Safety of Senna-Based Laxatives

A recent study  (Vilanova-Sanchez A, et al. J Pediatr Surg 2018; 53: 722-7) provides reassurance regarding the safety of senna-based laxatives in kids.

The authors performed a literature review and reviewed their personal experience (2014 to 2017) of prescribing Senna in 640 patients. In this cohort, 230 (36%) had functional constipation.

Key findings:

  • Besides abdominal cramping or diarrhea during the first weeks of administration, there were no other long-term side effects from Senna found in the pediatric literature with long-term treatment
  • At their institution, 83 (13%) patients presented minor side effects such as abdominal cramping, vomiting or diarrhea, almost half (48%) of which resolved spontaneously within two weeks.
  • “We did not see any side effects in 540 (84.3%) patients.”  The median length of treatment was 338 days and median dose was 17.5 mg.  “430 (80%) of them are currently taking Senna.”
  • 17 patients (2.2%) developed blisters during their treatment. Patients who developed blisters had higher doses 60 mg/day; 60 [12–100] vs. 17.5 [1.7–150] (p < 0.001). All of the blistering episodes were related to night-time accidents, with a long period of stool to skin contact.

In their discussion, the authors note that senna and other anthranoid glycosides are not absorbed in the small intestine.  They are maintained as prodrugs until they reach the large intestine where they are metabolized to the active form. In addition, “despite an extensive search of both the medical and lay literature we did not find any reference to long term tolerance due to treatment which we find is a frequently mentioned concern by families and clinicians”

The authors comments on the study from Nationwide Children’s Hospital website:

  • “The safety profile of senna is as good as or better than many common medications a person would be on, including over-the-counter medications routinely given to very young children, and tolerance does not appear to be a concern,” says Dr. Levitt, who is also a professor of Surgery at The Ohio State University College of Medicine. “We hope this paper will make physicians more comfortable in using senna-based laxatives, and that they will be more widely used.”
  • Senna is often more effective than polyethylene glycol. This study shows that it is safe as well.  “A physician should consider senna as the first line medication,” says Dr. Levitt.

My take: Many patients who come to pediatric gastroenterologists have not responded to polyethylene glycol.  Senna has been effective in many of these patients as part of a bowel regimen which usually includes behavior modification and diet.

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