Early research shows that taking a specific St. John's wort product three times daily improves migraine pain but does not reduce how often migraines occur. 2005;25(1):51-58. 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. Critical hypokalemic renal tubular acidosis due to Sjogren's syndrome: association with the purported immune stimulant echinacea. Avoid combination.Mavyret August 2017, Gliclazide: St. John's wort may decrease the serum concentration of gliclazide. Most clinical research on St. John’s wort has used standardized preparations that contain between 0.3 and 1 mg of the active compound, hypericum. A low-hyperforin (3.5 mg) St. John's wort extract induced less than a 12% change in the median AUCs of alprazolam, caffeine, tolbutamide, and digoxin; these interactions were deemed to be clinically insignificant interactions.Arold 2005, A systematic review of current evidence concluded that Hypericum extracts are well tolerated and safe, aside from the potential for unintended interactions with other drugs.Clauson 2008,, Knüppel 2004, Schulz 2006, Stevinson 1999 A number of studies report no serious adverse effects, and in a review of clinical trials, St. John's wort was associated with fewer and milder adverse reactions compared with conventional antidepressants.Stevinson 1999 Adverse effects from H. perforatum were rare and mild. St Johns wort increases expression of P-glycoprotein: implications for drug interactions. Avoid combination.Dooley 2012, Sirturo May 2015, Svensson 2013, Benzodiazepines (metabolized by oxidation): St. John's wort may increase the metabolism of benzodiazepines (metabolized by oxidation). Monitor therapy.Nieminen 2010, Palbociclib: St. John's wort may decrease the serum concentration of palbociclib. Suspected withdrawal syndrome after cessation of St. John's wort. Never delay or disregard seeking professional medical advice from your doctor or other qualified health care provider because of something you have read on WebMD. View abstract. Cappuzzo, K. A. Herbal product use in a patient with polypharmacy. The body breaks down medications used for HIV/AIDS. Phytother Res. CYP3A4 inducers (moderate) may increase serum concentrations of the active metabolite(s) of ifosfamide. Phenobarbital (Luminal) interacts with ST. JOHN'S WORT. 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. Kleber E, Obry T, Hippeli S, et al. Black cohosh and St. John's wort for climacteric complaints: a randomized trial. View abstract. Br.J.Pharmacol. View abstract. View abstract. BMJ 2005;330:503. Psychopharmacology (Berl). 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. This could lead to serious side effects including heart problems, shivering, and weakness. View abstract. Biochemical activities of extracts from Hypericum perforatum L. 1st Communication: inhibition of dopamine-beta-hydroxylase. View abstract. Butterweck, V., Wall, A., Lieflander-Wulf, U., Winterhoff, H., and Nahrstedt, A. After repeat doses of 900 mg/day of extract, hyperforin steady-state levels of about 100 ng/mL have been reported, with a half-life of 9 hours.Russo 2014, St. John's wort, particularly hyperforin, has been shown in vitro and in vivo to inhibit monoamine oxidase type A (MAO-A) and MAO-B as well as the reuptake of norepinephrine, dopamine, and serotonin. This could cause serious side effects including heart problems, shivering, and anxiety. Monitor therapy.Drucker 2011, Lankerani 2004, Naldi 1999, Visudyne June 2012, Vincristine (liposomal): St. John's wort may decrease the serum concentration of vincristine (liposomal). 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. J Child Adolesc.Psychopharmacol. The lowest minimum bactericidal concentrations (350 mcg/mL) were observed for S. epidermidis, Bacillus subtilis, and C. albicans, and were fairly comparable between the 2 extracts. Photochem Photobiol 1999;69:42S. Szegedi A, Kohnen R, Dienel A, Kieser M. Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John's wort): randomised controlled double blind non-inferiority trial versus paroxetine. Contraception 2005;71:402-8. Serotonin, norepinephrine and dopamine involvement in the antidepressant action of hypericum perforatum. View abstract. Do not take St. John's wort if you are taking imatinib (Gleevec). Monitor therapy.Lilja 2004, Selectol July 2017, Ceritinib: St. John's wort may decrease the serum concentration of ceritinib. View abstract. 2009;16(2):307-314. Avoid combination.Eliquis December 2012, Artemether: St. John's wort may decrease serum concentrations of the active metabolite(s) of artemether. DELICIOUS FLAVOR –St. Fenfluramine (Pondimin) interacts with ST. JOHN'S WORT. Br J Clin Pharmacol 2003;55:203-11.. View abstract. Avoid combination.Istodax June 2013, Serotonin modulators: Serotonin modulators may enhance the adverse/toxic effect of other serotonin modulators. Dolton MJ, Mikus G, Weiss J, et al. BY MOUTH: Did you or will you purchase this product in-store or online? View abstract. Avoid combination.Biktarvy February 2018, Boceprevir: St. John's wort may decrease the serum concentration and AUC of boceprevir. Prim Care Companion CNS Disord 2013;15(1). Preparations vary greatly in chemical content and quality, and may be standardized regarding quantity of hyperforin (commonly 3% to 5%) or hypericin (commonly 0.3%) constituents. Consult Pharm. Extreme tiredness (chronic fatigue syndrome). Nierenberg AA, Burt T, Matthews J, et al. The body breaks down imatinib to get rid of it. Avoid combination.Olysio November 2013, Sofosbuvir: P-gp/ABCB1 inducers may decrease the serum concentration of sofosbuvir. Am.J.Ther. View abstract. St. John's Wort Tea: Fresh St. John's Wort tea is delicious, it has a delightful light lemony flavor. Lavie, G., Valentine, F., Levin, B., Mazur, Y., Gallo, G., Lavie, D., Weiner, D., and Meruelo, D. Studies of the mechanisms of action of the antiretroviral agents hypericin and pseudohypericin. Life Sci 6-1-2001;69(2):181-190. Pakseresht S, Boustani H, Azemi ME, et al. Three new hyperforin Analogues from Hypericum perforatum. A normal dose range would be anywhere from 300 to 1200 mg a day. Clinical studies have also reported induction of CYP2E1. Clinical trials evaluating the efficacy of St. John's wort in depression have commonly used 900 mg of extract daily in 3 divided doses for periods of up to 12 weeks (range, 200 to 1,800 mg/day).Kasper 2008, Linde 2000, Papakostas 2007, Two studies used a topical hypericum cream containing hypericin 1% and 1.5%.Arndt 2013, Tardivo 2012, The use of St. John's wort in perinatal depression has been considered; however, insufficient data exist to support its use.Freeman 2009 There is a lack of systematic evidence on the safety of Hypericum in pregnancy or lactation.Dugoua 2006, Freeman 2009 A small study of case-matched infants born to mothers consuming St. John's wort during pregnancy found an increase in colic, drowsiness, and lethargy.Dugoua 2006, Studies in rats suggest the preparation may have teratogenic and toxic effects,Gregoretti 2004, Lee 2003, Russo 2014 while other studies suggest no changes in cognitive development or long-term behavior.Dugoua 2006 Emmenagogue and abortifacient effects due to uterine stimulant action have been suggested,Brinker 1998, Ernst 2002, Rotblatt 2002, Shipochliev 1981 but evidence is weak.Dugoua 2006, In 2 separate studies, the rates of major postnatal malformations (eg, hypospadias, bilateral hip dislocation, heart septum defect, obstructed ureter) in children of women exposed to St. John's wort while pregnant were 5% and 8.1%. Most of these products are standardized to have 0.3% of hypericin. Clin Pharmacol Ther 2000;67:451-7. Clin Pharmacol Ther 2003;74:525-35. View abstract. Photosensitization may also occur. Barnes J, Barber N, Wheatley D, Williamson EM. 1994;7 Suppl 1:S60-S62. It has a strong affinity for GABA, glutamate, and adenosine receptors.Sood 2010 It induces the cytochrome P450 (CYP-450) system, the uridine diphosphate glucuronosyltransferase (UGT) isozyme, and P-glycoprotein.Kummer 2016, Markert 2015, Pereira 2013 Downregulation of beta-adrenergic receptors has also been documented.Russo 2014 The major coactive constituents shown to mediate the broad-spectrum inhibition of neurotransmitter reuptake are hypericin, hyperforin, quercetin, and kaempferol.Chrubasik-Hausmann 2018, Bioactivities of the various constituents in St. John's wort are a result not only of their bioavailability but also of the complex interactions of the constituents themselves, some of which are light dependent. Arzneimittelforschung. View abstract. A systematic review of newer pharmacotherapies for depression in adults: Evidence report summary. Kobak, K. A., Taylor, L. V., Warner, G., and Futterer, R. St. John's wort versus placebo in social phobia: results from a placebo-controlled pilot study. Drug Metab Dispos. View abstract. 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. Linde, K., Berner, M. M., and Kriston, L. St John's wort for major depression. 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. View abstract. Be sure to have your blood checked regularly. St. John's wort increases a chemical in the brain called serotonin. Amino acids include cysteine, gamma-aminobutyric acid (GABA), glutamine, leucine, lysine, and others.Bombardelli 1995, Hahn 1992, Newall 1996, Upton 1997, St. John's wort products are not regulated by the US Food and Drug Administration because they are classified as dietary supplements.Congress 1994 Several reports evaluating commercial preparations of St. John's wort have found inconsistencies in active ingredients, such as potency variations of labeled hypericin concentrations (from 47% to 165%),Constantine 1998 different concentrations of major components among brands,Liu 1999 and marked deviations in hyperforin and adhyperforin amounts in certain preparations.Melzer 1998 Several reports address these issues, with various proposed standardization methods.Khwaja 1999, Kurth 1998, Mason 1999, Schempp 1999, Animal and human studies have elucidated the pharmacokinetic differences among the structurally similar components hypericin, pseudohypericin, and hyperforin. 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