II. Precautions

  1. Avoid chronic use of these agents

III. Preparations: Anthraquinone Laxative

  1. Cascara (Casanthranol) Extract
    1. Onset of activity within 6-12 hours
    2. Dose: 325 mg PO qhs
  2. Senna Extract (Senokot)
    1. Onset of activity within 6-12 hours
    2. Adult: 10-15 ml PO qhs or 2-4 tablets PO bid
    3. Child: Senna Syrup (8.8 grams per 5 ml)
      1. Age 2-6 years: 2.5 to 7.5 ml per day divided bid
      2. Age 6-12 years: 5 to 15 ml per day divided bid
    4. Combinations with senna and Docusate
      1. Senekot-S
      2. Peri-Colace (previously contained Cascara)

IV. Preparations: Diphenylmethane Laxative

  1. Bisacodyl (Dulcolax)
    1. Onset of activity
      1. Oral: 6-12 hours
      2. Rectal: 60 minutes
    2. Dose
      1. Adult: 10 mg PO/PR per day (PO may be repeated)
      2. Child (6-12 years old): 5 mg PO/PR
    3. Protocol
      1. Start at 1 tablet once daily orally after breakfast
      2. Advance up to 3 tablets orally twice daily
    4. Cost: <50 cents per day
  2. Phenolphthalein (OTC Preparations: Correctol, Ex-Lax)
    1. As an OTC medication, high risk of overuse
    2. Dose: 100 mg tablets, 1-2 PO q8 hours
    3. Associated with Stevens-Johnson Syndrome

V. Adverse Effects: Long-term use (Laxative abuse)

  1. Colonic denervation and atony (Cathartic colon)
    1. Decreased motility of right colon
    2. Associated with Anthraquinone Laxatives
    3. Results from myenteric plexus injury
  2. Constipation
  3. Electrolyte and nutritional disturbance
    1. Hypokalemia
    2. Sodium overload
    3. Protein-losing Enteropathy
  4. Melanosis coli
    1. Benign darkening of colonic mucosa
    2. Macrophage deposition in lamina propria

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Cost: Medications

bisacodyl (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
BISACODYL 10 MG SUPPOSITORY Generic OTC $0.08 each
BISACODYL EC 5 MG TABLET Generic OTC $0.02 each
senna (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
SENNA 8.6 MG TABLET Generic OTC $0.02 each
SENNA 8.8 MG/5 ML SYRUP Generic OTC $0.04 per ml
SENNA LAX 8.6 MG TABLET Generic OTC $0.02 each
SENNA LAXATIVE 8.6 MG TABLET Generic OTC $0.02 each
SENNA PLUS TABLET Generic OTC $0.03 each
SENNA PROMPT CAPSULE Generic OTC $0.08 each
SENNA S TABLET Generic OTC $0.03 each
SENNA-GEN NF TABLET Generic OTC $0.02 each
SENNA-LAX 8.6 MG TABLET Generic OTC $0.02 each
SENNALAX-S TABLET Generic OTC $0.03 each
SENNA-TIME 8.6 MG TABLET Generic OTC $0.02 each
SENNA-TIME S TABLET Generic OTC $0.03 each
senokot (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
SENOKOT 8.6 MG TABLET Generic OTC $0.02 each
SENOKOT TO GO 8.6 MG TABLET Generic OTC $0.02 each
SENOKOT-S TABLET Generic OTC $0.03 each
peri-colace (on 1/21/2015 at Medicaid.Gov Survey of pharmacy drug pricing)
PERI-COLACE TABLET Generic OTC $0.03 each
ex-lax (on 10/22/2014 at Medicaid.Gov Survey of pharmacy drug pricing)
EX-LAX CHOCOLATE OTC $0.14 each
EX-LAX MAXIMUM STR 25 MG TAB Generic OTC $0.07 each
EX-LAX PILLS Generic OTC $0.12 each

Ontology: Bisacodyl (C0005632)

Definition (NCI) A synthetic pyridinylmethylene-diacetate ester derivative stimulant laxative, Bisacodyl acts with a parasympathetic effect directly on mucosal sensory nerves, increasing peristaltic contractions. It is used for occasional constipation, in pre- and postoperative treatment, and in conditions that require facilitation of defecation. (NCI04)
Definition (MSH) A diphenylmethane stimulant laxative used for the treatment of constipation and for bowel evacuation. (From Martindale, The Extra Pharmacopoeia, 30th ed, p871)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D001726
SnomedCT 391851004, 13565005, 387075009
LNC LP14916-8, MTHU002176
English Bisacodyl, Phenol, 4,4'-(2-pyridinylmethylene)bis-, diacetate (ester), bisacodyl (medication), bisacodyl, Bisacodyl [Chemical/Ingredient], BISACODYL, Bisacodyl - chemical (substance), Bisacodyl - chemical, Bisacodyl (product), Bisacodyl (substance), Bisacodyl, NOS
Swedish Bisakodyl
Czech bisakodyl
Finnish Bisakodyyli
Russian BISAKODIL, БИСАКОДИЛ
Japanese ビサコジル
Polish Bisakodyl
Spanish bisacodilo (producto), bisacodilo (sustancia), bisacodilo, Bisacodilo
French Bisacodyl
German Bisacodyl
Italian Bisacodil
Portuguese Bisacodil

Ontology: Senna Extract (C0036656)

Definition (NCI) An extract made from the dried leaflets on the pods of Cassia angustifolia or Cassia acutifolia with cathartic activity. Dimeric glycosides in dried senna extract are converted to the active monoanthrones by bacterial action in the colon. Through direct effects on enterocytes, enteric neurons, and muscle, monoanthrones produce giant migrating colonic contractions in addition to water and electrolyte secretion. As do other stimulant laxatives, monoanthrones may induce a limited low-grade inflammation in the colon through activation of prostaglandin/cyclic AMP and nitric oxide/cyclic GMP pathways and perhaps inhibition of Na+, K+-ATPase.
Definition (MSH) Preparations of Cassia senna and C. angustifolia (see SENNA PLANT). They contain sennosides, which are anthraquinone type CATHARTICS and are used in many different preparations as laxatives.
Definition (PDQ) An extract made from the dried leaflets on the pods of Cassia angustifolia or Cassia acutifolia with laxative properties. Dimeric glycosides in dried senna extract are converted to the active monoanthrones by bacterial action in the colon. Through direct effects on enterocytes, enteric neurons, and muscle, monoanthrones produce giant migrating colonic contractions in addition to water and electrolyte secretion. As do other stimulant laxatives, monoanthrones may induce a limited low-grade inflammation in the colon through activation of prostaglandin/cyclic AMP and nitric oxide/cyclic GMP pathways and perhaps inhibition of Na+, K+-ATPase. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=480408&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=480408&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C61324" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D012676
Swedish Sennaextrakt
English senna extract, Senna Extract [Chemical/Ingredient], Senna Extract, Extract, Senna, SENNA EXTRACT
Czech senna - extrakt
Finnish Sennauute
Russian SENNY EKSTRAKT, СЕННЫ ЭКСТРАКТ
Japanese セノコット, ヨーデルS, ヨーヤクール, アジャストA, センナエキス
Polish Wyciąg z senesu
Portuguese Extrato de Sene, Extrato de Cene, Extrato de Cássia, Extrato de Sena
French Extrait de séné
German Senna-Extrakt
Italian Estratto di Senna
Spanish Extracto de Senna

Ontology: Cascara sagrada (C0205704)

Definition (MSH) Dried aged bark of a buckthorn, Frangula purshiana (FRANGULA), that contains the anthraquinone EMODIN and cascarosides. It is used as a laxative (CATHARTICS).
Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
MSH D002362
SnomedCT 23888001, 387128007
English Cascara, Cascara sagrada, Sacred Bark, cascara sagrada, laxatives cascara sagrada, cascara sagrada (medication), Cascara Sagrada Fluid Extract, cascara sagrada fluid extract, Cascara Sagrada, CASCARA SAGRADA FLUID EXTRACT, CASCARA SAGRADA @ @ FLUID EXTRACT, Cascara [Chemical/Ingredient], cascara sagrada extract, cascara, Cascara (product), Cascara (substance), CASCARA SAGRADA ORAL FLUID EXTRACT, CASCARA SAGRADA@@ORAL@FLUID EXTRACT, CASCARA SAGRADA, CASCARA SAGRADA EXTRACT
Portuguese Cáscara
Swedish Sagrada
Czech kaskara
Finnish Sagradankuori
Italian Cascara sagrada, Cascara
Russian KAZANTRANOL, KASKARA, CASANTHRANOL, КАЗАНТРАНОЛ, КАСКАРА
Japanese カスカラ, カスカラサグラダ, カサントラノール
French Écorce sacrée, Cascara
Polish Kaskara
Spanish cáscara (producto), cáscara (sustancia), cáscara sagrada, cáscara, Cáscara
German Cascara

Ontology: Casanthranol (C0205705)

Definition (NCI) A concentrated mixture of anthranol glycosides from cascara sagrada (dried bark of Rhamnus p.) and used as a laxative in constipation and various medical conditions, stimulant laxative Casanthranol encourages bowel movements by acting on the intestinal wall to increase muscle contractions. (NCI04)
Definition (MSH) A concentrated mixture of anthranol glycosides derived from cascara sagrada.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002362
SnomedCT 116530002, 400300006
LNC LP171651-5
English casanthranol, casanthranol (medication), laxatives casanthranol, Casanthranol [Chemical/Ingredient], Casanthranol (product), Casanthranol (substance), Casanthranol, CASANTHRANOL
Portuguese Casantranol
Spanish Casantranol, casantranol (producto), casantranol (sustancia), casantranol
German Casanthranol
French Casanthranol
Italian Casanthranol

Ontology: Melanosis coli (C0221391)

Concepts Disease or Syndrome (T047)
SnomedCT 11256005
English Melanosis coli, melanosis coli (diagnosis), melanosis coli, colon melanosis, melanosis of colon, melanosis, coli melanosis, Colonic pseudomelanosis, Melanosis of colon, Melanosis coli (disorder), colon; melanosis, melanosis; colon
Italian Melanosi del colon
Japanese 結腸メラノーシス, ケッチョウメラノーシス
Czech Střevní melanóza
Hungarian Melanosis coli
Dutch colon; melanose, melanose; colon, melanosis coli
Spanish melanosis coli (trastorno), melanosis coli, melanosis del colon, seudomelanosis colónica, Melanosis del colon
Portuguese Melanose do cólon
French Mélanose colique
German Melanosis coli

Ontology: Stimulant laxative (C0304553)

Concepts Pharmacologic Substance (T121)
SnomedCT 317511006, 56762002
English Stimulant laxative, STIMULANT LAXATIVES, [GA204] STIMULANT LAXATIVES, stimulant laxatives, laxatives stimulant, laxative stimulants, laxative stimulant, stimulant laxative, Stimulant laxatives, Stimulant laxative (substance), Stimulant laxatives (product), Stimulant laxative, NOS, Stimulant laxatives (substance)
Spanish laxante estimulante (sustancia), laxante estimulante, laxantes estimulantes (producto), laxantes estimulantes

Ontology: Diphenylmethane laxative (C0304558)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
SnomedCT 61939007, 387345006
English Diphenylmethane laxative (product), Diphenylmethane laxative (substance), Diphenylmethane laxative, Diphenylmethane laxative, NOS
Spanish laxante de difenilmetano (producto), laxante de difenilmetano (sustancia), laxante de difenilmetano

Ontology: Peri-Colace (C0307257)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
English Peri-Colace, peri colace, peri-colace, Peri-Colace (obsolete)

Ontology: Anthraquinone laxative (C0360063)

Concepts Pharmacologic Substance (T121)
SnomedCT 74780007, 387424000
English Anthraquinone laxatives, Anthraquinone laxative (product), Anthraquinone laxative (substance), Anthraquinone laxative, Anthraquinone laxative, NOS
Spanish laxante de antraquinona (producto), laxante de antraquinona (sustancia), laxante de antraquinona

Ontology: Phenolphthalein (C0600489)

Definition (NCI) An organic compound used as a laboratory reagent and pH indicator. Phenolphthalein exerts laxative effects by stimulating the intestinal mucosa and constricting smooth muscles. However, phenolphthalein is no longer used as a laxative due to the suspected carcinogenicity of this compound.
Definition (MSH) An acid-base indicator which is colorless in acid solution, but turns pink to red as the solution becomes alkaline. It is used medicinally as a cathartic.
Concepts Pharmacologic Substance (T121) , Indicator, Reagent, or Diagnostic Aid (T130) , Organic Chemical (T109)
MSH D020113
SnomedCT 255671009, 19595005, 398955002
LNC LP14911-9, MTHU002165
English phenolphthalein, Phenolphthalein, 1(3H)-Isobenzofuranone, 3,3-bis(4-hydroxyphenyl)-, phenolphthalein (medication), laxatives phenolphthalein, 3,3-Bis(4-hydroxyphenyl)-1(3H)-isobenzofuranone, 3,3-Bis(p-hydroxyphenyl)phthalide, Phenolphthalein [Chemical/Ingredient], Phenolphthalein (product), Phenolphthalein (substance), PHENOLPHTHALEIN, PHENOLPHTHALEIN,WHITE, PHENPOLPHTHALEIN
Swedish Fenolftalein
Czech fenolftalein
Finnish Fenolftaleiini
Russian FENOLFTALEIN, ФЕНОЛФТАЛЕИН
Japanese フェノールフタレイン
Polish Fenoloftaleina
Spanish fenolftaleína (producto), fenolftaleína (sustancia), fenolftaleína, Fenolftaleína
French Phénolphtaléine
German Phenolphthalein
Italian Fenolftaleina
Portuguese Fenolftaleína

Ontology: Correctol laxative (C0618983)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C038509
English Correctol laxative, Correctol (obsolete), Correctol Capl (obsolete)

Ontology: Senokot (C0699932)

Definition (NCI) A standardized, concentrated preparation, by Purdue, containing the anthraquinone glycosides sennosides extracted from senna leaves with laxative activity. Sennosides act on and irritate the lining of the intestine wall, thereby causing increased intestinal muscle contractions leading to vigorous bowel movement.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C002839
English Senokot, senokot

Ontology: Ex-Lax (C0720319)

Definition (NCI) A commercial preparation, by Novartis, with laxative activity. Ex-Lax contains anthraquinone glycosides sennosides, extracted from senna leaves. Sennosides irritate the lining of the intestine wall, thereby causing increased intestinal muscle contractions that lead to vigorous bowel movement and relief constipation.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D020113
English ex-lax, ex lax, Ex-Lax, Manesco Brand of Phenolphthalein, Novartis Brand of Phenolphthalein