F1000Research 2019, 8:256 Last updated: 29 MAR 2021 SYSTEMATIC REVIEW Application of genus Cassia in the treatment of Constipation: A systematic review [version 1; peer review: 2 approved with reservations] Muhammad Shahzad Aslam Department of Chemistry, Xiamen University Malaysia, Sepang, Selangor, 43900, Malaysia v1 First published: 05 Mar 2019, 8:256 Open Peer Review https://doi.org/10.12688/f1000research.17893.1 Latest published: 08 Mar 2021, 8:256 https://doi.org/10.12688/f1000research.17893.2 Reviewer Status Invited Reviewers Abstract Purpose: Role of genus cassia in the treatment of Constipation 1 2 Methods: Methodological analysis, systematic review, and meta- analysis of identified studies using RevMan version 2 Result and Discussion: Cassia fistula was partially effected in treating (revision) constipation however there is a need for improvement in the protocol 08 Mar 2021 of studies to reduce biases. These results were only limited to one species so it cannot be generalized among all species of Cassia. version 1 Conclusion: Cassia fistula is partially effective in reducing the pain and 05 Mar 2019 report report consistency of stool during constipation among children. Keywords 1. Massimo Bellini, University of Pisa, Pisa, Italy Cassia, Cassia fistula, Constipation, Pediatric gastroenterology 2. Farhad Shokraneh , University of Nottingham, Nottingham, UK Any reports and responses or comments on the article can be found at the end of the article. Corresponding author: Muhammad Shahzad Aslam ([email protected]) Author roles: Aslam MS: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests: No competing interests were disclosed. Grant information: This research was supported by Xiamen University Malaysia. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2019 Aslam MS. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Aslam MS. Application of genus Cassia in the treatment of Constipation: A systematic review [version 1; peer review: 2 approved with reservations] F1000Research 2019, 8:256 https://doi.org/10.12688/f1000research.17893.1 First published: 05 Mar 2019, 8:256 https://doi.org/10.12688/f1000research.17893.1 Page 1 of 16 F1000Research 2019, 8:256 Last updated: 29 MAR 2021 Introduction December 2018 for identification of the records. Table 1 shows Constipation is a clinical disorder attributed to ineffectual the search strategy for PubMed Central. During screening of the colonic impulsion and/or increased resistance to the prolifera- records only full-length open access articles were considered. tion of colonic matters1. Approximately 20% of the world popu- Abstract only or closed access articles were excluded11. Only lation suffers from chronic constipation2. It is one of the most articles involving children aged between 2–15 were included. common pediatric problems3. It was found to be the second All review articles, in-vivo studies and those >10 years from the most stated disorder in the field of pediatric gastroenterology. search data were excluded. A preliminary search of the PubMed, Treatment costs for children with constipation will be around CNKI, Scopus, Web of Science, Google Scholar and PsycINFO three times higher than children without constipation in the databases and digital archive such as PubMed Central, yielded United States4. African American children, particularly girls, 2207 papers published in English from the last ten years. are greatly affected by constipation, which has been associated Duplicate and irrelevant articles were removed (n=2203). One with poor hygiene conditions5. article was further removed during screening due to closed access (n=3). One publication was removed because the article did not Commonly, constipation is treated by Cisapride in children6, meet the eligibility criteria (n=2). A PRISMA Flow Diagram other treatments include polyethylene glycol 3350 and lactu- is given in Figure 1. lose, however polyethylene glycol 3350 has been found to be Literature screening more effective7. Supplemented and non-supplemented yogurt Identification of articles were performed at level 1 using the helps in reducing abdominal pain and to enhance defecation search strategy as mentioned in Table 1. Duplicate articles, frequency8. It has been observed that different species of irrelevant articles such as polyherbal formulation, review arti- Cassia act an effective as a laxative such as Cassia fistula, Cassia cles, or any article other than Cassia or Senna were removed at alata, and Cassia augustifolia9–11. The genus Cassia is well level 2. Only four4 articles were identified as being relevant. One known in alternative medicine as hepatoprotective12, laxative, and record was excluded due to not being a full text article. Abstracts in the treatment of ringworm infection13, skin diseases14 and were being reviewed for the following inclusion and exclusion leprosy15. It has many pharmacological properties including criteria at level 4 and one article was removed for not meeting acting as a hypolipidemic agent16, anti-microbial17, anti-fungal18, the eligibility criteria i.e. Randomized, clinical trial on Con- and anti-cancer agent19. Genus Cassia contains a number stipation, full-length open access articles, Pediatric Functional of bioactive compounds such as anthraquinone20, tannin21, Constipation (age range: 2–15 years). coumarins22, triterpene, volatile oil23, phenolic glycoside24, flavonoids25from different parts of the plant. Different species Eligibility criteria of Cassia possess laxative properties due to various anthraqui- Types of studies. The author has selected studies of randomized none derivative such as aloe-emodin, rhein, chrysophanol open label, prospective, controlled, parallel-group clinical trial and chrysoobtusin. In this review, we systematically assessed for meta-analysis. Baseline characteristics of randomized tri- the laxative potential of different species of Cassia. als of studies included on pediatric functional constipation are presented in Table 4. Characteristics of the studies included are Methods mentioned in Table 5. Literature search strategy A systematic literature search was conducted in accordance Types of participants. The author included studies involving with the Preferred Reporting Items for Systematic Reviews and patients (aged 2–15 years) with Functional constipation. The Meta-Analyses (PRISMA) guidelines. Using the keywords (Senna diagnosis of Functional constipation was according to according AND Laxatives AND Clinical trial) (Cassia AND Laxatives to the Rome III criteria26. Inclusion and exclusion criteria were AND Clinical trial) (Cassia AND Clinical trial) (Senna AND based on Study design, participants, intervention, outcome Clinical trial) and publication range from 01 January 1960 till 31 (SPIO) criteria and indicated in Table 2. Table 1. Search strategy. PubMed Central (“cassia”[MeSH Terms] OR “cassia”[All Fields]) ((“cassia”[MeSH Terms] OR “cassia”[All Fields]) AND AND (“clinical trial”[All Fields] OR “clinical trials as (“laxatives”[All Fields] OR “laxatives”[MeSH Terms] OR topic”[MeSH Terms] OR “clinical trial”[All Fields]) AND “laxatives”[All Fields])) AND (“clinical trial”[All Fields] OR “clinical (“1960/01/01”[PubDate]: “2018/12/31”[PubDate]) trials as topic”[MeSH Terms] OR “clinical trial”[All Fields]) AND (“1960/01/01”[PubDate] : “2018/12/31”[PubDate]) (“Senna”[MeSH Terms] OR “Senna”[All Fields]) ((“senna plant”[MeSH Terms] OR (“senna”[All Fields] AND AND (“clinical trial”[All Fields] OR “clinical trials as “plant”[All Fields]) OR “senna plant”[All Fields] OR “senna”[All topic”[MeSH Terms] OR “clinical trial”[All Fields]) AND Fields]) AND (“laxatives”[All Fields] OR “laxatives”[MeSH Terms] (“1960/01/01”[PubDate]: “2018/12/31”[PubDate]) OR “laxatives”[All Fields])) AND (“clinical trial”[All Fields] OR “clinical trials as topic”[MeSH Terms] OR “clinical trial”[All Fields]) AND (“1960/01/01”[PubDate] : “2018/12/31”[PubDate]) Page 2 of 16 F1000Research 2019, 8:256 Last updated: 29 MAR 2021 Figure 1. PRISMA flow diagram. Types of interventions. Included studies were focused on the approval protocol, outcomes assessment, validity and reliability role Cassia in the treatment of Functional constipation. Unfortu- of outcome measure,attempt to blind researcher, follow-up, nately, there were only two studies identified. appropriate statistical analysis and missing data reported. Ten item defined evaluation of methodological quality (MQ) is pre- Types of outcomes. Eligible studies included consisted of sented in Figure 2. Risk of Bias were assessed using Cochrane the following outcomes: improvement in the episodes of collaboration’s tool on the basis of the following criteria such as fecal incontinence per week, improvement in the episodes of selection bias, performance bias, attrition bias, reporting bias retentive posturing per week, improvement in the average of and miscellaneous. Cochrane Collaboration’s tool for assessing severity of pain of defecation (by VAS), improvement in the risk of bias was used and the results are presented in