Complementary/Alternative Medicine: This monograph describes a natural or herbal product that is not subject to FDA guidelines for medicines. Patients and clinicians are advised to read package labels carefully to ensure safe and efficacious use.

• PO: Management of mild to moderate depression and obsessive compulsive disorder (OCD). (Not effective for major depression.)
• Topical: Inflammation of the skin, blunt injury, wounds, and burns
• Other uses are for capillary strengthening, decreasing uterine bleeding, and reducing tumor size

Contraindicated in:

• Pregnancy and lactation.

Use Cautiously in:

• Children 6–17 years: use orally no longer than 8 wk
• History of phototoxicity
• Surgery (discontinue 2 wk prior to surgical procedures)
• Alzheimer's disease (may induce psychosis)
• Patients undergoing general anesthesia (may cause cardiovascular collapse)
• History of suicide attempt, severe depression, schizophrenia, or bipolar disorder (can induce hypomania or psychosis).

CNS: dizziness, restlessness, sleep disturbances.

CV: hypertension.

GI: abdominal pain, bloating, diarrhea, dry mouth, feeling of fullness, flatulence, nausea, vomiting.

Neuro: neuropathy.

Derm: allergic skin reactions (hives, itching, skin rash), phototoxicity.
Misc: serotonin syndrome.

Natural-Drug Products:

• Concurrent use with alcohol or other antidepressants (including SSRIs and MAO inhibitors) may ↑ risk of adverse CNS reactions.
• May ↓ the effectiveness and serum concentrations of digoxin, alprazolam, amitriptyline, imatinib, irinotecan, warfarin, and protease inhibitors.
• Use with MAO Inhibitors, tramadol, pentazocine, and selective serotonin agonists could result in serotonin syndrome.
• May ↓ effectiveness of oral contraceptives.
• May ↓ plasma cyclosporine and tacrolimus levels by 30–70% and cause acute transplant rejection.
• May ↑ metabolism of phenytoin and phenobarbital and cause loss of seizure control.
• Avoid use of St. John’s wort and MAO Inhibitors within 2 wk of each other.

Natural-Natural Products:

• May ↑ risk of serotonin syndrome when taken with tryptophan and SAM-e.

Preparations for Oral Use

• Dried herb: ^OTC;
• Dried (hydroalcoholic) extract: ^OTC;
• Oil: ^OTC;
• Tincture: ^OTC;

Preparations for Topical Application

• Liquid: ^OTC;
• Semisolid: ^OTC;

• PO (Adults): Mild Depression—300 mg of St. John’s wort (standardized to 0.3% hypericin) 3 times daily or 250 mg twice daily of 0.2% hypericin extract. OCD—450 mg twice daily of extended release preparation.
• Topical (Adults): 0.2–1 mg total hypericin daily.

Amber, Demon chaser, Goatweed, Hardhay, Klamath weed, Rosin rose, Tipton weed

• Derived from Hypericum perforatum; the active component is hypericin.
• PO: Antidepressant action may be due to ability to inhibit reuptake of serotonin and other neurotransmitters.
• Topical: Anti-inflammatory, antifungal, antiviral, and antibacterial properties.

• PO: Decreased signs and symptoms of depression.
• Topical: Decreased inflammation of burns or other wounds.

Therapeutic Classification: antidepressants

Absorption: Unknown.

Distribution: Unknown.

Metabolism/Excretion: Unknown.

Half-life: Hypericum constituents—24.8–26.5 hr.

• Instruct patient to take St. John’s wort as directed.
• Patients with depression should be evaluated by health care professional. Standard therapy may be of greater benefit for moderate to severe depression.
• Instruct patient to consult health care professional before taking other Rx, OTC, or herbal products concurrently with St. John’s wort. May reduce the therapeutic effectiveness of other drugs. May potentiate effect of sedatives and side effects of other antidepressants. Do not take within 2 wk of MAO inhibitor therapy.
• Caution patients to avoid sun exposure and use protective sunscreen to reduce the risk of photosensitivity reactions.
• Inform patient to purchase herbs from a reputable source and that products and their contents vary among different manufacturers.
• Caution patient not to use alcohol while taking St. John’s wort.
• Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
• Inform patient that St. John’s wort is usually taken for a period of 4–6 wk. If no improvement is seen, another therapy should be considered.

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