Do you use St Johns Wort?

[compaq]

Dr Mariano, you seem to treat a lot of mood disorders, and you certainly are studious and up to date on much research.

What is your opinion of St Johns Wort?
Do you and have you used it in your practice? (How did that go?)

Would like to hear your thoughts on this herb. Thanks Dr.

[DrMariano2]

@compaq 4970 wrote:

Dr Mariano, you seem to treat a lot of mood disorders, and you certainly are studious and up to date on much research.

What is your opinion of St Johns Wort?
Do you and have you used it in your practice? (How did that go?)

Would like to hear your thoughts on this herb. Thanks Dr.

St John’s Wort is an herbal medication. Like many herbal medications, it has many chemical components, some of which are the actual effective ingredients.

It might be as effective as other antidepressants in treating mild to moderate depression, though may not be as effective for severe depression.

How it works is not clear. The best guess is that like antidepressant medications, it reduces serotonin reuptake, dopamine reuptake, and norepinephrine reuptake. It may also have effects on GABA and glutamate signaling.

It increases the activity of Cytochrome P450 enzyme 3A4 and 2C9. P450 3A4 is a major enzyme that helps degrade/detoxify/eliminate numerous substances. This increased activity weakens other medications by more quickly eliminating them. These other medications include reproductive hormones, oral contraceptives, certain immuno suppressive medications (such as Tacrolimus), Benzodiazepines (such as Alprazolam, Midazolam), Beta-blockers *such as carvedilol), calcium channel blockers (such as Verapamil), Statins (such as Simvastatin), etc.

Some patients come to me already on St. John’s Wort and stay on it since it works for them. Some patients prefer an herbal treatment first, after we discuss the treatment alternatives.

I generally don’t commonly prescribe St. Johns Wort because of two things:

1. I prefer to know how something I prescribe works so I can anticipate problems and risks. We don’t know how exactly St. Johns Work works.

2. It weakens too many medications and hormones. If it weakens birth control, for example, a patient can wind up with an unplanned pregnancy. Many heart medications are weakened by St. Johns Wort, increasing the risk for a cardiovascular complication. I prefer a cleaner medication if possible.

There are many options to the use of St. Johns Wort – many which may cost less to use and are cleaner in regard to potential risks and problems.

[compaq]

And, would we expect liver enzymes to be raised from long term St Johns Wort intake?

[DrMariano2]

@compaq 6712 wrote:

And, would we expect liver enzymes to be raised from long term St Johns Wort intake?

The activity of Liver Enzymes Cytochrome P450 enzyme 3A4 and 2C9 will always be elevated so long as St. Johns Wort is taken.

[compaq]

@DrMariano 6747 wrote:

The activity of Liver Enzymes Cytochrome P450 enzyme 3A4 and 2C9 will always be elevated so long as St. Johns Wort is taken.

Wow I never came across that on the bottle or heard of any substantial warning regarding liver and SJW.

Is this increased liver activity a cause for health concern in your opinion? Is there anything to do to mitigate it?

Thanks again Dr Mariano.

[DrMariano2]

@compaq 6748 wrote:

Wow I never came across that on the bottle or heard of any substantial warning regarding liver and SJW.

Is this increased liver activity a cause for health concern in your opinion? Is there anything to do to mitigate it?

Thanks again Dr Mariano.

Like any other medication, one needs to take into account interactions with other treatments to avoid problems. Some anticonvulsants, like Carbamazepine, increase liver enzyme activity like St Johns Wort.

The potential for interactions with other medications doesn’t rule out the use of such medications since interactions are common with nearly every treatment.

When combining such a medication with others, like birth control pills or cardiac medications, one has to make dose adjustments or other interventions to take the interactions into account to avoid unknowingly weakening the other treatment. In the case of some heart medication, the risk of not adjusting for the interaction may be potentially dangerous. For birth control pills, not making an adjustment may result in an unplanned pregnancy with the further risk of birth defects.

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