st. john's wort

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.

REMS

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

Contraind./Precautions ⬆ ⬇

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).

Adv. Reactions/Side Effects ⬆ ⬇

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

Interactions ⬆ ⬇

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.

Availability ⬆ ⬇

Preparations for Oral Use

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

Preparations for Topical Application

Liquid: ^OTC
Semisolid: ^OTC

Route/Dosage ⬆ ⬇

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.
(Adults ): 0.2–1 mg total hypericin daily.

US Brand Names ⬆ ⬇

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

Action ⬆ ⬇

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.

Therapeutic effects:

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

Classifications ⬆ ⬇

Therapeutic Classification: antidepressants

Pharmacokinetics ⬆ ⬇

Absorption: Unknown.

Distribution: Unknown.

Metabolism/Excretion: Unknown.

Half-Life: Hypericum constituents: 24.8–26.5 hr.

Time/Action Profile ⬆ ⬇

ROUTE	ONSET	PEAK	DURATION
PO	10–14 days	within 4–6 wk	unknown

Patient/Family Teaching ⬆ ⬇

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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Indications ⬇