Embedded Files
Pharmacologic Category
Dosing: Adult
Note: Several types of senna products are available on the market and multiple formulations exist that are not equivalent; products composed of sennosides are considered OTC medications; senna pod concentrate and senna leaf extract are considered dietary supplements and are not interchangeable on a mL-to-mL (or mg-to-mg) basis with other senna products that contain sennosides; close attention must be paid to the product description and concentration when ordering or administering.
Constipation: Oral:
Sennosides:
Syrup (8.8 mg sennosides/5 mL): 10 to 15 mL (17.6 mg to 26.4 mg sennosides) once daily; maximum: 15 mL (26.4 mg sennosides) twice daily.
Tablets:
8.6 mg sennosides/tablet: Two tablets (17.2 mg sennosides) once daily; maximum: 4 tablets (34.4 mg sennosides) twice daily
15 mg sennosides/tablet: Two tablets (30 mg sennosides) once or twice daily
17.2 mg sennosides/tablet: One tablet (17.2 mg sennosides) once daily; maximum: 2 tablets (34.4 mg sennosides) twice daily
25 mg sennosides/tablet: Two tablets (50 mg sennosides) once or twice daily
Senna leaf extract syrup (176 mg/5 mL senna leaf extract): Note: Senna leaf extract is considered a dietary supplement and is not interchangeable on a mL-to-mL (or mg-to-mg) basis with other senna products that contain sennosides.
10 to 15 mL (352 to 528 mg senna leaf extract) once daily (preferably at bedtime); may increase to 10 to 15 mL (352 to 528 mg senna leaf extract) twice daily if needed; maximum daily dose: 30 mL/day
* See Dosage and Administration in AHFS Essentials for additional information.
Dosing: Geriatric
Refer to adult dosing.
Dosing: Pediatric
Note: Several types of senna products are available on the market and multiple formulations exist that are not equivalent; products composed of sennosides are considered OTC medications; senna pod concentrate and senna leaf extract are considered dietary supplements and are not interchangeable on a mL to mL (or mg to mg) basis with other senna products that contain sennosides; close attention must be paid to the product description and concentration when ordering or administering.
Constipation: Oral:
Sennosides:
Syrup (8.8 mg sennosides/5 mL):
Children 2 to <6 years: 2.5 to 3.75 mL (4.4 to 6.6 mg sennosides) at bedtime, not to exceed 3.75 mL (6.6 mg sennosides) twice daily
Children 6 to <12 years: 5 to 7.5 mL (8.8 to 13.2 mg sennosides) at bedtime, not to exceed 7.5 mL (13.2 mg sennosides) twice daily
Children ≥12 years and Adolescents: 10 to 15 mL (17.6 mg to 26.4 mg sennosides) at bedtime, not to exceed 15 mL (26.4 mg sennosides) twice daily.
Tablets:
8.6 mg sennosides/tablet:
Children 2 to <6 years: 1/2 tablet (4.3 mg sennosides) at bedtime, not to exceed 1 tablet (8.6 mg sennosides) twice daily
Children 6 to <12 years: 1 tablet (8.6 mg sennosides) at bedtime, not to exceed 2 tablets (17.2 mg sennosides) twice daily
Children ≥12 years and Adolescents: 2 tablets (17.2 mg sennosides) at bedtime, not to exceed 4 tablets (34.4 mg sennosides) twice daily
15 mg sennosides/tablet:
Children 6 to <12 years: 1 tablet (15 mg sennosides) once or twice daily
Children ≥12 years and Adolescents: 2 tablets (30 mg sennosides) once or twice daily
25 mg sennosides/tablet:
Children 6 to <12 years: 1 tablet (25 mg sennosides) once or twice daily
Children ≥12 years and Adolescents: 2 tablets (50 mg sennosides) once or twice daily
Senna pod concentrate liquid (Fletcher's Laxative for Kids; 167 mg/5 mL senna pod concentrate): Note: Senna pod concentrate is considered a dietary supplement and is not interchangeable on a mL to mL (or mg to mg) basis with other senna products that contain sennosides.
Children 2 to <6 years: 5 to 10 mL (167 to 333 mg senna pod concentrate) once or twice daily
Children and Adolescents 6 to 15 years: 10 to 15 mL (333 to 500 mg senna pod concentrate) once or twice daily
Senna Leaf Extract Syrup (176 mg/5 mL senna leaf extract): Note: Senna leaf extract is considered a dietary supplement and is not interchangeable on a mL to mL (or mg to mg) basis with other senna products that contain sennosides. Begin with once daily dosing (at bedtime); increase to twice daily if needed.
Children 2 to <6 years: 2.5 to 3.75 mL (88 to 132 mg senna leaf extract) once or twice daily; maximum daily dose: 7.5 mL/day
Children ≥6 years to <12 years: 5 to 7.5 mL (176 to 264 mg senna leaf extract) once or twice daily; maximum daily dose: 15 mL/day
Children ≥12 years and Adolescents: 10 to 15 mL (352 to 528 mg senna leaf extract) once or twice daily; maximum daily dose: 30 mL/day
Bowel evacuation: Children ≥12 years and Adolescents: Oral: 130 mg sennosides between 2:00 PM to 4:00 PM on the day prior to procedure
Use: Labeled Indications
Constipation: Relieves occasional constipation (irregularity); generally causes bowel movement in 6 to 12 hours
* See Uses in AHFS Essentials for additional information.
Use: Off-Label: Adult
Colonic cleansing before colonoscopy (adjunct)Level of Evidence [C]
Data from one uncontrolled study evaluating the use of senna as an adjunct to reduce the amount of polyethylene glycol (PEG) solution necessary suggests that the use of senna as an adjunct in this setting may be beneficial Ref. While the advantage of a lower amount of PEG solution with the use of senna is tolerated better by patients, the lower volumes of PEG solution may reduce the quality of the bowel preparation as was seen in one randomized controlled trial Ref. Additional data may be necessary to further define the role of senna as an adjunct in colonic cleansing before colonoscopy.
Based on the recommendations for Optimizing Adequacy of Bowel Cleansing for Colonoscopy, the US Multi-Society Task Force on Colorectal Cancer by the American College of Gastroenterology, American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, the use of adjunctive agents for precolonoscopy cleansing of the mucosa such as simethicone, flavored electrolyte solutions (eg, Gatorade), prokinetics, spasmolytics, bisacodyl, senna, olive oil, and probiotics is not recommended for routine use since none have consistently shown improved efficacy, safety, or tolerability of the bowel preparation. However, senna may be used in select situations.
Level of Evidence Definitions
Level of Evidence Scale
Clinical Practice Guidelines
Constipation:
AGA, “Guideline on the Medical Management of Opioid-Induced Constipation,” October 2018
Administration: Oral
Once-daily doses should be preferentially taken at bedtime. Administer 2 hours before or after other medications.
Administration: Pediatric
Oral: Administer at bedtime (preferable) with water; syrup can be taken with juice or milk or mixed with ice cream to mask taste.
Storage/Stability
Store at 20°C to 25°C (77°F); excursions are permitted between 15°C and 30°C (59°F to 86°F).
Medication Patient Education with HCAHPS Considerations
What is this drug used for?
• It is used to treat constipation.
Frequently reported side effects of this drug
• Abdominal cramps
Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:
• Severe abdominal pain
• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.
Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.
Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.
Medication Safety Issues
Sound-alike/look-alike issues:
Warnings/Precautions
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.
Other warnings/precautions:
• Appropriate use: Failure to have a bowel movement or occurrence of rectal bleeding after use should be reported to health care provider.
• Self-medication (OTC use): Not recommended for use in patients experiencing stomach pain, nausea, vomiting, or a sudden change in bowel movements which lasts >2 weeks. Not recommended for OTC use in children <2 years of age. Do not use for more than 1 week.
* See Cautions in AHFS Essentials for additional information.
Geriatric Considerations
Elderly are often predisposed to constipation due to disease, immobility, drugs, and a decreased “thirst reflex” with age enhancing the possibility of dehydration. Avoid stimulant cathartic use on a chronic basis if possible. Use osmotic, lubricant, stool softeners, and bulk agents as prophylaxis. Patients should be instructed for proper dietary fiber and fluid intake as well as regular exercise. Monitor closely for fluid/electrolyte imbalance, CNS signs of fluid/electrolyte loss, and hypotension.
Pregnancy Considerations
Treatment of constipation in pregnant women is similar to that of non-pregnant patients and medications may be used when diet and lifestyle modifications are not effective. Agents other than senna are preferred as initial treatment. Stimulant laxatives, including senna, are not recommended for chronic use, but may be used intermittently when needed (Christie [ACG 2007]).
Breast-Feeding Considerations
Rhein, an active metabolite of senna, is present in breast milk.
Breast milk was sampled following maternal administration of sennosides A+B (equivalent to ~sennosides 15 mg [rhein 9.8 mg]) and plantago to 20 women. Dosing occurred in the evening of postpartum days 2, 3, and 4. Breast milk was sampled prior to and for 26 hours after the last dose. The highest concentrations of rhein were found 10 hours after the dose, which was the first sample following drug administration. Rhein was still measurable in breast milk 26 hours after the dose in half of the women. Authors of the study calculated the daily amount of rhein present in breast milk to be 0.007% of the maternal dose (Faber 1988).
Although there have been reports of diarrhea or loose stools in breastfeeding infants, bowel patterns were not changed in most cases (Baldwin 1963; Duncan 1957; Greenhalf 1973; Shelton 1980; Werthmann 1973). The WHO considers use of senna for maternal constipation to be compatible with breastfeeding; however, it should only be used when dietary changes are inadequate (WHO 2002).
Briggs' Drugs in Pregnancy & Lactation
Adverse Reactions
Frequency not defined: Gastrointestinal: Abdominal cramps, diarrhea, nausea, vomiting
* See Cautions in AHFS Essentials for additional information.
Allergy and Idiosyncratic Reactions
Metabolism/Transport Effects
None known.
Drug Interactions Open Interactions
Dichlorphenamide: Laxatives may enhance the hypokalemic effect of Dichlorphenamide. Risk C: Monitor therapy
Polyethylene Glycol-Electrolyte Solution: Senna may enhance the adverse/toxic effect of Polyethylene Glycol-Electrolyte Solution. Risk C: Monitor therapy
Advanced Practitioners Physical Assessment/Monitoring
Determine cause of constipation before treating.
Nursing Physical Assessment/Monitoring
Determine cause of constipation before treating.
Dosage Forms: US
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Leaves, Oral:
Generic: (454 g)
Liquid, Oral:
Senexon: 8.8 mg/5 mL (237 mL [DSC]) [contains methylparaben, propylene glycol, propylparaben]
Generic: 8.8 mg/5 mL (237 mL)
Syrup, Oral:
Senna-GRX: 8.8 mg/5 mL (15 mL, 236 mL) [contains parabens, propylene glycol]
Generic: 8.8 mg/5 mL (5 mL, 236 mL, 237 mL); 176 mg/5 mL (15 mL, 237 mL)
Tablet, Oral:
Ex-Lax: 15 mg [DSC] [sodium free]
Ex-Lax Maximum Strength: 25 mg [DSC] [sodium free]
Geri-kot: 8.6 mg
GoodSense Laxative Pills: 25 mg [contains brilliant blue fcf (fd&c blue #1), corn starch]
GoodSense Senna Laxative: 8.6 mg
Perdiem Overnight Relief: 15 mg [DSC]
Senexon: 8.6 mg [DSC]
Senna Lax: 8.6 mg [DSC]
Senna Laxative: 8.6 mg
Senna Smooth: 15 mg [contains sodium benzoate]
Senna-Lax: 8.6 mg
Senna-Tabs: 8.6 mg
Senna-Time: 8.6 mg
SennaCon: 8.6 mg [DSC]
Senno: 8.6 mg
Senokot: 8.6 mg
Senokot Extra Strength: 17.2 mg
Senokot XTRA: 17.2 mg [DSC]
Generic: 8.6 mg
Tablet Chewable, Oral:
Ex-Lax: 15 mg [DSC]
Ex-Lax: 15 mg [DSC] [chocolate flavor]
Anatomic Therapeutic Chemical (ATC) Classification
- A06AB06
Generic Available (US)
May be product dependent
Pricing: US
Syrup (Senna Oral)
176 mg/5 mL (per mL): $0.29
Tablets (Senna Smooth Oral)
15 mg (per each): $0.22
Tablets (Senno Oral)
8.6 mg (per each): $0.05
Tablets (Senokot Extra Strength Oral)
17.2 mg (per each): $0.48
Tablets (Senokot Oral)
8.6 mg (per each): $0.23
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Mechanism of Action
The anthraquinone group of stimulant laxatives includes the plant-derived agents such as senna. Stimulant laxatives typically induce defecation by stimulating peristaltic activity on the intestine by direct action on intestinal mucosa or nerve plexus, therefore increasing motility.
Pharmacodynamics/Kinetics
Onset of action: Oral: Within 6 to 24 hours
Metabolism: Hepatic
Excretion: Feces (via bile); urine
Local Anesthetic/Vasoconstrictor Precautions
No information available to require special precautions
Effects on Dental Treatment
No significant effects or complications reported
Effects on Bleeding
No information available to require special precautions
Related Information
Index Terms
Sennosides
References
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;28:100-104.[PubMed 19491001]
Ahlfors CE. Benzyl alcohol, kernicterus, and unbound bilirubin. J Pediatr. 2001;139(2):317-319.[PubMed 11487763]
Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52.[PubMed 27060684]
Baldwin WF. Clinical study of senna administration to nursing mothers: assessment of effects on infant bowel habits. Can Med Assoc J. 1963;89:566-568.[PubMed 14045350]
Centers for Disease Control (CDC). Neonatal deaths associated with use of benzyl alcohol—United States. MMWR Morb Mortal Wkly Rep. 1982;31(22):290-291. http://www.cdc.gov/mmwr/preview/mmwrhtml/00001109.htm[PubMed 6810084]
Christie J, Rose S. Constipation, diarrhea, hemorrhoids, and fecal incontinence. In: Pregnancy in gastrointestinal disorders. Bethesda (MD): ACG Monograph American College of Physicians; 2007. p. 4–9. Available at https://www.acg.gi.org.
Duncan AS. Standardized senna as a laxative in the puerperium; a clinical assessment. Br Med J. 1957;1(5016):439-441.[PubMed 13396280]
Ex-Lax Maximum Strength tablets (sennosides) [prescribing information]. Parsippany, NJ: Novartis; February 2013.
Ex-Lax Regular Strength chewable tablet (senna) [prescribing information]. Parsippany; NJ: Novartis Consumer Health, Inc; September 2014.
Ex-Lax Regular Strength tablets (sennosides) [prescribing information]. Parsippany, NJ: Novartis; February 2013.
Fletcher's Laxative (senna) [prescribing information]. Orchard Park, NY: The Mentholatum Company.
"Inactive" ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics (AAP) Committee on Drugs. Pediatrics. 1997;99(2):268-278.[PubMed 9024461]
Greenhalf JO, Leonard HS. Laxatives in the treatment of constipation in pregnant and breast-feeding mothers. Practitioner. 1973;210(256):259-263.[PubMed 4570522]
Hookey LC, Depew WT, Vanner SJ. Combined low-volume polyethylene glycol solution plus stimulant laxatives versus standard-volume polyethylene glycol solution: A prospective, randomized study of colon cleansing before colonoscopy. Can J Gastroenterol, 2006;20(2):101-105.[PubMed 16482236]
Iida Y, Miura S, Asada Y, et al. Bowel preparation for the total colonoscopy by 2,000 mL of balanced lavage solution (Golytely) and sennoside. Gastroenterol Jpn, 1992;27:728-733.[PubMed 1468604]
Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126.[PubMed 10891521]
Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Am J Gastroenterol, 2014;109(10):1528-1545.[PubMed 25223578]
Mahadevan U and Kane S, "American Gastroenterological Association Institute Medical Position Statement on the Use of Gastrointestinal Medications in Pregnancy," Gastroenterology, 2006, 131(1):278-82.[PubMed 16831610]
Senexon syrup (sennosides) [prescribing information]. Livonia, MI: Rugby; February 2013.
Senna Liquid (sennosides) [prescribing information]. Livonia, MI: Rugby Laboratories; October 2019.
Senna Syrup (senna leaf extract) [prescribing information]. Greenville, SC: Pharmaceutical Associates, Inc; June 2017.
Senokot tablet (senna) [prescribing information]. Stamford, CT: Purdue Products L.P.; February 2013.
Senokot tablets (senna concentrate) [prescribing information]. Stamford, CT: Purdue; 2011.
Senokot XTRA tablets (senna concentrate) [prescribing information]. Stamford, CT: Purdue; 2016.
Shelton MG. Standardized senna in the management of constipation in the puerperium: a clinical trial. S Afr Med J. 1980;57(3):78-80.[PubMed 6996138]
Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42(1):4-5.[PubMed 4511106]
World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the eleventh WHO model list of essential drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/
Brand Names: International
Adjust-A (JP); Bekunis (AT, CH, CY, ES, GR, IL, KW, LU, MX, PL, PT, SG); Bekunis Instant (DE); Cholax (CL); Ciruelax Comp (MX); Colonorm (AT); Darmol (AT, CH, HU); Depuran (ZA); Efectilax (CL); Falquilax (IT); Fuca (BE); Fuca Excellent (NL); Jungborn (IL); Lacass (BR); Lagenbach (MX); Laxal (JO, KW); Laxante Olan (ES); Laxen (PH); Linella (SE); List Senny (CZ); Midro (BE, CH); Midro Tee (DE); Naturlax (CL); Neholis (ES); Purgaton (EG); Pursennid (AE, FI, SE); Pursennide (FR); Ramend (DE); Regulax (HR, HU, LT, PL, RU, SK, UA); Senade (LV); Senadex (LT); Senadexin (RU, UA); Senadin (UA); Senalax (PH); Senareti (BR); Senna (CY); Sennalax (ZA); Sennalax Fort (EG); Sennefol (PL); Sennocol (NL); Sennoket (JO); Sennove Lusky (CZ); Senokot (AU, GB, HK, IE, KW, MY, PH, SG, TH, TR); Soflax (ZA); Thea Bona (DK); X-Prep (AT); Xenna (PL); Yodel-S (JP)
Last Updated 2/21/20
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