ST JOHN'S WORT: Uses, Side Effects, Interactions and Warnings

ST. JOHN'S WORT

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Amber, Amber Touch-and-Heal, Barbe de Saint-Jean, Chasse-diable, Demon Chaser, Fuga Daemonum, Goatweed, Hardhay, Herbe à la Brûlure, Herbe à Mille Trous, Herbe Aux Fées, Herbe Aux Mille Vertus, Herbe Aux Piqûres, Herbe de Saint Éloi, Herbe de la...
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ST JOHN'S WORT Overview Information

St. John's wort is a plant with yellow, star-shaped flowers and five petals that grows in Europe, North and South America, Australia, New Zealand, and Eastern Asia. The plant grows in sunny, well-drained areas. It grows to be 50-100 cm tall.

St. John's wort might cause serious interactions with some drugs. Because of this, France has banned the use of St. John's wort in products. Several other countries, including Japan, the United Kingdom, and Canada are in the process of updating warning labels on St. John's wort products.

St. John's wort is most commonly used for depression and conditions that sometimes go along with depression such as anxiety, tiredness, loss of appetite and trouble sleeping. There is some strong scientific evidence that it is effective for mild to moderate depression.

Other uses include heart palpitations, moodiness and other symptoms of menopause, mental disorders that present physical symptoms, premenstrual syndrome (PMS), attention deficit-hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), social phobia, and seasonal affective disorder (SAD).

St. John's wort has been tried to help quit smoking, for fibromyalgia, chronic fatigue syndrome (CFS), burning feelings in the mouth, migraine and other types of headaches, muscle pain, nerve pain and nerve damage throughout the body, pain that travels down the sciatic nerve in the leg, and irritable bowel syndrome. It is also used for cancer (including brain cancer), HIV/AIDS, hepatitis C, herpes simplex, to help with a procedure to unblock clogged arteries, weight loss, and to treat a disease that causes the skin to lose color.

An oil can be made from St. John's wort. Some people take this oil by mouth for indigestion. Some people apply this oil to their skin to treat bruises and scrapes, inflammation and muscle pain, scaly and itchy skin (psoriasis), first degree burns, wounds, tooth pulling, bug bites, hemorrhoids, nerve pain, and to treat a disease that causes the skin to lose color. But applying St. John's wort directly to the skin is risky. It can cause serious sensitivity to sunlight.

In manufacturing, St. John's wort extracts are also used in alcoholic beverages.

The active ingredients in St. John's wort can be deactivated by light. That's why you will find many products packaged in amber containers. The amber helps, but it doesn't offer total protection against the adverse effects of light.

How does it work?

For a long time, investigators thought a chemical in St. John's wort called hypericin was responsible for its effects against depression. More recent information suggests another chemical, hyperforin, as well as adhyperforin, and several other similar chemicals may play a larger role in depression. Hyperforin and adhyperforin act on chemical messengers in the nervous system that regulate mood.

ST JOHN'S WORT Uses & Effectiveness

Likely Effective for:

Depression. Taking St. John's wort extracts improves mood and decreases anxiety and insomnia related to depression. It seems to be about as effective in treating depression as many prescription drugs. In fact, clinical guidelines from the American College of Physicians-American Society of Internal Medicine suggest that St. John's wort can be considered an option along with antidepressant medications for short-term treatment of mild depression. However, since St. John's wort does not appear to be more effective or significantly better tolerated than antidepressant medications, and since St. John's wort causes many drug interactions, the guidelines suggest it might not be an appropriate choice for many people, particularly those who take other medications. St. John's wort might not be as effective for more severe cases of depression.

Possibly Effective for:

Menopausal symptoms. Some evidence suggests that some specific combinations of St. John's wort plus black cohosh (Remifemin; Gynoplus, Jin-Yan Pharm) can help improve menopausal symptoms such as hot flashes. The effects of St. John's wort alone on menopausal symptoms are inconsistent. Some, but not all, research suggests that St. John's wort might reduce hot flashes. However, St. John's wort does not seem to improve sleep, quality of life, or other menopausal symptoms when used alone.
The conversion of mental experiences or states into bodily symptoms (somatization disorder). Treatment with a specific St. John's wort product (LI 160, Lichtwer Pharma) daily for 6 weeks seems to reduce symptoms of somatization disorder.
Wound healing. Applying an ointment containing St. John's wort three times daily for 16 days seems to improve wound healing and reduce scar formation after a Cesarean section (C-section).

Possibly Ineffective for:

Burning mouth syndrome. Taking St. John's wort three times daily for 12 weeks does not reduce pain from burning mouth syndrome.
Hepatitis C virus (HCV) infection. Taking St. John's wort by mouth does not seem to be effective for treating adults with hepatitis C virus infection.
HIV/AIDS. Taking St. John's work by mouth does not seem to be effective for treating HIV-infected adults.
Irritable bowel syndrome (IBS). Early research shows that taking a specific St. John's wort extract (St. John's Wort Extract Extra Strength, Enzymatic Therapy) twice daily is not effective for reducing symptoms of IBS.
Nerve damage outside the brain or spinal cord (polyneuropathy). Taking St. John's wort by mouth does not seem to relieve pain in diabetic or non-diabetic people with polyneuropathy.
Social phobia. Taking St. John's wort daily does not seem to improve social phobia or social anxiety.

Insufficient Evidence for:

A procedure to widen blocked arteries (angioplasty). Early research shows that taking St. John's wort three times daily for 2 weeks after a procedure to widen blocked arteries improves outcomes of the procedure in people who are also taking blood thinning medications. It is thought that St. John's wort might help the blood thinning medications work better in some people.
Anxiety. Some reports suggest that taking St. John's wort alone or together with valerian improves anxiety disorder. Also, taking one capsule of a specific product that contains St. John's wort and valerian root (Sedariston Concentrate, Aristo Pharma GmbH) daily for one week, followed by one or two capsules twice daily for another week, reduces anxiety more than the medication diazepam.
Attention deficit-hyperactivity disorder (ADHD). Some research suggests that taking St. John's wort daily for 4 weeks might improve attention and activity in adolescents with ADHD. But other research shows that taking a St. John's wort extract for 8 weeks does not improve ADHD symptoms in children ages 6-17 years.
Brain tumor (glioma). Early research shows that taking hypericin, a chemical in St. John's wort, by mouth for up to 3 months might reduce tumor size and improve the survival rate in people with brain tumors.
Herpes. Early research suggests that using a specific combination of St. John's wort and copper sulfate pentahydrate (Dynamiclear) might help reduce symptoms, including stinging, burning and pain, in people with cold sores or genital herpes.
Migraine headache. Early research suggests that taking a specific St. John's wort product (Perforan, Godaru, Iran) three times daily improves the severity of migraine pain but does not reduce how often migraines occur.
Obsessive-compulsive disorder (OCD). There is conflicting evidence about the effectiveness of St. John's wort for OCD. The reason for contradictory findings could be due to differences in study design, differences in the St. John's wort products used, or other factors.
Skin redness and irritation (plaque psoriasis). Early research suggests that applying St. John's wort liquid or ointment to the skin decreases the severity and the size of psoriasis patches.
Premenstrual syndrome (PMS). There is conflicting evidence about the use of St. John's wort for treating PMS. Some early research suggests that St. John's wort might help reduce PMS symptoms, including sleeping problems, coordination, confusion, crying, headache, fatigue, food cravings and swelling, by even as much as 50% in some women. However, other research shows that taking St. John's wort does not reduce anxiety or other PMS symptoms.
Seasonal affective disorder (SAD). Early studies suggest that St. John's wort might help SAD. It appears to improve symptoms of anxiety, decreased sex drive, and sleep disturbances associated with SAD. It is useful alone or in combination with light therapy.
Smoking cessation. Early research suggests that taking a specific St. John's wort extract (LI-160, Lichtwer Pharma US) once or twice daily starting one week before and continuing for 3 months after quitting smoking does not improve long-term quit rates.
Tooth pulling. Early research suggests that applying a homeopathic St. John's wort preparation does not improve dental pain after a tooth is pulled or after dental surgery.
Stomach upset.
Bruises.
Skin conditions.
Nerve pain.
Sciatica.
Excitability.
Fibromyalgia.
Chronic fatigue syndrome (CFS).
Muscle pain.
Cancer.
Weight loss.
Other conditions.

More evidence is needed to rate St. John's wort for these uses.

ST JOHN'S WORT Side Effects & Safety

St. John's wort is LIKELY SAFE when taken by mouth for up to 12 weeks. Some evidence suggests it can be used safely for over one year. It can cause some side effects such as trouble sleeping, vivid dreams, restlessness, anxiety, irritability, stomach upset, fatigue, dry mouth, dizziness, headache, skin rash, diarrhea, and tingling. Take St. John's wort in the morning or lower the dose if it seems to be causing sleep problems.

St. John's wort is POSSIBLY UNSAFE when taken by mouth in large doses. When taken by mouth in large doses, it might cause severe reactions to sun exposure. Wear sun block outside, especially if you are light-skinned.

St. John's wort interacts with many drugs (see the section below). Let your healthcare provider know if you want to take St. John's wort. Your healthcare provider will want to review your medications to see if there could be any problems.

There isn't enough reliable information available to know if St. John's wort is safe when it is applied to the skin. St. John's wort might cause severe reactions to sun exposure.

Special Precautions & Warnings:

Pregnancy and breast-feeding: St. John's wort is POSSIBLY UNSAFE when taken by mouth during pregnancy. There is some evidence that it can cause birth defects in unborn rats. No one yet knows whether it has the same effect in unborn humans. Nursing infants of mothers who take St. John's wort can experience colic, drowsiness, and listlessness. Until more is known, do not use St. John's wort if you are pregnant or breast-feeding.

Children: St. John's work is POSSIBLY SAFE when taken by mouth for up to 8 weeks in children 6-17 years-old.

Alzheimer's disease: There is concern that St. John's wort might contribute to dementia in people with Alzheimer's disease.

Anesthesia: Use of anesthesia in people who have used St. John's wort for 6 months may lead to serious heart complications during surgery. Stop using St. John's wort at least 2 weeks before a scheduled surgery.

Attention deficit-hyperactivity disorder (ADHD): There is some concern that St. John's wort might worsen symptoms of ADHD, especially in people taking the medication methylphenidate for ADHD. Until more is known, don't use St. John's wort if you are taking methylphenidate.

Bipolar disorder: People with bipolar disorder cycle between depression and mania, a state marked by excessive physical activity and impulsive behavior. St. John's wort can bring on mania in these individuals and can also speed up the cycling between depression and mania.

Depression: In people with major depression, St. John's wort might bring on mania, a state marked by excessive physical activity and impulsive behavior.

Infertility: There are some concerns that St. John's wort might interfere with conceiving a child. If you are trying to conceive, don't use St. John's wort, especially if you have known fertility problems.

Schizophrenia: St. John's wort might bring on psychosis in some people with schizophrenia.

Surgery: St. John's wort might affect serotonin levels in the brain and as a result interfere with surgical procedures. Stop using St. John's wort at least two weeks before a scheduled surgery.

ST JOHN'S WORT Interactions

Major Interaction Do not take this combination

Alprazolam (Xanax) interacts with ST. JOHN'S WORT
Alprazolam (Xanax) is commonly used for anxiety. The body breaks down alprazolam (Xanax) to get rid of it. St. John's wort can increase how fast the body gets rid of alprazolam (Xanax). Taking St. John's wort along with alprazolam (Xanax) might decrease the effectiveness of alprazolam (Xanax).
Aminolevulinic acid interacts with ST. JOHN'S WORT
Aminolevulinic acid can make your skin sensitive to the sunlight. St. John's wort might also increase your sensitivity to sunlight. Taking St. John's wort along with aminolevulinic acid might increase the chances of sunburn, blistering or rashes on areas of skin exposed to sunlight. Be sure to wear sunblock and protective clothing when spending time in the sun.
Amitriptyline (Elavil) interacts with ST. JOHN'S WORT
The body breaks down amitriptyline (Elavil) to get rid of it. St. John's wort can increase how quickly the body gets rid of some medications. St. John's wort might decrease the effectiveness of amitriptyline (Elavil) by increasing how quickly the body breaks down amitriptyline (Elavil).
Birth control pills (Contraceptive drugs) interacts with ST. JOHN'S WORT
Some birth control pills contain estrogen. The body breaks down the estrogen in birth control pills to get rid of it. St. John's wort might increase the break down of estrogen. Taking St. John's wort along with birth control pills might decrease the effectiveness of birth control pills. If you take birth control pills along with St. John's wort, use an additional form of birth control such as a condom.

Some birth control pills include ethinyl estradiol and levonorgestrel (Triphasil), ethinyl estradiol and norethindrone (Ortho-Novum 1/35, Ortho-Novum 7/7/7), and others.
Cyclosporine (Neoral, Sandimmune) interacts with ST. JOHN'S WORT
The body breaks down cyclosporine (Neoral, Sandimmune) to get rid of it. St. John's wort might increase how quickly the body breaks down cyclosporine (Neoral, Sandimmune). By increasing the breakdown of cyclosporine (Neoral, Sandimmune) St. John's wort might decrease the effectiveness of cyclosporine (Neoral, Sandimmune). Do not take St. John's wort if you are taking cyclosporine (Neoral, Sandimmune).
Digoxin (Lanoxin) interacts with ST. JOHN'S WORT
Digoxin (Lanoxin) helps the heart beat more strongly. St. John's wort might decrease how much digoxin (Lanoxin) the body absorbs. By decreasing how much digoxin (Lanoxin) the body absorbs St. John's wort might decrease the effects of digoxin (Lanoxin).
Fenfluramine (Pondimin) interacts with ST. JOHN'S WORT
Fenfluramine (Pondimin) increases a chemical in the brain. This chemical is called serotonin. St. John's wort also increases serotonin. Taking fenfluramine with St. John's wort might cause there to be too much serotonin. This could cause serious side effects including heart problems, shivering, nausea, headache, and anxiety.
Imatinib (Gleevec) interacts with ST. JOHN'S WORT
The body breaks down imatinib to get rid of it. St. John's wort might increase how quickly the body gets rid of imatinib (Gleevec). Taking St. John's wort along with imatinib (Gleevec) might decrease the effectiveness of imatinib (Gleevec). Do not take St. John's wort if you are taking imatinib (Gleevec).
Irinotecan (Camptosar) interacts with ST. JOHN'S WORT
Irinotecan (Camptosar) is used to treat cancer. The body breaks down irinotecan (Camptosar) to get rid of it. St. John's wort might increase how fast the body breaks down irinotecan (Camptosar) and decrease the effectiveness of irinotecan (Camptosar).
Medications changed by the liver (Cytochrome P450 3A4 (CYP3A4) substrates) interacts with ST. JOHN'S WORT
Some medications are changed and broken down by the liver. St. John's wort might increase how quickly the liver breaks down some medications. Taking St. John's wort along with some medications that are broken down by the liver can decrease the effectiveness of some medications. Before taking St. John's wort talk to your healthcare provider if you are taking any medications that are changed by the liver.

Some medications changed by the liver include lovastatin (Mevacor), ketoconazole (Nizoral), itraconazole (Sporanox), fexofenadine (Allegra), triazolam (Halcion), and many others.
Medications for depression (Antidepressant drugs) interacts with ST. JOHN'S WORT
St. John's wort increases a brain chemical called serotonin. Some medications for depression also increase the brain chemical serotonin. Taking St. John's wort along with these medications for depression might increase serotonin too much and cause serious side effects including heart problems, shivering, and anxiety. Do not take St. John's wort if you are taking medications for depression.

Some of these medications for depression include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), amitriptyline (Elavil), clomipramine (Anafranil), imipramine (Tofranil), and others.
Medications for HIV/AIDS (Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs)) interacts with ST. JOHN'S WORT
The body breaks down medications used for HIV/AIDS. St. John's wort can increase how quickly the body breaks down these medications. Taking St. John's wort might decrease how well some medications used for HIV/AIDS work.

Some of these medications used for HIV/AIDS include nevirapine (Viramune), delavirdine (Rescriptor), and efavirenz (Sustiva).
Medications for HIV/AIDS (Protease Inhibitors) interacts with ST. JOHN'S WORT
The body breaks down medications used for HIV/AIDS to get rid of them. Taking St. John's wort might increase how quickly the body breaks down these medications. This could decrease the effectiveness of some medications used for HIV/AIDS.

Some of these medications used for HIV/AIDS include amprenavir (Agenerase), nelfinavir (Viracept), ritonavir (Norvir), and saquinavir (Fortovase, Invirase).
Medications for pain (Narcotic drugs) interacts with ST. JOHN'S WORT
The body breaks down some medications for pain to get rid of them. St. John's Wort might decrease how fast the body gets rid of some medications for pain. By decreasing how fast the body gets rid of some medications for pain, St. John's wort might increase the effects and side effects of some medications for pain.

Some medications for pain include meperidine (Demerol), hydrocodone, morphine, OxyContin, and many others.
Medications moved by pumps in cells (P-Glycoprotein Substrates) interacts with ST. JOHN'S WORT
Some medications are moved by pumps in cells. St. John's wort can make these pumps more active and decrease how much of some medications get absorbed by the body. This might decrease the effectiveness of some medications.

Some medications that are moved by these pumps include etoposide, paclitaxel, vinblastine, vincristine, vindesine, ketoconazole, itraconazole, amprenavir, indinavir, nelfinavir, saquinavir, cimetidine, ranitidine, diltiazem, verapamil, corticosteroids, erythromycin, cisapride (Propulsid), fexofenadine (Allegra), cyclosporine, loperamide (Imodium), quinidine, and others.
Medications that increase sensitivity to sunlight (Photosensitizing drugs) interacts with ST. JOHN'S WORT
Some medications can increase sensitivity to sunlight. St. John's Wort might also increase your sensitivity to sunlight. Taking St. John's wort along with medications that increase sensitivity to sunlight could increase the chances of sunburn, blistering or rashes on areas of skin exposed to sunlight. Be sure to wear sunblock and protective clothing when spending time in the sun.

Some drugs that cause photosensitivity include amitriptyline (Elavil), Ciprofloxacin (Cipro), norfloxacin (Noroxin), lomefloxacin (Maxaquin), ofloxacin (Floxin), levofloxacin (Levaquin), sparfloxacin (Zagam), gatifloxacin (Tequin), moxifloxacin (Avelox), trimethoprim/sulfamethoxazole (Septra), tetracycline, methoxsalen (8-methoxypsoralen, 8-MOP, Oxsoralen), and Trioxsalen (Trisoralen).
Meperidine (Demerol) interacts with ST. JOHN'S WORT
St. John's wort increases a chemical in the brain called serotonin. Meperidine (Demerol) can also increase serotonin in the brain. Taking St. John's wort along with meperidine (Demerol) might cause too much serotonin in the brain and serious side effects including heart problems, shivering, and anxiety.
Nefazodone (Serzone) interacts with ST. JOHN'S WORT
Nefazodone can increase a chemical in the brain. This chemical is called serotonin. St. John's wort can also increase serotonin. Taking St. John's wort with nefazodone might cause there to be too much serotonin. This could lead to serious side effects including heart problems, shivering, and restlessness.
Nortriptyline (Pamelor) interacts with ST. JOHN'S WORT
The body breaks down nortriptyline (Pamelor) to get rid of it. St. John's wort can increase how quickly the body breaks down nortriptyline (Pamelor). This could decrease the effectiveness of nortriptyline (Pamelor).
Paroxetine (Paxil) interacts with ST. JOHN'S WORT
Paroxetine (Paxil) increases a chemical in the brain. This chemical is called serotonin. St. John's wort also increases serotonin. Taking paroxetine (Paxil) and St. John's wort together might cause there to be too much serotonin. This could lead to serious side effects including heart problems, shivering, and weakness.
Pentazocine (Talwin) interacts with ST. JOHN'S WORT
St. John's wort increases a brain chemical called serotonin. Pentazocine (Talwin) also increases serotonin. Taking St. John's wort along with pentazocine (Talwin) might increase serotonin too much. This could cause serious side effects including heart problems, shivering, and anxiety. Do not take St. John's wort if you are taking pentazocine (Talwin).
Phenobarbital (Luminal) interacts with ST. JOHN'S WORT
The body breaks down phenobarbital (Luminal) to get rid of it. St. John's wort might increase how quickly the body breaks down phenobarbital. This could decrease how well phenobarbital works.
Phenprocoumon interacts with ST. JOHN'S WORT
The body breaks down phenprocoumon to get rid of it. St. John's wort increases how quickly the body breaks down phenprocoumon. This decreases the effectiveness of phenprocoumon.
Phenytoin (Dilantin) interacts with ST. JOHN'S WORT
The body breaks down phenytoin (Dilantin) to get rid of it. St. John's wort might increase how quickly the body breaks down phenytoin. Taking St. John's wort and taking phenytoin (Dilantin) might decrease the effectiveness of phenytoin (Dilantin) and increase the possibility of seizures.
Reserpine interacts with ST. JOHN'S WORT
St. John's wort can decrease the effects of reserpine.
Sedative medications (Barbiturates) interacts with ST. JOHN'S WORT
Medications that cause sleepiness and drowsiness are called sedatives. St. John's wort might decrease the effectiveness of sedative medications. It is not clear why this interaction occurs.
Sertraline (Zoloft) interacts with ST. JOHN'S WORT
Sertraline (Zoloft) can increase a chemical in the brain. This chemical is called serotonin. St. John's wort also increases serotonin. This can cause there to be too much serotonin in the brain. This could lead to serious side effects including heart problems, shivering, and irritability.
Tacrolimus (Prograf, Protopic) interacts with ST. JOHN'S WORT
The body breaks down tacrolimus (Prograf, Protopic) to get rid of it. St. John's wort can increase how quickly the body breaks down tacrolimus. This can cause tacrolimus to be less effective.
Tramadol (Ultram) interacts with ST. JOHN'S WORT
Tramadol (Ultram) can affect a chemical in the brain called serotonin. St. John's wort can also affect serotonin. Taking St. John's wort along with tramadol (Ultram) might cause too much serotonin in the brain and side effects including confusion, shivering, stiff muscles, and other side effects.
Warfarin (Coumadin) interacts with ST. JOHN'S WORT
Warfarin (Coumadin) is used to slow blood clotting. The body breaks down warfarin (Coumadin) to get rid of it. St. John's wort might increase the breakdown and decrease the effectiveness of warfarin (Coumadin). Decreasing the effectiveness of warfarin (Coumadin) might increase the risk of clotting. Be sure to have your blood checked regularly. The dose of your warfarin (Coumadin) might need to be changed.

Moderate Interaction Be cautious with this combination

Clopidogrel (Plavix) interacts with ST. JOHN'S WORT
The body breaks down clopidogrel (Plavix) to a chemical that decreases blood clotting in the body. Taking St. John's wort along with clopidogrel (Plavix) might increase how well the body breaks down clopidogrel (Plavix) and decrease blood clotting too much.
Dextromethorphan (Robitussin DM, and others) interacts with ST. JOHN'S WORT
St. John's wort can affect a brain chemical called serotonin. Dextromethorphan (Robitussin DM, others) can also affect serotonin. Taking St. John's wort along with dextromethorphan (Robitussin DM, others) might cause too much serotonin in the brain and serious side effects including heart problems, shivering, and anxiety. Do not take St. John's wort if you are taking dextromethorphan (Robitussin DM, and others).
Fexofenadine (Allegra) interacts with ST. JOHN'S WORT
The body breaks down fexofenadine (Allegra) to get rid of it. St. John's wort might decrease how quickly the body gets rid of fexofenadine. This could cause fexofenadine (Allegra) to stay in the body too long. This could lead to increased effects and side effects of fexofenadine (Allegra).
Medications changed by the liver (Cytochrome P450 1A2 (CYP1A2) substrates) interacts with ST. JOHN'S WORT
Some medications are changed and broken down by the liver. St. John's wort might increase how quickly the liver breaks down some medications. Taking St. John's wort along with some medications that are changed by the liver can decrease the effectiveness of some medications. Before taking St. John's wort talk to your healthcare provider if you take any medications that are changed by the liver.

Some of these medications that are changed by the liver include clozapine (Clozaril), cyclobenzaprine (Flexeril), fluvoxamine (Luvox), haloperidol (Haldol), imipramine (Tofranil), mexiletine (Mexitil), olanzapine (Zyprexa), pentazocine (Talwin), propranolol (Inderal), tacrine (Cognex), zileuton (Zyflo), zolmitriptan (Zomig), and others.
Medications changed by the liver (Cytochrome P450 2C9 (CYP2C9) substrates) interacts with ST. JOHN'S WORT
Some medications are changed and broken down by the liver. St. John's wort might increase how quickly the liver breaks down some medications. Taking St. John's wort along with some medications that are broken down by the liver can decrease the effectiveness of your medication. Before taking St. John's wort talk to your healthcare provider if you take any medications that are changed by the liver.

Some medications that are changed by the liver include amitriptyline (Elavil), diazepam (Valium), zileuton (Zyflo), celecoxib (Celebrex), diclofenac (Voltaren), fluvastatin (Lescol), glipizide (Glucotrol), ibuprofen (Advil, Motrin), irbesartan (Avapro), losartan (Cozaar), phenytoin (Dilantin), piroxicam (Feldene), tamoxifen (Nolvadex), tolbutamide (Tolinase), torsemide (Demadex), warfarin (Coumadin), and others.
Medications for depression (MAOIs) interacts with ST. JOHN'S WORT
St. John's wort increases a chemical in the brain. This chemical is called serotonin. Some medications used for depression also increase serotonin. Taking St. John's wort with these medications used for depression might cause there to be too much serotonin. This could cause serious side effects including heart problems, shivering, and anxiety.

Some of these medications used for depression include phenelzine (Nardil), tranylcypromine (Parnate), and others.
Medications for migraine headaches ("Triptans") interacts with ST. JOHN'S WORT
Some medications for migraine headaches can affect a chemical in the brain called serotonin. St. John's wort can also affect serotonin. Taking St. John's wort along with some medications for migraine headache might cause too much serotonin in the brain and serious side effects including confusion, shivering, stiff muscles, and other side effects.

Some medications for migraine headache include frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig).
Procainamide interacts with ST. JOHN'S WORT
St. John's wort extract might increase how much procainamide the body absorbs. This could increase the effects and side effects of procainamide. But the significance of this potential interaction is not known.
Simvastatin (Zocor) interacts with ST. JOHN'S WORT
The body breaks down simvastatin (Zocor) to get rid of it. St. John's wort increases how quickly the body breaks down simvastatin. This can cause simvastatin to be less effective.

Minor Interaction Be watchful with this combination

Methylphenidate (Concerta, Daytrana, Metadate, Ritalin) interacts with ST. JOHN'S WORT
Taking St. John's wort along with methylphenidate might decrease how well methylphenidate works for controlling symptoms of attention deficit-hyperactivity disorder (ADHD).
Theophylline interacts with ST. JOHN'S WORT
The body breaks down theophylline to get rid of it. St. John's wort might increase how quickly the body gets rid of theophylline. Taking St. John's wort along with theophylline might decrease the effectiveness of theophylline. But it is not clear if this interaction is a big concern.

ST JOHN'S WORT Dosing

ADULTS

BY MOUTH:

For mild to moderate depression:
- In most studies, St. John's wort extract was standardized to 0.3% hypericin content and used at doses of 300 mg three times daily.
- Some studies have used St. John's wort extract standardized to 0.2% hypericin at doses of 250 mg twice daily.
- St. John's wort extract standardized to 5% hyperforin has been used at doses of 300 mg three times daily.
For premenstrual syndrome (PMS): St. John's wort extract standardized to 0.3% hypericin dosed at 300 mg once daily has been used.
For body symptoms associated with depression: 300 mg three times daily of the standardized hypericin extract has been used.
For somatization disorder: a specific extract (LI 160, Lichtwer Pharma) 600 mg/day has been used.

APPLIED TO THE SKIN:

For wound healing: An ointment containing a 5% St. John's wort extract applied three times daily beginning 24 hours after a C-section and continued for 16 days has been used.

CHILDREN

BY MOUTH:

For mild to moderate depression: 150-300 mg of St. John's wort three times daily for 8 weeks in children 6-17 years-old has been used. A specific St. John's wort extract (LI 160, Lichtwer, Pharma) 300-1800 mg in three divided doses daily for up to 6 weeks has been used.

Do not suddenly stop taking St. John's wort. This might cause unpleasant side effects. If you decide to stop taking St. John's wort, reduce the dose slowly over time.

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References:

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Mai I, Kruger H, Budde K, et al. Hazardous pharmacokinetic interaction of Saint John's wort (Hypericum perforatum) with the immunosuppressant cyclosporin. Int J Clin Pharmacol Ther 2000;38:500-2. View abstract.

Mai I, Stormer E, Bauer S, et al. Impact of St John's wort treatment on the pharmacokinetics of tacrolimus and mycophenolic acid in renal transplant patients. Nephrol Dial Transplant 2003;18:819-22.. View abstract.

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Morimoto T, Kotegawa T, Tsutsumi K, et al. Effect of St. John's wort on the pharmacokinetics of theophylline in healthy volunteers. J Clin Pharmacol 2004;44:95-101. View abstract.

Moschella C, Jaber BL. Interaction between cyclosporine and Hypericum perforatum (St. John's wort) after organ transplantation. Amer J Kidney Dis 2001;38:1105-7. View abstract.

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Murch SJ, Simmons CB, Saxena PK. Melatonin in feverfew and other medicinal plants. Lancet 1997;350:1598-9. View abstract.

Murphy PA, Kern SE, Stanczyk FZ, Westhoff CL. Interaction of St. John's Wort with oral contraceptives: effects on the pharmacokinetics of norethindrone and ethinyl estradiol, ovarian activity and breakthrough bleeding. Contraception 2005;71:402-8. View abstract.

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Ondrizek RR, Chan PJ, Patton WC, King A. Inhibition of human sperm motility by specific herbs used in alternative medicine. J Assist Reprod Genet 1999;16:87-91. View abstract.

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Roots I, Johne A, Schmider J, Brockmoller J, et al. Interaction of a herbal extract from St. John's wort with amitriptyline and its metabolites. Clin Pharmacol Ther 2000;67:159, abstract PIII-69.

Ruschitzka F, Meier PJ, Turina M, et al. Acute heart transplant rejection due to Saint John's wort. Lancet 2000;355:548-9. View abstract.

Saito YA, Rey E, Almazar-Elder AE, et al. A randomized, double-blind, placebo-controlled trial of St. John's wort for treating irritable bowel syndrome. Am J Gastroenterol 2010;105:170-7. View abstract.

Samadi S, Khadivzadeh T, Emami A, et al. The effect of Hypericum perforatum on the wound healing and scar of cesarean. J Altern Complement Med 2010;16:113-7. View abstract.

Schempp C, Pelz K, Wittmer A, et al. Antibacterial activity of hyperforin from St. John's wort, against multiresistant Stapylococcus aureus and gram-positive bacteria. Lancet 1999;353:2129. View abstract.

Schempp CM, Kirkin V, Simon-Haarhaus B, et al. Inhibition of tumour cell growth by hyperforin, a novel anticancer drug from St. John's wort that acts by induction of apoptosis. Oncogene 2002;21:1242-50.. View abstract.

Schempp CM, Ludtke R, Winghofer B, Simon JC. Effect of topical application of hypericum perforatum extract on skin sensitivity to solar simulated radiation. Photodermatol Photoimmunol Photomed 2000;16:125-8. View abstract.

Schempp CM, Muller K, Winghofer B, et al. Single-dose and steady-state administration of Hypericum perfotatum extract (St. John's wort) does not influence skin sensitivity to UV radiation, visible light, and solar-stimulated radiation. Arch Dermatol 2001;137:512-3. View abstract.

Schempp CM, Winghofer B, Langheinrich M, et al. Hypericin levels in human serum and interstitial skin blister fluid after oral single-dose and steady state administration of Hypericum perforatum extract (St. John's Wort). Skin Pharmacol Appl Skin Physiol 1999;12:299-304. View abstract.

Schempp CM, Winghofer B, Ludtke R, et al. Topical application of St. John's wort (Hypericum perforatum L.) and its metabolite hyperforin inhibits the allostimulatory capacity of epidermal cells. Br J Dermatol 2000;142:979-84. View abstract.

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Schrader E. Equivalence of St. John's wort extract (Ze 117) and fluoxetine: a randomized, controlled study in mild-moderate depression. Int Clin Psychopharmacol 2000;15:61-8. View abstract.

Schule C, Baghai T, Ferrera A, Laakmann G. Neuroendocrine effects of Hypericum extract WS 5570 in 12 healthy male volunteers. Pharmacopsychiatry 2001;34:S127-33. View abstract.

Schulz V. Incidence and clinical relevance of the interactions and side effects of Hypericum preparations. Phytomedicine 2001;8:152-60. View abstract.

Schwarz UI, Buschel B, Kirch W. Unwanted pregnancy on self-medication with St John's wort despite hormonal contraception. Br J Clin Pharmacol 2003;55:112-3. View abstract.

Shan MD, Hu LH, Chen ZL. Three new hyperforin Analogues from Hypericum perforatum. J Nat Prod 2001;664:127-30. View abstract.

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Shelton RC. St John's Wort for the treatment of depression. Lancet Neurol 2002;1:275. View abstract.

Shimizu K, Nakamura M, Isse K, Nathan PJ. First-episode psychosis after taking an extract of Hypericum perforatum (St John's Wort). Hum Psychopharmacol 2004;19:275-6. View abstract.

Siepmann M, Krause S, Joraschky P, et al. The effects of St John's wort extract on heart rate variability, cognitive function and quantitative EEG: a comparison with amitriptyline and placebo in healthy men. Br J Clin Pharmacol 2002;54:277-82. View abstract.

Sindrup SH, Madsen C, Bach FW, et al. St. John's wort has no effect on pain in polyneuropathy. Pain 2000;91:361-5. View abstract.

Singer A, Wonnemann M, Muller WE. Hyperforin, a major antidepressant constituent of St. John's wort, inhibits serotonin uptake by elevating free intracellular Na+1. J Pharmacol Exp Ther 1999;290:1363-8.. View abstract.

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Jensen AG, Hansen SH, Nielsen EO. Adhyperforin as a contributor to the effect of Hypericum perforatum L. in biochemical models of antidepressant activity. Life Sci 2001;68:1593-605. View abstract.

Pajonk, F., Scholber, J., and Fiebich, B. Hypericin-an inhibitor of proteasome function. Cancer Chemother.Pharmacol 2005;55(5):439-446. View abstract.

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Papakostas, G. I., Crawford, C. M., Scalia, M. J., and Fava, M. Timing of clinical improvement and symptom resolution in the treatment of major depressive disorder. A replication of findings with the use of a double-blind, placebo-controlled trial of Hypericum perforatum versus fluoxetine. Neuropsychobiology 2007;56(2-3):132-137. View abstract.

Pietta, P., Gardana, C., and Pietta, A. Comparative evaluation of St. John's wort from different Italian regions. Farmaco 2001;56(5-7):491-496. View abstract.

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Sardella, A., Lodi, G., Demarosi, F., Tarozzi, M., Canegallo, L., and Carrassi, A. Hypericum perforatum extract in burning mouth syndrome: a randomized placebo-controlled study. J.Oral Pathol.Med. 2008;37(7):395-401. View abstract.

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Schempp, C. M., Winghofer, B., Muller, K., Schulte-Monting, J., Mannel, M., Schopf, E., and Simon, J. C. Effect of oral administration of Hypericum perforatum extract (St. John's Wort) on skin erythema and pigmentation induced by UVB, UVA, visible light and solar simulated radiation. Phytother Res 2003;17(2):141-146. View abstract.

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Fogle RH, Murphy PA, Westhoff CL, Stanczyk FZ. Does St. John's wort interfere with the antiandrogenic effect of oral contraceptive pills? Contraception 2006;74:245-8. View abstract.

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Gurley BJ, Barone GW. Herb-drug interaction involving St. John's wort and cyclosporine. AAPS Ann Mtg & Expo Indianapolis, IN:2000;Oct 29- Nov 2: presentation #3443.

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Holme SA, Roberts DL. Erythroderma associated with St John's wort. Br J Dermatol 2000;143:1127-8. View abstract.

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Hussain MD, Teixeira MG. Saint John's wort and analgesia: effect of Saint John's wort on morphine induced analgesia. AAPS Ann Mtg & Expo Indianapolis, IN:2000;Oct 29- Nov 2:presentation #3453.

Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. JAMA 2002;287:1807-14. View abstract.

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Al-Akoum, M., Maunsell, E., Verreault, R., Provencher, L., Otis, H., and Dodin, S. Effects of Hypericum perforatum (St. John's wort) on hot flashes and quality of life in perimenopausal women: a randomized pilot trial. Menopause. 2009;16(2):307-314. View abstract.

Andreescu, C., Mulsant, B. H., and Emanuel, J. E. Complementary and alternative medicine in the treatment of bipolar disorder--a review of the evidence. J.Affect.Disord. 2008;110(1-2):16-26. View abstract.

Bancirova, M. and Lasovsky, J. The photodynamic effect: the comparison of chemiexcitation by luminol and phthalhydrazide. Luminescence. 2011;26(6):410-415. View abstract.

Barbenel, D. M., Yusufi, B., O'Shea, D., and Bench, C. J. Mania in a patient receiving testosterone replacement postorchidectomy taking St John's wort and sertraline. J Psychopharmacol 2000;14(1):84-86. View abstract.

Berlanda, J., Kiesslich, T., Engelhardt, V., Krammer, B., and Plaetzer, K. Comparative in vitro study on the characteristics of different photosensitizers employed in PDT. J.Photochem.Photobiol.B 9-2-2010;100(3):173-180. View abstract.

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Bhattacharya, S. K., Chakrabarti, A., and Chatterjee, S. S. Activity profiles of two hyperforin-containing hypericum extracts in behavioral models. Pharmacopsychiatry 1998;31 Suppl 1:22-29. View abstract.

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Bladt, S. and Wagner, H. Inhibition of MAO by fractions and constituents of hypericum extract. J Geriatr.Psychiatry Neurol. 1994;7 Suppl 1:S57-S59. View abstract.

Bombardelli E and Morazzoni P. Hypericum perforatum. Fitoterapia 1995;66(1):43-68.

Brattstrom, A. Long-term effects of St. John's wort (Hypericum perforatum) treatment: a 1-year safety study in mild to moderate depression. Phytomedicine. 2009;16(4):277-283. View abstract.

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Canning, S., Waterman, M., Orsi, N., Ayres, J., Simpson, N., and Dye, L. The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial. CNS.Drugs 2010;24(3):207-225. View abstract.

Cappuzzo, K. A. Herbal product use in a patient with polypharmacy. Consult Pharm. 2006;21(11):911-915. View abstract.

Carpenter, S. and Kraus, G. A. Photosensitization is required for inactivation of equine infectious anemia virus by hypericin. Photochem.Photobiol. 1991;53(2):169-174. View abstract.

Chatterjee SS, Bhattacharya SK, Singer A, and et al. Hyperforin inhibits synaptosomal uptake of neurotransmitters in vitro and shows antidepressant activity in vivo. Pharmazie 1998;53(3):9.

Clewell, A., Barnes, M., Endres, J. R., Ahmed, M., and Ghambeer, D. K. Efficacy and tolerability assessment of a topical formulation containing copper sulfate and hypericum perforatum on patients with herpes skin lesions: a comparative, randomized controlled trial. J.Drugs Dermatol. 2012;11(2):209-215. View abstract.

Cohen, P. A., Hudson, J. B., and Towers, G. H. Antiviral activities of anthraquinones, bianthrones and hypericin derivatives from lichens. Experientia 2-15-1996;52(3):180-183. View abstract.

Cott, J. M. In vitro receptor binding and enzyme inhibition by Hypericum perforatum extract. Pharmacopsychiatry 1997;30 Suppl 2:108-112. View abstract.

Couldwell, W. T., Gopalakrishna, R., Hinton, D. R., He, S., Weiss, M. H., Law, R. E., Apuzzo, M. L., and Law, R. E. Hypericin: a potential antiglioma therapy. Neurosurgery 1994;35(4):705-710. View abstract.

Couldwell, W. T., Surnock, A. A., Tobia, A. J., Cabana, B. E., Stillerman, C. B., Forsyth, P. A., Appley, A. J., Spence, A. M., Hinton, D. R., and Chen, T. C. A phase 1/2 study of orally administered synthetic hypericin for treatment of recurrent malignant gliomas. Cancer 11-1-2011;117(21):4905-4915. View abstract.

Cui, Y., Ang, C. Y., Beger, R. D., Heinze, T. M., Hu, L., and Leakey, J. In vitro metabolism of hyperforin in rat liver microsomal systems. Drug Metab Dispos. 2004;32(1):28-34. View abstract.

Degar, S., Prince, A. M., Pascual, D., Lavie, G., Levin, B., Mazur, Y., Lavie, D., Ehrlich, L. S., Carter, C., and Meruelo, D. Inactivation of the human immunodeficiency virus by hypericin: evidence for photochemical alterations of p24 and a block in uncoating. AIDS Research and Human Retroviruses 1992;8(11):1929-1936. View abstract.

Demiroglu, Y. Z., Yeter, T. T., Boga, C., Ozdogu, H., Kizilkilic, E., Bal, N., Tuncer, I., and Arslan, H. Bone marrow necrosis: a rare complication of herbal treatment with Hypericum perforatum (St. John's wort). Acta Medica.(Hradec.Kralove) 2005;48(2):91-94. View abstract.

Demisch L, Holzl J, Gollnik B, and et al. Identification of selective MAO-type-A inhibitors in Hypericum perforatum L. (Hyperforat). Pharmacopsychiat. 1989;22:194.

Di Carlo, G., Nuzzo, I., Capasso, R., Sanges, M. R., Galdiero, E., Capasso, F., and Carratelli, C. R. Modulation of apoptosis in mice treated with Echinacea and St. John's wort. Pharmacol Res 2003;48(3):273-277. View abstract.

Di, Matteo, V, Di Giovanni, G., Di Mascio, M., and Esposito, E. Effect of acute administration of hypericum perforatum-CO2 extract on dopamine and serotonin release in the rat central nervous system. Pharmacopsychiatry 2000;33(1):14-18. View abstract.

Dona, M., Dell'Aica, I., Pezzato, E., Sartor, L., Calabrese, F., Della, Barbera M., Donella-Deana, A., Appendino, G., Borsarini, A., Caniato, R., and Garbisa, S. Hyperforin inhibits cancer invasion and metastasis. Cancer Res 9-1-2004;64(17):6225-6232. View abstract.

Etogo-Asse, F., Boemer, F., Sempoux, C., and Geubel, A. Acute hepatitis with prolonged cholestasis and disappearance of interlobular bile ducts following tibolone and Hypericum perforatum (St. John's wort). Case of drug interaction? Acta Gastroenterol.Belg. 2008;71(1):36-38. View abstract.

Fava, M., Alpert, J., Nierenberg, A. A., Mischoulon, D., Otto, M. W., Zajecka, J., Murck, H., and Rosenbaum, J. F. A Double-blind, randomized trial of St John's wort, fluoxetine, and placebo in major depressive disorder. J.Clin.Psychopharmacol. 2005;25(5):441-447. View abstract.

Feisst, C. and Werz, O. Suppression of receptor-mediated Ca2+ mobilization and functional leukocyte responses by hyperforin. Biochem Pharmacol 4-15-2004;67(8):1531-1539. View abstract.

Gastpar, M., Singer, A., and Zeller, K. Comparative efficacy and safety of a once-daily dosage of hypericum extract STW3-VI and citalopram in patients with moderate depression: a double-blind, randomised, multicentre, placebo-controlled study. Pharmacopsychiatry 2006;39(2):66-75. View abstract.

Ghazanfarpour, M., Kaviani, M., Asadi, N., Ghaffarpasand, F., Ziyadlou, S., Tabatabaee, H. R., and Dehghankhalili, M. Hypericum perforatum for the treatment of premenstrual syndrome. Int.J.Gynaecol.Obstet. 2011;113(1):84-85. View abstract.

Gobbi, M., Moia, M., Funicello, M., Riva, A., Morazzoni, P., and Mennini, T. In vitro effects of the dicyclohexylammonium salt of hyperforin on interleukin-6 release in different experimental models. Planta Med 2004;70(7):680-682. View abstract.

Greeson, J. M., Sanford, B., and Monti, D. A. St. John's wort (Hypericum perforatum): a review of the current pharmacological, toxicological, and clinical literature. Psychopharmacology (Berl) 2001;153(4):402-414. View abstract.

Guzelcan, Y., Scholte, W. F., Assies, J., and Becker, H. E. [Mania during the use of a combination preparation with St. John's wort (Hypericum perforatum)]. Ned.Tijdschr.Geneeskd. 10-6-2001;145(40):1943-1945. View abstract.

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Hicks, S. M., Walker, A. F., Gallagher, J., Middleton, R. W., and Wright, J. The significance of "nonsignificance" in randomized controlled studies: a discussion inspired by a double-blinded study on St. John's wort (Hypericum perforatum L.) for premenstrual symptoms. J.Altern.Complement Med. 2004;10(6):925-932. View abstract.

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