO of sennosides for maximum strength oral solution.
6 to 11 years: 34.4 mg/day PO of sennosides for capsules and tablets; 26.4 mg/day PO of sennosides for 8.8 mg/5 mL oral solution (not FDA-approved for maximum strength oral solution 25 mg/15 mL).
2 to 5 years: 17.2 mg/day PO of sennosides for tablets; 6.6 mg/day PO of sennosides for 8.8 mg/5 mL oral solution (not FDA-approved for maximum strength oral solution 25 mg/15 mL). Safety and efficacy have not been established for capsules.
1 year: Safety and efficacy have not been established.
-Infants
Safety and efficacy have not been established.
Patients with Hepatic Impairment Dosing
Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears no dosage adjustments are needed.
Patients with Renal Impairment Dosing
Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.
*non-FDA-approved indication
Atropine; Difenoxin: (Moderate) Diphenoxylate can decrease GI motility. Drugs used to treat constipation, such as laxatives, would counteract the effect of antidiarrheals. In general, it would be illogical to concurrently administer these drugs at the same time. If an antidiarrheal medication is needed, it would be wise to temporarily discontinue use of agents with laxative effects.
Bumetanide: (Minor) The risk of hypokalemia due to loop diuretics may be increased in patients receiving prolonged therapy with certain laxatives. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy in patients receiving loop diuretics. Senna rarely causes hypokalemia with proper use.
Dichlorphenamide: (Minor) Use dichlorphenamide and senna together with caution. Dichlorphenamide increases potassium excretion and can cause hypokalemia and should be used cautiously with other drugs that may cause hypokalemia including laxatives. Senna very rarely causes hypokalemia. Measure potassium concentrations at baseline and periodically during dichlorphenamide treatment. If hypokalemia occurs or persists, consider reducing the dichlorphenamide dose or discontinuing dichlorphenamide therapy.
Diphenoxylate; Atropine: (Moderate) Diphenoxylate can decrease GI motility. Drugs used to treat constipation, such as laxatives, would counteract the effect of antidiarrheals. In general, it would be illogical to concurrently administer these drugs at the same time. If an antidiarrheal medication is needed, it would be wise to temporarily discontinue use of agents with laxative effects.
Droperidol: (Minor) Caution is advised when using droperidol in combination with certain laxatives, which may lead to electrolyte abnormalities, especially hypokalemia. Such abnormalities may increase the risk for QT prolongation or cardiac arrhythmias. However, senna very rarely causes hypokalemia or other electrolyte abnormalities.
Ethacrynic Acid: (Minor) The risk of hypokalemia due to loop diuretics may be increased in patients receiving prolonged therapy with certain laxatives. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy in patients receiving loop diuretics. Senna rarely causes hypokalemia with proper use.
Furosemide: (Minor) The risk of hypokalemia due to loop diuretics may be increased in patients receiving prolonged therapy with certain laxatives. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy in patients receiving loop diuretics. Senna rarely causes hypokalemia with proper use.
Lactulose: (Major) In general, other laxatives, such as senna, should not be used concurrently with lactulose, especially during the initial phase of therapy for portal-systemic encephalopathy, because the loose stools resulting from their use may falsely suggest that adequate lactulose dosage has been achieved. (Major) In general, other laxatives, such as sennosides, should not be used concurrently with lactulose, especially during the initial phase of therapy for portal-systemic encephalopathy, because the loose stools resulting from their use may falsely suggest that adequate lactulose dosage has been achieved.
Loop diuretics: (Minor) The risk of hypokalemia due to loop diuretics may be increased in patients receiving prolonged therapy with certain laxatives. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy in patients receiving loop diuretics. Senna rarely causes hypokalemia with proper use.
Polyethylene Glycol: (Moderate) When polyethylene glycol is used as pre-procedure bowel preparation, avoid concomitant use of stimulant laxatives. Colonic mucosal aphthous ulcerations and ischemic colitis have been observed following use of osmotic laxatives for bowel preparation and concomitant use of stimulant laxatives may increase this risk.
Polyethylene Glycol; Electrolytes: (Moderate) When polyethylene glycol is used as pre-procedure bowel preparation, avoid concomitant use of stimulant laxatives. Colonic mucosal aphthous ulcerations and ischemic colitis have been observed following use of osmotic laxatives for bowel preparation and concomitant use of stimulant laxatives may increase this risk.
Polyethylene Glycol; Electrolytes; Ascorbic Acid: (Moderate) When polyethylene glycol is used as pre-procedure bowel preparation, avoid concomitant use of stimulant laxatives. Colonic mucosal aphthous ulcerations and ischemic colitis have been observed following use of osmotic laxatives for bowel preparation and concomitant use of stimulant laxatives may increase this risk.
Polyethylene Glycol; Electrolytes; Bisacodyl: (Moderate) When polyethylene glycol is used as pre-procedure bowel preparation, avoid concomitant use of stimulant laxatives. Colonic mucosal aphthous ulcerations and ischemic colitis have been observed following use of osmotic laxatives for bowel preparation and concomitant use of stimulant laxatives may increase this risk.
Torsemide: (Minor) The risk of hypokalemia due to loop diuretics may be increased in patients receiving prolonged therapy with certain laxatives. Monitor serum potassium levels to determine the need for potassium supplementation and/or alteration in drug therapy in patients receiving loop diuretics. Senna rarely causes hypokalemia with proper use.
Anthraquinone derivatives such as senna are stimulant laxatives. Stimulant laxatives work by irritating luminal sensory nerve endings, thereby stimulating colonic motility and reducing colonic water absorption. Senna can alter permeability of cell walls in the colon because it increases cyclic 3',5'-adenosine monophosphate, which also regulates active ion secretion. The result is increased fluid accumulation in the colon and a laxative action. Tolerance to stimulant laxatives is uncommon.
Pharmaco*kinetics:
Senna is administered orally and rectally. The pharmaco*kinetics of senna are not well characterized. There is insufficient evidence of distribution into breast milk, but amounts are unlikely to be a problem. Absorbed anthraquinones are believed to be metabolized by the liver and may be excreted via the bile in feces, and, possibly, in urine.
-Route-Specific Pharmaco*kinetics
Oral Route
There is minimal GI absorption following oral administration. Free anthraquinones are released in the colon as a result of enzymatic hydrolysis of the glycosides. With oral dosing, a laxative effect is typically produced in 6-12 hours but may take up to 24 hours.
Other Route(s)
Following rectal administration of senna, laxative effect is seen in 30 to 120 minutes.
DISCLAIMER: This drug information content is provided for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always consult their physician with any questions regarding a medical condition and to obtain medical advice and treatment. Drug information is sourced fromGSDD (Gold Standard Drug Database )provided by Elsevier.
