What is it?

St. John's wort is an herbal medicine used to treat mild to moderate depression, anxiety, and seasonal affective disorder. It is also used to increase memory and concentration.

Other names for St. John's wort include: Hypericum perforatum , common St. John's wort, Klamath weed

Ask your doctor, nurse, or pharmacist if you need more information about this medicine or if any information in this leaflet concerns you.

Before Using:

Tell your doctor if you ...

• are taking medicine or are allergic to any medicine (prescription or over-the-counter (OTC) or dietary supplement).
• are pregnant or plan to become pregnant while using this medicine.
• are using any other medicines.
• are breastfeeding.
• have any other health problems, such as high blood pressure or heart or blood vessel disease.

Dosage:

Talk with your doctor, pharmacist, or nurse about how much St. John's wort you should take. The amount depends on the strength of the medicine and the reason you are taking St. John's wort. If you are using this medicine without instructions from your caregiver, follow the directions on the label. Do not take more St. John's wort or take it more often than what is written on the directions.

To store this medicine:

Keep all medicine locked up and away from children. Store medicine away from heat and direct light. Do not store your medicine in the bathroom, near the kitchen sink, or in other damp places. Heat or moisture may cause the medicine to break down and not work the way it should work. Throw away medicine that is out of date or that you do not need. Never share your medicine with others.

Drug and Food Interactions:

Do not take St. John's wort without talking to your doctor first if you are taking:

• Acitretin (Soriatane(R)) (44)
• Aminolevulinic acid (Levulan Kerastick(R)) (46)
• The following medicine used to treat fungus infections: voriconazole (Vfend(R)) (82)
• Amiodarone (Cordarone(R), Pacerone(R)) (49)
• Medicines used to treat angina (chest pain): ranolazine (Ranexa(R)) (85)
• Blood thinning medicines (examples: bivalirudin (Angiomax(R)), heparin, warfarin (Coumadin(R))) (29,30)
• Dasatinib (Sprycel(R)) (79)
• Medicines used for diabetes to lower blood sugar (examples: insulin, gliclazide, glyburide (DiaBeta(R), Glynase PresTab(R), Micronase(R)), metformin (Glucophage(R), Glucovance(R)); rosiglitazone (Avandia(R))) (33)
• Drugs used for sleep or anxiety (examples: alprazolam (Xanax(R)), lorazepam (Ativan(R)), diazepam (Valium(R), midazolam (Versed(R))) (33)
• Medicines for high blood pressure or heart problems (examples: atenolol (Tenormin(R)), metoprolol (Toprol(R) Lopressor(R)), diltiazem (Cardizem(R) Dilacor(R)), verapamil (Calan(R) Isoptin(R)), nifedipine (Adalat(R), Procardia(R))) (14)
• Medicines used during anesthesia (examples: bupivacaine (Marcaine(R)), etomidate (Amidate(R)), halothane (Fluothane(R)), ketamine (Ketalar(R)), tetracaine (Pontocaine(R)), vecuronium (Norcuron(R))) (43,73)
• Carbamazepine (Tegretol(R)) (28)
• Clozapine (Clozaril(R)) (21)
• Birth control pills and other hormonal contraceptives may interact with St. John's wort, resulting in unplanned pregnancy (11,53)
• Medicine used to suppress the immune system (examples: cyclosporine (Sandimmune(R), Neoral(R), Sang Cya(R)); sirolimus (Rapamune(R)); tacrolimus (Prograf(R))) (10,56,58,67,69-71)
• Digoxin (Lanoxin(R)), digitoxin (Crystodigin(R)) (55)
• Medicines used to lower cholesterol (examples: atorvastatin (Lipitor(R)), fluvastatin (Lescol(R)), lovastatin (Mevacor(R)), pravastatin (Pravachol(R)), rosuvastatin (Crestor(R)), simvastatin (Zocor(R))) (25)
• Loperamide (Imodium(R)) (15)
• Methadone (46)
• Medicines used to treat pain (examples: codeine, fentanyl (Duragesic(R)), hydrocodone (Vicodin(R), Lorcet(R)), morphine (MS Contin(R), MSIR(R), Oramorph(R)), oxycodone (Endocet(R), Endodan(R), Oxycontin(R), Percocet(R), Percodan(R)), propoxyphene (Darvon(R), Darvocet(R))) (48), tramadol (Ultram(R)) (81)
• Omeprazole (Prilosec(R)) (51)
• Phenytoin (Dilantin(R)), phenobarbital (Luminal(R)) (28)
• Medicines used to treat AIDS or HIV disease (protease inhibitors and non-nucleoside reverse transcriptase inhibitors, including indinavir (Crixivan(R)), darunavir (Prezista(R)), delavirdine (Rescriptor(R)), efavirenz (Sustiva(R)), etravirine (Intelence(TM)), lamivudine (Epivir(R)), nelfinavir (Viracept(R)), nevirapine (Viramune(R)), ritonavir (Norvir(R)), saquinavir (Invirase(R)), zidovudine (Retrovir(R))) (7,23,83,84)
• Drugs used to treat depression or anxiety, including citalopram (Celexa(R)), escitalopram (Lexapro(R)), fluoxetine (Prozac(R)), fluvoxamine (Luvox(R)), paroxetine (Paxil(R)), sertraline (Zoloft(R)), venlafaxine (Effexor(R)), buspirone (Buspar(R)) (22,27,41,62-66)
• Drugs used to treat depression, including amitriptyline (Elavil(R)), clomipramine (Anafranil(R)), desipramine (Norpramin(R)), imipramine (Tofranil(R)), nefazodone (Serzone(R)), nortriptyline (Pamelor(R)), olanzapine (Zyprexa (R)), protriptyline (Vivactil(R)) (18,22,26,27,62-66)
• Medicines for migraine headaches (examples: sumatriptan (Imitrex(R)), naratriptan (Amerge(R)), rizatriptan (Maxalt(R)), zolmitriptan (Zomig(R)) (24,59)
• Reserpine (Resa(R), Serpalan(R)) (72)
• Theophylline (TheoDur(R) Respbid(R) SloBid(R)) (21)
• Trazodone (Desyrel(R)) (18)
• Over-the-counter allergy, cold, or flu medicines (examples: dextromethorphan, fexofenadine) (76, 77)
• Medicines used to treat Parkinson's disease or depression (isocarboxazid (Marplan(R)), tranylcypromine (Parnate(R)), phenelzine (Nardil(R), selegiline (Eldepryl(R), Emsam(R), Zelapar(R), rasagiline (Azilect(R)) (60,61)
• Levothyroxine (Levothroid(R), Synthroid(R)) (74)
• Drugs used to treat cancer, including cyclophosphamide (Cytoxan(R)), irinotecan (Camptosar(R)), paclitaxel (Taxol(R)), sunitinib (Sutent(R)), tamoxifen (Nolvadex(R), imatinib (Gleevec(TM)). Etoposide (VePesid(R)), temsirolimus (Torisel(R))(2,7,10,14,31,32,40,45,52,54,56-58,67,69,80)
• Estrogen and similar medicines used for hormone replacement (examples: conjugated estrogens (Premarin(R), Prempro(R)); estradiol (Alora(R), Climara(R))) (46)
• Ginkgo biloba (Ginkoba(R)) (66)
• Other medicines which cause your skin to be sensitive to the sun (there are many, so ask your doctor or pharmacist) (75)
• Foods which contain tyramine (examples: anchovies, avocados, bananas, caffeine foods, cheese, aged cheese, strong cheese, chocolate, canned figs, liqueurs, wine, chianti wine, beer, tenderized meat, beef, liver, chicken liver, meat extracts, genoa salami, salami, hard salami, dry sausage, bologna, pepperoni, smoked fish, caviar, pickled herring, soy sauce, lebanon, miso, raisins, sauerkraut, sherry, sour cream, soybean paste, brewer's yeast, yeast extract, yogurt) (34)

Warnings:

• Before taking St. John's wort, tell your doctor if you are pregnant or breastfeeding.
• You may need to take this medicine for 2 to 4 weeks before you start to feel any change.
• St. John's wort may interact with many more medicines than are listed here. Talk to your doctor or pharmacist before taking St. John's wort with any other medicine.
• This medicine may make your skin more sensitive to sunlight. Use a sunscreen when you are outdoors. Avoid sunlamps and tanning beds (5,13,75,78).

Side Effects:

Stop taking your medicine right away and talk to your doctor if you have any of the following side effects.

• Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing, or rash.

Other Side Effects:

You may have the following side effects, but this medicine may also cause other side effects. Tell your doctor if you have side effects that you think are caused by this medicine.

• Nausea, upset stomach, diarrhea, loss of appetite (6)
• Swelling (39)
• Drowsiness (38)
• Restlessness (68,70)
• Headache (68,70)
• Sexual difficulties (39)
• Frequent urination (39)

References:

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2. Peebles KA, Baker RA, Kurz EU et al: Catalytic inhibition of human DNA topoisomerase IIalpha by hypericin, a naphthodianthrome from St. John's wort (Hypericum perforatum). Biochem Pharmacol 2001; 62(8):1059-1070.

3. Mueller WE & Schaefer C: Johanniskraut. In vitro Studie ueber Hypericum-Extrakt, Hypericin, und Kaempferol als Antidepressiva. DAZ 1996; 136:1015-1022.

4. Fachinformation Hyperimerck 260mg(R), hypericum extract. Merck Generika GmbH, Darmstadt, Germany; 1997.

5. Roots T: Evaluation of photosensitization of the skin and multiple dose intake of Hypericum extract. Second International Congress on Phytomedicine. Munich, Germany; 1996.

6. Woelk H, Burkard G & Gruenwald J: Benefits and risks of the Hypericum extract LI 160: drug monitoring with 3250 patients. J Geriatric Psychiatry Neurol 1994; 7(Suppl 1):34-38.

7. Piscitelli SC, Burstein AH, Chaitt D et al: Indinavir concentrations and St. John's wort. Lancet 2000; 355.

8. Fachinformation: Helarium(R) Hypericum, hypericum extract. Bionorica GmbH, Neumarkt, Germany; 1996.

9. Fachinformation: Remotiv(R), hypericum extract. Bayer AG, Pharma Deutschland, Leverkusen, Germany; 1996.

10. Ruschitzka F, Meier P, Turina M et al: Acute heart transplant rejection due to St. John's wort. Lancet 2000; 355:548-549.

11. Gorski J, Hamman M, Wang Z et al: The effect of St. John's wort on the efficacy of oral contraception (abstract MPI-80). Clin Pharmacol Ther 2002; 71(2):P25

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25. Sugimoto K, Ohmori M, Tsuruoka S et al: Different effects of St. John's wort on the pharmacokinetics of simvastatin and pravastatin. Clin Pharmacol Ther 2001; 70(6):518-524.

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28. Burstein AH, Horton RL, Dunn T et al: Lack of effect of St. John's wort on carbamazepine pharmacokinetics in healthy volunteers. Clin Pharmacol Ther 2000; 68(6):605-612.

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43. Irefin S & Sprung J: A possible cause of cardiovascular collapse during anesthesia: Long-term use of St. John's wort. J CLin Anesth 2000; 12:498-499.

44. Product Information: Soriatane(R), acitretin. Roche Laboratores, Inc, Nutley, NJ; 2003.

45. Product Information: Gleevec(TM), imatinib mesylate. Novartis Pharmaceuticals, East Hanover, NJ; 2003.

46. Ladner DP, Klein SD, Steiner RA et al: Synergistic toxicity of delta-aminolaevulinic acid-induced protoporphyrin IX used for photodiagnosis and hypericum extract, a herbal antidepressant. Br J Dermatol 2001; 144(4):916-918.

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49. Product Information: Cordarone(R), amiodarone. Wyeth Laboratories, Philadelphia, PA (PI revised 08/2001), reviewed 12/2003.

50. Hebert MF, Park JM, Chen Y-L et al: Effects of St. John's wort (Hypericum perforatum) on tacrolimus pharmacokinetics in healthy volunteers. J Clin Pharmacol 2004; 44:89-94.

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56. Yu DK: The contribution of P-glycoprotein to pharmacokinetic drug-drug interactions. J Clin Pharmacol 1999; 39:1203-1211.

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66. Spinella M & Eaton LA: Hypomania induced by herbal and pharmaceutical psychotropic medicines following mild traumatic brain injury. Brain Injury 2002; 16(4):359-367.

67. Durr D, Stiger B, Kullak-Ublick GA et al: St. John's wort induces intestinal P-glycoprotein/MDR1 and intestinal and hepatic CYP3A4. Clin Pharmacol Ther 2000; 68(6):598-604.

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76. Wang Z, Hamman MA, Huang SM et al: Effect of St. John's wort of the pharmacokinetics of fexofenadine. Clin Pharmacol Ther 2002; 71(6):414-420.

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78. Jacobson JM, Feinman L, Liebes L et al: Pharmacokinetics, safety, and antiviral effects of hypericin, a derivative of St. John's wort plant, in patients with chronic hepatitis C virus infection. Antimicrob Agents Chemother 2001; 45(2):517-524.

79. Product Information: Sprycel(R) oral tablets, dasatinib oral tablets. Bristol-Myers Squibb, Princeton, NJ, 2008.

80. Product Information: Torisel(TM) KIT IV injection, temsirolimus IV injection. Wyeth Pharmaceuticals,Inc, Philadelphia, PA, 2007.

81. Product Information: Ultram ER(R) extended-release oral tablets, tramadol hcl extended-release oral tablets. PriCara, Raritan, NJ, 12/00/2005.

82. Product Information: Vfend(R) IV injection, oral tablets, suspension, voriconazole IV injection, oral tablets, solution. Roerig, New York, NY, Mar 1, 2008.

83. Product Information: Prezista(R) film coated oral tablets, darunavir film coated oral tablets. Tibotec,Inc, Raritan, NJ, 2008.

84. Product Information: Intelence(TM) oral tablets, etravirine oral tablets. Tibotec Therapeutics,Inc, Raritan, NJ, 2008.

85.Product Information: Ranexa(R) extended-release oral tablets, ranolazine extended-release oral tablets. CV Therapeutics Inc, Palo Alto, CA, 2008.