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: Mild to moderate depression and obsessive compulsive disorder. Not effective for major depression.
Topical Inflammation of the skin, blunt injury, wounds, and burns.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity to Hypericum perforatum;
Major depressive disorder;
Bipolar disorder or mania;
History of suicide attempt.

Use Cautiously in:

History of phototoxicity;
Surgery (discontinue ≥2 wk before procedure);
Alzheimer disease (may induce psychosis);
Patients undergoing general anesthesia (may cause cardiovascular collapse);
OB: Safety not established in pregnancy;
Lactation: Safety not established in breastfeeding;
Pedi: Safety and effectiveness not established in children.

Adv. Reactions/Side Effects ⬆ ⬇

CV: hypertension

Derm: allergic skin reactions (hives, itching, skin rash), phototoxicity

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

Neuro: dizziness, neuropathy, restlessness, sleep disturbances

Misc: serotonin syndrome

Interactions ⬆ ⬇

Natural-Drug Products:

Alcohol or other antidepressants (including SSRIs and MAO inhibitors) may ↑ risk of adverse CNS reactions.
May ↓ levels and effectiveness of digoxin, alprazolam, amitriptyline, imatinib, irinotecan, warfarin, and protease inhibitors.
MAO inhibitors, tramadol, and selective serotonin agonists may ↑ risk of serotonin syndrome; avoid use within 2 wk of starting/stopping MAO inhibitors.
May ↓ levels and effectiveness of oral contraceptives.
May ↓ levels of and risk of rejection with cyclosporine and tacrolimus.
May ↓ levels and effectiveness of phenytoin and phenobarbital.

Natural-Natural Products:

Tryptophan and SAM-e may ↑ risk of serotonin syndrome.

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 (standardized to 0.3% hypericin) 3 times daily or 250 mg twice daily of 0.2% hypericin extract. Obsessive compulsive disorder: 450 mg twice daily of extended release preparation.
(Adults ): Apply 0.2–1 mg of total hypericin once 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 or anxiety.
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 ⬆ ⬇

Explain purpose and side effects of herb to patient.
Advise patient to consult with health care provider before using any herbal supplement, especially when taken concurrently with Rx or OTC medications or vitamins. May ↓ 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.
Patients with depression should be evaluated by health care provider. Standard therapy may be of greater benefit for moderate to severe depression.
Advise patient to avoid sun exposure and use protective sunscreen to ↓ risk of photosensitivity reactions.
Advise patient to purchase herbs from a reputable source and that products and their contents vary among different manufacturers.
Advise patient to avoid alcohol while taking St. John’s wort.
Advise patient to notify health care provider of medication regimen before treatment or procedures.
Advise 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.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected or breastfeeding before using this herb.

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Indications ⬇