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Harms Associated with Usage of Senna Leaves (Sana Makki) in COVID-19

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Associated Harms with Usage of Senna Leaves (Sana Makki) in Covid-19
Harms associated with Usage of Senna Leaves (Sana Makki) in COVID-19
ISSN (Print): 2521-8514 ISSN (Online): 2521-8484
RADS J. Pharm. Pharm. Sci.
Harms Associated with Usage of Senna Leaves (Sana
Makki) in COVID-19
Irshad Hussain1,*, Che Suraya Zin2, Ehsanullah Malik3, Muhammad Shahzad Raza4
1Institute of Pharmacy, SMBB Medical University Larkana, Pakistan
2Kulliyyah of Pharmacy, International Islamic University Malaysia
3Department of Surgery,SMBB Medical University Larkana,Pakistan
4NMC, University of Health Sciences Lahore, Pakistan
Dear Editor,
A stimulant laxative; Senna is an ornamental plant of
the family Fabaceae. There has been ancient use of
the drug for its laxative/purgative action. The plant is
located in tropics. It contains the constituents
anthraquinones, dianthrones and anthrones.
Sennosides A& B are derivatives of anthraquinones
at 2.5% minimal concentration. Leaves of the plants
have been used for laxative/purgative action by
pediatricians, pediatric surgeons and pediatric
gastroenterologists [1]. Senna is described as a safe
option to treat constipation. There have been some
media reports of the misuse of Senna in Pakistan for
COVID-19 infection. Governor of the Sindh Province
has mentioned the use of Senna (Sana Makki) in
COVID-19 patients [2]. A YouTube video has been
viral of a person, a UK resident advising the use of
leaves of Senna to cure the COVID-19 and very
unscientifically presenting himself for penalty if his
claims are proved false provided that the drug is used
as prescribed by his method. While his method was
not based on any clinically published trial of him or
others. Illiterate peoples have started using the leaves
as suggested in the video. Impressed from convincing
technique of the person, there are heaps of recipes
of Sana Makki leaves mentioned in different links of
Facebook related with the methods told by Dr Nazeer
in his video. Due to usage by community in COVID-
19, the price of Senna leaves has jumped from Rs
250 per kg (USD 1.5) to around Rs 2500 per Kg (USD
15). Medical professionals have described such news
for of using Senna in COVID-19 as unproven,
baseless and misleading and warned the public not to
use the herb to avoid unintended side effects that
outweigh some of its health benefits [3]. Word
“Senna” was combined with the word COVID-19” or
SARS using AND as boolean and was searched at
Pubmed advanced database. There was none
retrieval of clinical evidence regarding the use and
effectiveness of Senna in the COVID-19 infection.
Only two articles were retrieved from the searched
results which were unrelated to the clinical use of
Senna. There has been no availability of any peer
reviewed or published clinical description regarding
the use of senna in the SARS, MERS and COVID-19.
Senna has been approved by FDA for its use in
constipation/laxative action and is included among the
Over-the-counter (OTCs) drugs requiring no
prescription [4]. Gastrointestinal symptoms have been
reported due to COVID-19 and have been included in
the symptoms of the disease [5]. Use of laxatives in
GIT symptoms can definitely synergize the motility
leading to diarrheal symptoms and dehydration
affecting the electrolyte balance of the patients. Loss
of nutrients in diarrhea and vomiting can also reduce
the immunity of patients reducing the powerful natural
defense of the body versus the COVID-19. It has
been recommended by the American Herbal Plant
Associations (AHPA) regarding the labelling
instructions of the senna leave products to not use
them if having diarrhea or abdominal pain and
requiring the consultation of health care provider for
use in pregnant and nursing mothers as the
constituents of Senna irritate the bowl linings for
laxative action [4]. There have been use of Senna
infusions in chronic constipation as similar use
recommendations in the prophetic medicines.
Medicinal plants have common anti-inflammatory
properties in providing symptomatic relief in common
cold, fever and sore throat. The myth of Senna use in
COVID-19 has been derived from such basis ignoring
the laxative/purgative action of the drug. However
safer herbal options like green tea and honey can be
soothing in COVID-19 symptoms. Use of Senna in
Harms associated with Usage of Senna Leaves (Sana Makki) in COVID-19
ISSN (Print): 2521-8514 ISSN (Online): 2521-8484 64
RADS J. Pharm. Pharm. Sci.
COVID-19 patients has been strongly discouraged
due to its enormous side effects like diarrhea, water
loss, electrolyte imbalance and hypokalemia. Such
side effects can be harsh for those patients already in
critical conditions. There have been many reported
interactions of Senna with many drugs and it is not
suited for heart, liver and kidney patients. Thereby,
the use of Senna remains incalculable and the risks
can outweigh the benefits. Senna can also not be
used for long time due to possibility of its dependency
on laxatives [6]. WHO has encouraged the clinical
investigations to find safe and effective herbs in the
treatment of COVID-19 [7]. Senna leaves may not be
used for the prophylaxis or treatment of COVID-19
without having any sufficient clinical data as the drug
is potent laxative and can raise the complications of
COVID-19 patients instead of benefits by augmenting
diarrhea and other gastrointestinal problems.
1. Vilanova-Sanchez A, Gasior AC, Toocheck N, et
al. Are Senna based laxatives safe when used as
long term treatment for constipation in children?. J
Pediatr Surg. 2018; 53(4):7227.
5. Lijing Yang, and Lei Tu. Implications of
gastrointestinal manifestations of COVID-19.
Lancet gastroenterology and Hepatology. 2020, 1-
(A Report by BBC Urdu).
ResearchGate has not been able to resolve any citations for this publication.
Background and aim: Senna is a stimulant laxative commonly used by pediatricians, pediatric gastroenterologists, and pediatric surgeons. Many clinicians avoid Senna for reasons such as tolerance or side effects but this has little scientific justification. We recently found several patients we were caring for developed perineal blistering during the course of Senna treatment. Because of this we chose to review the literature to identify side effects in children taking this medication as well as to analyze our Center's experience with Senna's secondary effects. Methods: We performed a literature review (MEDLINE, PUBMED) using the keywords of Senna, sen, sennosides and children, and pediatric and functional (idiopathic) constipation. We looked for articles with information regarding perineal blisters related to Senna as well as other secondary effects of Senna laxatives in children when used on a long-term basis. We also reviewed the charts of our patients who had previously taken Senna or are currently taking Senna, looking for adverse reactions. Results: Eight articles in the literature reported perineal blisters after administration of Senna laxatives in 28 patients. Of those occurrences, 18 patients (64%) had accidental administration of Senna and 10 (36%) had Senna prescribed as a long term treatment. All of the blistering episodes were related to high dose, night-time accidents, or intense diarrhea with a long period of stool to skin contact. At our institution, from 2014 to 2017, we prescribed Senna and have recorded data to 640 patients. During the study period, 17 patients (2.2%) developed blisters during their treatment. Patients who developed blisters had higher doses 60mg/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. 83 (13%) patients presented minor side effects such as abdominal cramping, vomiting or diarrhea which resolved once the type of laxatives were changed or enemas were started. The doses of Senna was not significantly different in these patients 15mg/day [4.4-150] vs. 17.5mg/day [1.5-150]. There were no other long-term side effects from Senna found in the pediatric literature for long-term treatment besides abdominal cramping or diarrhea during the first weeks of administration. We found no evidence of tolerance to Senna in our review. Conclusion: There is a paucity of information in the literature regarding side effects of sennosides as a long-term therapy, and to our knowledge, this is the first review of Senna side effects in children. Senna induced dermatitis is rare, but may occur when patients need a higher dose. All of the cases described had a long period of exposure of the skin to stool. Besides the perineal rash with blisters, we could find no other described major side effect with Senna administration in the pediatric population or evidence of the frequently mentioned concern of the development of tolerance to Senna. Pediatric caregivers should advise families of the rare side effect of skin blistering and educate them to change the diaper frequently in children who are not toilet- trained to reduce stool to skin exposure. We can conclude from this review that Senna is a safe treatment option for constipation in children. Level of evidence: IV.