Cassia senna

Cassia Senna Omer B. 2014

SENNA LEAF Cassia senna

Fabaceae

By Omer Bayazeid


SNNA LEAF

Definition:

Folium Sennae consists of the dried leaflets of Cassia senna L. (Fabaceae) Known as Alexandrain or Khartoum senna.

It contain not less than 2.5 per cent of hydroxyanthracene glycosides, calculated as sennoside B

(C42H 38O 20M r863) with refrence to the dried drug.

Synonyms:

Fabaceae are also referred to as Leguminosae. Although recognized as two distinct species in many pharmacopoeias , Cassia acutifolia Delile and are considered botanically to be synonyms of the single species Cassia senna L.

Description:

Low shrubs, up to 1.5m high, with compound paripinnate leaves, having 3–7 pairs of leaflets, narrow or rounded, pale green to yellowish green.

The entire, lanceolate to narrowly lanceolate, pinnate leaflets have a short petiolule and are 2-6 cm long and 7-12 mm wide. The leaflets have an asymmetric base and a thin, stiff and brittle, light green lamina which appears as if glabrous. The leaflets are often marked with transverse or oblique lines.(H )

Odour: Faint, characteristic.

Taste: To begin with sweetish, then bitter.

Constituents:

The main active constituents are sennoside A and B (ca.2.5%), which are rhein-dianthrone diglucosides . Smaller amounts of other diglucosides, monoanthraquinone glucosides and aglycones are also present.

Geographical distribution:

The plant is indigenous to tropical Africa. It grows wild near the Nile river from Aswan to Kordofan, and in the Arabian peninsula, India and Somalia. It is cultivated in India, Pakistan, and the Sudan.


Identification:

A. C. senna occur as grayish-green or brownish-green, thin, fragile leaflets, lanceolate, mucronate, asymmetrical at the base, usually 15-40 mm long and 5-15 mm wide .

B. Reduce to a powder. The powder is light green or greenish-yellow. Examine under a microscope using chloral hydrate solution.(P ) The powder shows the following diagnostic characters: Epidermis with polygonal cells containing mucilage; unicellular thick-walled trichomes, length, up to 260µm, slightly curved at the base, warty; paracytic stomata on both surfaces; under the epidermal cells a single row of palisade layer; cluster crystals of calcium oxalate distributed throughout the lacunose tissue; on the adaxial surface, sclerenchymatous fibres and a gutter-shaped group of similar fibres on the abaxial side containing prismatic crystals of calcium oxalate.

C. Thin-layer chromatography:

Test solution. To 0.5g of the powdered drug add 5ml of a mixture of equal volumes of ethanol (96%) and water and heat to boiling. Centrifuge and use the supernatant liquid. Reference solution: Dissolve 10 mg of senna extract in 1 ml of a mixture of equal volumes of ethanol (96%) and water.Plate: Silica gel G plate. Mobile Phase: glacial acetic acid, water, ethyl acetate, propanol ( 1:30:40:40)Detection: Spray with a 20% V/V solution of nitric acid and heat at 120 C for 10 min. Allow to cool and spray with a 50 g/L solution of potassium hydroxide in alcohol until the zones appear.Result: The principle zones in the chromatogram obtained with the test solution are similar in position ( sennosides B,A,D and C in order of increasing R f Value ).

Tests:

Foreign matter: Maximum 3% of foreign organs and maximum 1% of foreign elements.

Loss on drying: Maximum 12% determined on 1000g of the powdered drug by drying in an oven at 105C.

Total ash: Maximum 12%.

Ash soluble in hydrochloric acid: Maximum 2.5%.


Uses described:

In folk medicine, not supported by experimental or clinical data As an expectorant, a wound dressing, an antidysenteric, and a carminative agent; and for the treatment of gonorrhoea, skin diseases, dyspepsia, fever, and haemorrhoids.(W )

Laxative effects: Senna is an anthranoid-type stimulating laxative. The laxative effect is due to the action of sennoside and their active metabolite, rhein anthone, in the colon. The laxative effect is realized by inhibition of water and electrolyte absorption from the large intestinal contents. This will stimulate colon motility resulting in propulsive contraction.

Dosage:

Mode of Administration: Comminuted herb, powder or dried extract for teas, decoctions, cold macerates or elixirs. Liquid or solid forms of medication exclusively for oral use.(PDR )

How to Supplied:

Capsule —25 mg, 450 mg

Chewable tablet – 15 mg sennosides

Granules – 15 mg sennosides per teaspoon

Liquid – 2.5 oz. (alcohol 7% by volume), 8.8 mg sennosides per teaspoon

Tablet – 8.6 mg sennosides, 15 mg sennosides, 17 mg sennosides, 25 mg sennosdies (PDR )

Biological Activities:

(1) Antimicrobial.(2) Cytotoxic.(3) Thrombolytic activity.

Clinical pharmacology:

Pharmacology of Cassia Senna: Senna leaves and pods have been shown to have laxative activity. It is usefull in habitual constipation. Pharmacological investigations show that sennosides A and B account for the entire activity of the senna leaves and pods.Leaves contain glycosides, sennoside A, B, C and D.


Two naphthalene glycosides have been isolated from leaves and pods. The medicinal action of Senna can be attributed mainly to the anthraquinone glycosides, especially sennoside A and B. It appears that the aglycone portion is responsible for its action. The breakdown of the anthraquinone glycosides in the digestive tract can occur in one of two ways. The bowel flora can directly hydrolyze themin a similar way to that of free active aglycone. Alternatively, in the presence of bile and the sugar moiety, the free aglycone can be absorbed into the blood stream and secreted later into the colon. The final result is stimulation of the Auerbach plexus resulting in increased intestinal muscle contraction. In addition, its mucilage content decreases bodily absorption of fluid leading to an enhancement of the final laxative action.

1. Constipation: Taking senna orally is effective for short- term treatment of constipation. Senna is an FDA-approved nonprescription drug for adults and children ages 2 years and older. However, in children ages 3-15 years, mineral oil and a medication called lactulose might be more effective. In elderly people, senna plus psyllium is more effective than lactulose for treating ongoing constipation.

2. Bowel preparation before colonoscopy: Taking senna by mouth might be effective for bowel cleansing before colonoscopy; however, sodium phosphate or polyethylene glycol is more effective.

3. Pregnancy and Breast-Feeding: Senna is Possibly Safe during pregnancy and breast-feeding when used short-term. It is Possibly Unsafe when used long-term or in high doses. Long-term, frequent use, or use of high doses has been linked to serious side effects including laxative dependence and liver damage. Although small amounts of senna cross into breast milk, it doesn’t seem to be a problem for nursing babies. As long as the mother uses senna in recommended amounts, senna does not cause changes in the frequency or consistency of babies’ stools.

4. Interactions with Medications:

(a) Digoxin (Lanoxin) Senna is a type of laxative called a stimulant laxative. Stimulant laxatives can decrease potassium levels in the body. Low potassium levels can increase the risk of side effects of digoxin (Lanoxin).

(b) Warfarin (Coumadin) Senna can work as a laxative. In some people, senna can cause diarrhea. Diarrhea can increase the effects of warfarin and increase the risk of bleeding. If you take warfarin, do not take excessive amounts of senna.

(c) Water Pills (Diuretic Drugs) Senna is a laxative. Some laxatives can decrease potassium in the body. "Water pills" can also decrease potassium in the body. Taking senna along with "water pills" might decrease potassium in the body too much. Some "water pills" that can decrease potassium include chlorothiazide (Diuril), chlorthalidone (Thalitone), furosemide (Lasix), hydrochlorothiazide (HCTZ, Hydrodiuril, Microzide), and others.


(d) Laxative: Children over the age of two years and adults can orally take senna to treat constipation, but only on a short-term basis, which is about two weeks. If you take it any longer than that, you could cause your bowels to become dependent on it, and they might stop functioning properly. Overuse of senna can also cause an electrolyte imbalance that could worsen heart disease. Another use for senna is to cleanse the bowels before a colonoscopy.

(e) Losing Weight: to lose weight using senna typically means taking the product for longer than the recommended two weeks and possibly taking more than the recommended dosage of 17.2 milligrams daily. Overuse of this herb is considered senna abuse and can cause serious problems. Drugs.com reported a case of an anorexia nervosa patient who took up to 100 tablets of senna daily. When you take more than the dosage recommended on the package, you run the risk, as this patient did, of developing nephrocalcinosis, or too much calcium in the kidneys; finger clubbing, a deformity of the fingers; and osteoarthropathy, a bone and joint disease.

(f) Pregnancy: Constipation is a common problem that affects about half of all pregnant women at some point. Although senna is FDA- approved, it is approved as an herbal supplement, which falls under a different criterion than a medicine. Herbs, including senna, can come in different formulations and strengths, making them unsafe to take during pregnancy, according to the American Pregnancy Association. Senna has not been associated with abnormalities or birth defects, according to Drugs.com. However, not enough information is available to confidently deem senna safe for pregnant women, so it is best to avoid it while pregnant and breastfeeding.

(g) Hemorrhoids: The herb of senna is quite popular as chief ingredient in many teas and colon cleansing products prescribed to heal hemorrhoids. Senna contains special components known as sennosides that act on the lining of the bowel causing a laxative effect. Constipation or hard stools is one of the triggering factors for causing and worsening hemorrhoids. Other folk medicine uses are for skin diseases, gonorrhea, fever and upset stomach

5. Dyspeptic Syndrome: Senna contains natural enzymes that help in regulating the bowel movements and also restoring the gastric juice secretion in stomach. It is therefore, the herb is found effective in treating dyspeptic syndrome. Senna supplements, if used in proper dosage for certain period, have shown potential role in reducing the irritability in intestines by improving overall digestion.

6. Gastrointestinal Conditions: Senna possesses natural anti-inflammatory properties due to its compound called resveratrol and hence is used in various gastrointestinal conditions where inflammation is one of the symptoms. Furthermore, component found in senna called barakol is used for counteracting aconitine poisoning in the gastrointestinal tract. Senna, in some cases, has been used to empty the stomach and intestines so as to relieve from acidity and constipation. The herb specifically acts on lower bowel alleviating the symptoms of constipation. In addition, various products containing senna as their main ingredient have been prescribed to get rid of abdominal cramps, pains, sprains and discomfort.


7. Obesity: as Dietary Supplement In most of the dieter’s tea, the herb of senna is found as primary ingredient. Due to the combination of acting as laxative and stimulant, regular intake of senna tea is found to reduce the appetite without disturbing other body systems. It is also revealed that its quick gastric and intestinal emptying property augments overall therapy of weight loss as food moves through the systems quite earlier than many calories get absorbed. However, this may lead to even dangerous weight loss and hence, before taking senna supplement it is important to fix the dosage and period.

8. Usual Dosage: The herb or its extracts may be taken in several forms - capsules, tablets, and decoction as well as tea. A number of people take capsules and tablets prepared from the senna extract to alleviate constipation. Normally, capsules and tablets containing 10 mg to 60 mg of sennosides are taken daily for a period of 10 days. However, it is not advisable to continue using the medication for more than 10 days. In case there is no relief from constipation even after taking the medication for 10 days, one should consult a physician for necessary actions. In additionto this, consuming a mint tea prepared with the herb is effective for curing cramps. While the dose for the adults is 10 mg to 60 mg of senna daily for 10 days, children above the age of six years may be administered half the adult dose. However, the herb should never be given to children below the age of six as it may prove to be detrimental. It is best to take senna after consulting a physician.

Toxicity:

The major symptoms of overdose are griping and severe diarrhoea with consequent losses of fluid and electrolytes. Treatment should be supportive with generous amounts of fluid. Electrolytes, particularly potassium, should be monitored, especially in children and the elderly.

Warnings:

Stimulant laxative products should not be used when abdominal pain, nausea, or vomiting are present. Rectal bleeding or failure to have a bowel movement after use of a laxative may indicate a serious condition. Chronic abuse, with diarrhoea and consequent fluid electrolyte losses, may cause dependence and need for increased dosages, disturbance of the water and electrolyte balance (e.g. hypokalaemia), atonic colon with impaired function, albuminuria and haematuria. The use of stimulant laxatives for more than 2 weeks requires medical supervision. Chronic use may lead to pseudomelanosis coli (harmless). Hypokalaemia may result in cardiac and neuromuscular dysfunction, especially if cardiac glycosides (digoxin), diuretics, corticosteroids, or liquorice root are taken. .

Precautions General Use for more than 2 weeks requires medical attention.


Drug interactions:

Decreased intestinal transit time may reduce absorption of orally administered drugs. The increased loss of potassium may potentiate the effects of cardiotonic glycosides (digitalis, strophanthus). Existing hypokalaemia resulting from long- term laxative abuse can also potentiate the effects of antiarrhythmic drugs, such as quinidine, which affect potassium channels to change sinus rhythm. Simul- taneous use with other drugs or herbs which induce hypokalaemia, such as thiazide diuretics, adrenocorticosteroids, or liquorice root, may exacerbate electrolyte imbalance.

Drug and laboratory test interactions Urine discoloration by anthranoid metabolites may lead to false positive test results for urinary urobilinogen, and for estrogens measured by the Kober procedure.

Carcinogenesis, mutagenesis, and impairment of fertility No in vivo genotoxic effects have been reported to date. Although chronic abuse of anthranoid-containing laxatives was hypothesized to play arole in colorectal cancer, no causal relationship between anthranoid laxative abuse and colorectal cancer has been demonstrated.

Pregnancy: non-teratogenic effects Use during pregnancy should be limited to conditions in which changes in diet or fibre laxatives are not effective. .

Nursing mothers Use during breast-feeding is not recommended owing to insufficient data on the excretion of metabolites in breast milk. Small amounts of active metabolites (rhein) are excreted into breast milk, but a laxative effect in breast-fed babies has not been reported.

Pediatrics use Contraindicated for children under 10 years of age.

Other precautions No information available on teratogenic effects in pregnancy.

Adverse reactions:

Senna may cause mild abdominal discomfort such as colic or cramps .A single case of hepatitis has been described after chronic abuse. Melanosis coli, a condition which is characterized by pigment-loaded macro- phages within the submucosa, may occur after long-term use. This condition is clinically harmless and disappears with cessation of treatment. Long-term laxative abuse may lead to electrolyte disturbances (hypokalaemia, hypocalcaemia), metabolic acidosis or alkalosis, malabsorption, weight loss, albuminuria, and haematuria. Weakness and orthostatic hypotension may be exacerbated in elderly patients when stimulant laxatives are repeatedly used. Conflicting data exist on other toxic effects such as intestinal-neuronal damage due to long-term misuse.


Posology The correct individual dose is the smallest required producing a comfortable, soft-formed motion. Powder: 1–2g of leaf daily at bedtime. Adults and children over 10 years: standardized daily dose equivalent to 10–30mg sennosides (calculated as sennoside B) taken at night.

Overview of Clinical trials:

The efficacy of senna preparations has been evaluated in clinical trials in the treatment of constipation and for bowel cleansing before radiological investigations or colonoscopy. In the majority of the studies combinations of senna with fibre were investigated. For bowel cleansing high doses of a senna preparation were tested.

There is no well-designed non-experimental descriptive study with a mono-preparation of senna available which investigates the short-term use of occasional constipation. Evidence is obtained from experts’ reports and opinions and extensive clinical experiences.

Well-designed clinical studies are available for combination products for occasional constipation and for high doses of senna preparations for bowel cleansing and they clarify the pharmacodynamics. Furthermore pharmacological studies in humans are available.

The conditions determined in the pharmacovigilance actions for anthranoid-containing laxatives have to be maintained for the moment because further investigations are needed to clarify the carcinogenic risk.

The results of the most recent studies are inconsistent. However, a risk was also revealed for constipation itself and underlying dietary habits. The use in children under 12 years of age is contraindicated and use during lactation is not recommended. During pregnancy only a specified extract (as described above) can be regarded as safe, but with the advice that the use is to be avoided during the first trimester. Senna leaves should only be used intermittently and if other actions like behavioural modification, dietary changes and use of bulk forming agents failed.

Provided that the correct dose and duration of administration and the advices given in the SPC are followed, senna can be regarded as a safe and effective medicinal plant for the short-term use in cases of occasional constipation. In this indication the benefit/risk ratio is positive.

The data available on use for bowel cleansing in a high dose are not consistent. An adequate bowel cleansing can be achieved as well by other preparation methods than with a high dose of senna with a less favourable benefit-risk-ratio. In particular if different methods are combined, lower doses of senna seem to be effective enough. Use at a high dose cannot therefore be recommended. In an unpublished multicentre, prospective, controlled, randomised, two-parallel-group, observer-blind study in 133 patients, which was presented in the application procedure of a senna preparation (150 mg hydoxyanthracene glycosides, calculated as sennoside B) for bowel cleansing a statistically significant non-inferiority of this preparation in combination with 2 l PEG-ELS could not be shown in comparison to


4 l PEG-ELS. The descriptive evaluation shows a better bowel cleansing in the rectum, colon descendens, colon transversum and flexura coli dextra for 4 l PEG-ELS and an equivalent cleansing for both preparations in the colon sigmoideum , colon ascendens and caecum.

Up to now there is no clear evidence to recommend a specific dose nor a specific combination of different bowel cleansing methods. No recommendation concerning the use of senna for bowel cleansing is therefore made in the Community herbal monograph, even not for a special patient group, who is not able to ingest high amounts of fluid, e.g. patients suffering from cardiac insufficiency.

Traditional use:

Senna was traditionally used for purification the blood, bowel and other organs in many diseases. In former times, such purification was often the first step to treat a lot of diseases. Such a procedure is now obsolete. There are no plausible pharmacological data available for the purification of the blood 1 As referred to in the HMPC ‘Guideline on the assessment of clinical safety and efficacy in the preparation of Community herbal monographs for well-established and of Community herbal monographs/entries to the Community list for traditional herbal products/substances/preparations and other organs than the bowel, or for use as a cholagogum. In view of possible risks, such traditional uses cannot be recommended. This is in accordance with the German pharmacovigilance actions for anthranoid-containing laxatives.


References:

1. European Pharmacopia 7.0 Volume 1.2. PDR for Herbal Medicine.3. Herbal Drug.4. E/S/C/O/P.5. WHO Monographs.

Health & Medicine

Cassia senna