St. John’s wort preparations

St. John s wort is available as tablets, capsules, drops, and teas. Many brands exist and Hypericum is widely available in health food stores or through the Internet. There is an oil form for external use but this has no place in treating depression. Many St. John s wort preparations have other ingredients and should be avoided. 

Grenier M, Sun P, Drobitch R. Effect of St. John s wort preparations on cell viability, induction of nitric oxide and ethoxyresomfin O-deethylase activity in glial cell culture. Proceedings of the 5th Annual S5Tnposium on Pharmaceutical Sciences. J Pharm Pharmaceut Sci 2002 5 106. 

Wurglics M, Westerhoff K, Kaunzinger A, et al. Batch-to-batch reproducibility of St. John s wort preparations. Pharmacopsychiatry 2001 34(suppl 1) S152-S156. 

Draves AH, Walker SE. Analysis of the hypericin and pseudohypericin content of commercially available St John s Wort preparations. Can J Clin Pharmacol 2003 10(3) 114-118. 

Inducers of CYP3A4 such as St. John s wort preparations (H. perforatum), phenobarbital, carbamazepine, and rifampin may reduce plasma concentrations of estrogens, possibly resulting in a decrease in therapeutic effects and/or changes in the uterine bleeding profile ... 

St John s wort 2. Red clover 3. Saw palmetto 1. Oral contraceptives Failure of contraception. Theoretically, saw palmetto could interfere with oral contraception and hormone replacement therapy St John s wort preparations induce metabolizing CYP3A4 enzymes and glycoprotein drug transporters of these medications Avoid concomitant use. Use an alternative contraceptive methods (barrier methods) if the herb is introduced... 

Bilia et al. reported the efficiency of two-dimensional homonuclear H- H correlated spectroscopy and two-dimensional reverse heteronuclear shift correlation spectroscopy in evaluating the composition of phloroglucinols, flavonols and naphthodianthrones in a dried extract of St John s wort. They successfully assigned carbon resonances for these three classes of compounds and also identified shikimic and chlorogenic acids, sucrose, lipid, polyphenols and traces of solvent (methanol) during the extraction process. This rapid technique is an alternative to HPLC, TLC or capillary GC for the analysis of St John s wort preparations. Another report utilized near-infrared reflectance spectroscopy (NIRS) for the... 

St. John s wort, few, if any, cautionary statements are found on bottles of St. John s wort preparations. This has prompted some discussion regarding the need for additional regulation in sales of these herbal products [97]. 

Preparations of St. John s Wort have been recommended or prescribed by European MDs and naturopaths for the treatment of depression and certain anxiety states for centuries, although questions as to its efficacy and mechanism of action remain unresolved. In addition to the putative efficacy of St. John s Wort preparations for the treatment of unipolar depression, a few studies have shown promising results for its use in the treatment of Seasonal Affective Disorder (SAD) [50]. At the time of... 

In a study using tolbutamide as a prohe drug for CYP2C9 aetivity, St John s wort 900 mg daily had no effeet on the metaholism of a single dose of tolhutamide either after one day or after 2 weeks of use. Similarly, in another study, a St John s wort preparation with low hyperforin eontent (Esbericum) at a dose of 240 mg daily had no effeet on tolhutamide metaholism. ... 

The CSM in the UK noted that pharmacodynamic (potentiation) interactions have been identified between triptans and St John s wort Hypericum perforatum) leading to an increased risk of adverse effects. They surest that patients taking triptans should not take St John s wort preparations. ... 

John s wort the decreases were only 8.6% and 4.3%, respectively. In this study, irinotecan was given as a single 350-mg/ni intravenous dose every 3 weeks, and during one cycle a St John s wort preparation was given three times daily, heginning 14 days before and stopping 4 days after the irinotecan. ... 

Information seems to be limited to these reports, but the interaction would appear to be established. The extent of the interaction may depend on the St John s wort preparation involved and dose used and seems to be correlated with the dose of hyperforin. See also Drug-herb interactions , (p.lO). Reductions in serum digoxin levels of the size seen with LI 160 could diminish the control of arrhythmias or heart failure. Digoxin serum levels should therefore be well monitored if St John s wort is either started or stopped and appropriate dosage adjustments made if necessary. The recommendation of the CSM in the UK is that St John s wort should not be used by patients taking digoxin. ... 

In kidney transplant patients orally administered 900 mg daily of a low-hyperforin (0.6 mg hyperforin daily) or regular (42 mg hyperforin daily) St. John s wort preparation in addition to the standard dose of cyclosporine, no clinically relevant changes in cyclosporine levels were observed during the low-hyperforin treatment period. During treatment with the regular St. John s wort extract, a 45% reduction in plasma levels (AUC042) of cyclosporine was observed (Mai et al. 2004). Cyclosporine is metabolized by CYP3A4 (Dresser et al. 2003). 

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