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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Last Update: December 20, 2013.



Senna is a popular herbal laxative that is available without prescription. Senna is generally safe and well tolerated, but can cause adverse events including clinically apparent liver injury when used in high doses for longer than recommended periods.


Senna belongs to a large genus of flowering plants found throughout the tropics, commonly used species being Cassia acutifolio (Alexandrian senna) and C. angustifolio (Indian or Tinnevelly senna). Extracts of the leaves, flowers and fruit of senna have been used for centuries in folk medicine as a laxative and stimulant. Senna is also included in several herbal teas, used for purging and in weight loss. The active components in senna extracts are anthraquinone derivatives and their glucosides, referred to as senna glycosides or sennosides. They appear to act as a local irritant on the colon, which promotes peristalsis and evacuation. Senna may also enhance intestinal fluid accumulation and increase the moisture content of stool by inhibiting electrolyte and water reabsorption from the colon. Senna is minimally absorbed. Senna is used in many over-the-counter laxatives in combination with other agents under trade names such as Ex-lax, Fletcher’s Castoria and Senokot. The typical dose is 15 to 30 mg of sennosides twice a day, but is recommended for short term use only (less than one week). Side effects include abdominal cramps and electrolyte imbalance. Long term use or abuse can lead to “cathartic” colon with diarrhea, cramps, weight loss and darkened pigmentation of the colonic mucosa.


Use of senna in the recommended doses for a limited period of time has been associated with few side effects, most of which are mild and transient and related to its laxative action. With longer term and higher dose use of senna, however, adverse events have been described including several cases of clinically apparent liver injury. The time to onset of liver injury was usually after 3 to 5 months of use, and the pattern of serum enzyme elevations was hepatocellular. The liver injury was usually mild-to-moderate in severity and resolved rapidly with discontinuation. In at least one instance, reexposure led to rapid recurrence of liver injury. Immunoallergic features and autoimmune markers were not present in the published cases.

Mechanism of Injury

The liver injury due to senna has been attributed to the anthraquinone derivatives present in the herbal extract, but the clinical characteristics of the published cases suggest an idiosyncratic rather than direct hepatotoxic etiology. Other anthraquinones used to treat constipation have been implicated in causing liver injury with long term use, including cascarosides (cascara) and hydroxyanthraquinone.

Outcome and Management

Liver injury from long term senna use is rare, and most cases have been self-limited and rapidly reversible upon stopping the laxative. However, cases with a severe course with signs of acute liver failure have been described. There is no evidence of cross sensitivity to hepatic damage with other laxatives. Restarting senna has been associated with recurrence of liver injury and should be avoided.

Drug Class: Herbal and Dietary Supplements

Other Drugs in the Subclass, Anthraquinones: Cascara



Senna – Generic


Herbal and Dietary Supplements


Fact Sheet at MedlinePlus/Natural Medicines Comprehensive Database


Senna8013-11-4Herbal mixtureNot Applicable


References updated: 20 December 2013

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    (24 year old man developed fatigue 6 months after starting Doxidan [containing hydroxyanthraquinone for chronic constipation] and at 12 months developed nausea and syncope [bilirubin 0.8 mg/dL, AST 560 U/L, Alk P 339 U/L, ANA negative, slight neutropenia], liver biopsy showing chronic hepatitis, resolving within 1 month of stopping, recurring upon rechallenge).
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  • Vanderperren B, Rizzo M, Angenot L, Haufroid V, Jadoul M, Hantson P. Acute liver failure with renal impairment related to the abuse of senna anthraquinone glycosides. Ann Pharmacother 2005; 39: 1353-7. [PubMed: 15956233]
    (52 year old woman developed jaundice, acute liver failure, lactic acidosis, and phosphate loosing nephropathy after ingesting herbal tea made from senna fruits for 3 years [bilirubin 6.2 mg/dL, ALT 9160 U/L, INR 5.3], requiring temporary ventilator support, ultimately resolving).
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