The effect of hypericum extract on cardiac conduction as seen in the electrocardiogram compared to that of imipramine

Dietary Supplements and Current Available Evidence

Dietary supplements are frequently used in surgical patients. Surgeons should be up to date with regard to the efficacies and potential complications related to these supplements. This article provides the most updated practices and evidence of commonly used supplements.

St John's wort for major depression

BACKGROUND

In some countries extracts of the plant Hypericum perforatum L. (popularly called St. John's wort) are widely used for treating patients with depressive symptoms.

OBJECTIVES

To investigate whether extracts of hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of major depression; and whether they have fewer adverse effects than standard antidepressant drugs.

SEARCH STRATEGY

Trials were searched in computerised databases, by checking bibliographies of relevant articles, and by contacting manufacturers and researchers.

SELECTION CRITERIA

Trials were included if they: (1) were randomised and double-blind; (2) included patients with major depression; (3) compared extracts of St. John's wort with placebo or standard antidepressants; (4) included clinical outcomes assessing depressive symptoms.

DATA COLLECTION AND ANALYSIS

At least two independent reviewers extracted information from study reports. The main outcome measure for assessing effectiveness was the responder rate ratio (the relative risk of having a response to treatment). The main outcome measure for adverse effects was the number of patients dropping out due to adverse effects.

MAIN RESULTS

A total of 29 trials (5489 patients) including 18 comparisons with placebo and 17 comparisons with synthetic standard antidepressants met the inclusion criteria. Results of placebo-controlled trials showed marked heterogeneity. In nine larger trials the combined response rate ratio (RR) for hypericum extracts compared with placebo was 1.28 (95% confidence interval (CI), 1.10 to 1.49) and from nine smaller trials was 1.87 (95% CI, 1.22 to 2.87). Results of trials comparing hypericum extracts and standard antidepressants were statistically homogeneous. Compared with tri- or tetracyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), respectively, RRs were 1.02 (95% CI, 0.90 to 1.15; 5 trials) and 1.00 (95% CI, 0.90 to 1.11; 12 trials). Both in placebo-controlled trials and in comparisons with standard antidepressants, trials from German-speaking countries reported findings more favourable to hypericum. Patients given hypericum extracts dropped out of trials due to adverse effects less frequently than those given older antidepressants (odds ratio (OR) 0.24; 95% CI, 0.13 to 0.46) or SSRIs (OR 0.53, 95% CI, 0.34-0.83).

AUTHORS' CONCLUSIONS

The available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation.

Drug treatment of depression in the 2000s: An overview of achievements in the last 10 years and future possibilities

During the past 10 years our knowledge about the pharmacotherapy of depression has been consolidated, and a variety of very interesting new compounds launched onto the market. The pipeline of the pharmaceutical industry is still filled with an assortment of new developments and very promising new approaches towards the pharmacotherapy of depressive disorders. Future pharmacological treatments of depression will not only enhance serotonergic and noradrenergic neurotransmission: other systems, such as the melatonergic receptor system and the hypothalamus-pituitary-adrenal axis, are also the targets of newly developed and upcoming substances with putative antidepressant effects. The main advantages of the currently available newer pharmacotherapeutic options are the broadening of the spectrum of possible antidepressant treatments, which is of particular importance for the growing number of patients suffering from difficult-to-treat depression, and a far better tolerability profile in comparison to older compounds such as tricyclic antidepressants. Unresolved issues are the unacceptably high rate of non-responsiveness during antidepressant treatment, a latency of sometimes several weeks until clinical improvement and remission can be achieved, and a variety of possible side effects also present during treatment with modern compounds. This review mainly presents the development of antidepressant pharmacotherapies during the past 10 years, together with pharmacokinetic and pharmacodynamic information and a comparison of different pharmacological treatment principles evaluated in randomized controlled clinical trials. In addition, new pharmacological strategies that are not yet available on the market and strategies currently under development are reviewed in detail. The study of new treatment options is of major importance to provide better strategies for the clinical management of depression in the future, and is thus also of great socio-economic importance.

Anti-depressive therapies after heart transplantation

OBJECTIVE

Despite an improved quality of life, about 33% of heart transplant recipients will develop depressive symptoms post-operatively. To date, no review has explored the efficacy and safety of pharmacologic or psychologic interventions in this patient group.

METHODS

We conducted a comprehensive Medline, EmBase, Psycinfo search for studies of the treatment of depression in heart transplant recipients.

RESULTS

We identified 34 studies of variable methodologic quality. Selective serotonin re-uptake inhibitors (SSRIs), particularly citalopram and new-generation anti-depressants (mirtazapine), seem to represent the best therapeutic choices for this population. Tricyclic anti-depressants (TCAs), and electroconvulsive therapy (ECT) should be reserved for severe depression unresponsive to other treatments, whereas monoamine oxidase inhibitors (MAOIs) should be avoided. St John's wort, an alternative herbal drug, has been associated with life-threatening immunosuppression. Psychologic therapy offers further advantages after heart transplantation.

CONCLUSIONS

Further well-conducted, randomized, controlled trials are needed to clarify the efficacy and the safety of pharmacologic (SSRIs and atypical anti-depressants) and psychologic interventions in the management of depression after heart transplantation.

Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know

BACKGROUND

Widespread use of herbal medications/supplements among the presurgical population may have a negative effect on perioperative patient care. Thus, the authors' goal was to identify the prevalence of such use in a cosmetic surgery patient population compared with use among the general public; to assess physician awareness of proper management of these herbal medications/supplements; and to review the literature to provide rational strategies for managing perioperative patients taking these remedies.

METHODS

To assess patient (n = 100) and general public (n = 100) usage rates, open-ended lists of (1) the most common herbal medications/supplements and (2) homeopathic treatments were compiled. Board-certified plastic surgeons (n = 20) were then given the same list of herbs/supplements and surveyed on their awareness of these treatments and perioperative side effects.

RESULTS

The usage rate for cosmetic versus public surveys for herbal medicines/supplements was 55 percent versus 24 percent (p < 0.001), with 35 percent versus 8 percent (p < 0.001) engaging in homeopathic practices, respectively. Cosmetic patients' top four herbal/supplements of usage were chondroitin (18 percent), ephedra (18 percent), echinacea (14 percent), and glucosamine (10 percent). The top four used by the general public were echinacea (8 percent), garlic (6 percent), ginseng (4 percent), and ginger (4 percent). The physician survey demonstrated awareness of 54 percent of the listed supplements/herbal medicines, 85 percent of which were not suggested to be discontinued preoperatively, with only ephedra achieving 100 percent physician discontinuation preoperatively.

CONCLUSIONS

Herbal medicines and supplements displayed greater prevalence in the cosmetic surgery population than in the population at large. Furthermore, side effects and potential complications warrant addressing these remedies as pharmaceuticals rather than as safe and "natural." Thus, a descriptive "top-10" list with perioperative recommendations was compiled for the plastic surgeon.

Safety of St. John's Wort extract compared to synthetic antidepressants

The clinical efficacy of some standardized St. John's Wort extracts (SWEs) such as WS((R)) 5570, WS((R)) 5572 or LI 160 in the treatment of mild, moderate and severe major depression has been demonstrated in 38 controlled clinical trials and two recent meta-analyses. Sixteen post-marketing surveillance studies with such preparations, based on a total of 34,804 patients, recorded an incidence of adverse events (AEs) among patients between 0% and 6%. Of these studies, the four large-scale surveillance studies with a total of 14,245 patients recorded a rate of AEs ranging from 0.1% to 2.4% and a drop-out rate due to AEs of 0.1-0.9%. This is at least ten-fold lower than that recorded with synthetic antidepressants. AEs associated with SWE treatment were mild and transient in nearly all cases. As with synthetic antidepressants, pharmacokinetic interactions may occur occasionally as a result of activity changes of drug-metabolising and drug-transporting proteins, especially CYP 3A4 and P-gp. Risks to the patient are not caused by SWE but by drugs with a narrow therapeutic range. Consequently, SWE preparations should not be taken concurrently with other antidepressants, with coumarin-type anticoagulants, the immunosuppressants cyclosporine and tacrolimus, protease and reverse transcriptase inhibitors used in anti-HIV treatment or with certain antineoplastic agents. However, such cases are extremely rare and, with medical supervision, easily avoided. In conclusion, the safety of SWE must be considered more favourable than that of synthetic antidepressants.

Toxicity and drug interactions associated with herbal products: ephedra and St. John's Wort

Health care providers are being increasingly confronted with the use of herbal medications by their patients. It is imperative that patients be questioned regarding herbal preparation use and that health care providers become familiar with these agents. Research into the active components and mechanisms of action of various herbals is ongoing [350]. Long-range studies need to be performed to follow patients for efficacy or toxicity in chronic use [351,352]. Adverse reactions to herbal remedies should be reported to the FDA MedWatch at http://www.fda.gov/medwatch. As withany therapeutic agent, risk of use must always be weighed against potential benefits.

St John's wort for depression

BACKGROUND

Extracts of the plant Hypericum perforatum L. (popularly called St. John's wort) have been used in folk medicine for a long time for a range of indications including depressive disorders.

OBJECTIVES

To investigate whether extracts of hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of depressive disorders in adults; and whether they have have less adverse effects than standard antidepressant drugs.

SEARCH STRATEGY

Trials were searched in computerized databases (Cochrane Collaboration Depression, Anxiety & Neurosis Group Clinical Trials Registers; PubMed); by checking bibliographies of pertinent articles; and by contacting manufacturers and researchers.

SELECTION CRITERIA

Trials were included if they: (1) were randomized and double-blind; (2) included patients with depressive disorders; (3) compared extracts of St. John's wort with placebo or standard antidepressants; and (4) included clinical outcomes such as scales assessing depressive symptoms.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, outcomes and results was extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of hypericum with placebo and standard antidepressants was the responder rate ratio (responder rate in treatment group/responder rate in control group). The main outcome measure for adverse effects was the number of patients dropping out for adverse effects.

MAIN RESULTS

A total of 37 trials, including 26 comparisons with placebo and 14 comparisons with synthetic standard antidepressants, met the inclusion criteria. Results of placebo-controlled trials showed marked heterogeneity. In trials restricted to patients with major depression, the combined response rate ratio (RR) for hypericum extracts compared with placebo from six larger trials was 1.15 (95% confidence interval (CI), 1.02-1.29) and from six smaller trials was 2.06 (95% CI, 1.65 to 2.59). In trials not restricted to patients with major depression, the RR from six larger trials was 1.71 (95% CI, 1.40-2.09) and from five smaller trials was 6.13 (95% CI, 3.63 to 10.38). Trials comparing hypericum extracts and standard antidepressants were statistically homogeneous. Compared with selective serotonin reuptake inhibitors (SSRIs) and tri- or tetracyclic antidepressants, respectively, RRs were 0.98 (95% CI, 0.85-1.12; six trials) and 1.03 (95% CI, 0.93-1.14; seven trials). Patients given hypericum extracts dropped out of trials due to adverse effects less frequently than those given older antidepressants (Odds ratio (OR) 0.25; 95% CI, 0.14-0.45); such comparisons were in the same direction, but not statistically significantly different, between hypericum extracts and SSRIs (OR 0.60, 95% CI, 0.31-1.15).

AUTHORS' CONCLUSIONS

Current evidence regarding hypericum extracts is inconsistent and confusing. In patients who meet criteria for major depression, several recent placebo-controlled trials suggest that the tested hypericum extracts have minimal beneficial effects while other trials suggest that hypericum and standard antidepressants have similar beneficial effects. As the preparations available on the market might vary considerably in their pharmaceutical quality, the results of this review apply only to the products tested in the included studies.

St John's wort for depression: meta-analysis of randomised controlled trials

BACKGROUND

Extracts of Hypericum perforatum (St John's wort) are widely used to treat depression. Evidence for its efficacy has been criticised on methodological grounds.

AIMS

To update evidence from randomised trials regarding the effectiveness of Hypericum extracts.

METHODS

We performed a systematic review and meta-analysis of 37 double-blind randomised controlled trials that compared clinical effects of Hypericum monopreparation with either placebo or a standard antidepressant in adults with depressive disorders.

RESULTS

Larger placebo-controlled trials restricted to patients with major depression showed only minor effects over placebo, while older and smaller trials not restricted to patients with major depression showed marked effects. Compared with standard antidepressants Hypericum extracts had similar effects.

CONCLUSIONS

Current evidence regarding Hypericum extracts is inconsistent and confusing. In patients who meet criteria for major depression, several recent placebo-controlled trials suggest that Hypericum has minimal beneficial effects while other trials suggest that Hypericum and standard antidepressants have similar beneficial effects.

Perioperative anesthesia clinical considerations of alternative medicines

The presence of nutraceutical agents in the United States health care system dictates the need for a general understanding of these agents by all physicians and health care providers. Increasing trend toward reimbursement of herbal medicines by the insurance companies and managed care organizations have further encouraged their use. Because herbs are listed under the "supplement" category by the Food and Drug Administration, the Dietary Supplement and Health Education Act establishes no protocol for standardization of the products labeled as "supplements" thereby increasing the risk for adverse effects associated with the use of these products. Moreover, there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded safety and efficacy trials on these drugs. Reports indicate that within the last 2 decades,more than 100 herbogenic deaths have occurred [100]. Many serious complications have been reported, including renal failure and need for renal or hepatic transplantation after taking nutraceuticals [101-107]. The anesthesiologists should have a detailed knowledge and understanding of the potential risks and purported benefits of herbal medicines and should thoroughly inquire about patient's use of herbal products [108- 11 ]. In addition,the education of each patient regarding the serious, potential drug-herb inter-actions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA), suggests that all herbal medications should be discontinued 2 to 3 weeks before an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he or she should be urged to bring the container so that the anesthesiologist can review the contents of the herb or preparation. Although this idea holds some promise in the elective-care settings, anesthetic care in emergency settings should be based on a thorough drug-intake history from the patient or a relative, if possible.Unfortunately, the anesthesia literature has not addressed this new group of health supplements, despite many of these drugs having the potential to cause serious health problems and drug-herb interactions. There is a need to conduct additional scientific clinical trials to study the anesthetic responses to commonly used nutraceutical agents.

St John's wort: a systematic review of adverse effects and drug interactions for the consultation psychiatrist

St. John's wort is an herb commonly used in Europe for decades and more recently the topic of scientific investigation in this country. St. John's wort has been found more effective than placebo and equally as effective as tricyclic antidepressants in the short-term management of mild-to-moderate depression. Comparisons to selective serotonin reuptake inhibitors have provided equivocal data. While it is generally well tolerated in clinical use, there is accumulating evidence of significant interactions with drugs. This evidence-based presentation of the literature includes a brief description of pharmacodynamics and clinical applications, followed by a systematic review of adverse effects, toxicity, and drug interactions.

St. John's Wort: clinical status in psychiatry

Depression and anxiety are among the top 10 health problems for which complementary and alternative therapies (CATs) are most frequently used, and medicinal herbs are among the most popular of these treatments. St. John's wort (Hypericum perforatum) is a perennial herb that has become a widely used depression therapy. Extracts of hypericum have shown affinity for receptors within multiple neurochemical systems. The primary active substance responsible for the antidepressant effect is not well defined, but most work has concentrated specifically on the hypericin and hyperforin components. Although hypericum has demonstrated significant antidepressant and antianxiety effects in multiple studies, there are several recent studies that do not support the previous evidence. In all reported studies, hypericum extracts have been well tolerated. In addition, new psychiatric uses for hypericum in obsessive-compulsive disorder, generalized anxiety disorder, menopausal symptoms, and alcohol dependence have been reported. Because patients are choosing to pursue CAT as a first-line therapy, psychiatrists will need to have a better understanding of phytomedicines used for treating depression and anxiety, and thus be better prepared to serve as effective allies of their patients.

St. John's Wort

OBJECTIVE

The objective of this article is to review the current knowledge of the pharmacology, sites of action, and therapeutic effectiveness of St. John's Wort.

METHOD

The method used was a review of the available literature, using keywords to search the medline database. Bibliographies of the papers, thus obtained, were searched for further documents not referenced by medline. We reviewed papers from this collection.

RESULTS

This review reveals that most of the available data on efficacy and safety of St. John's Wort involve its use in mild to moderate depression. Much, but not all of the prevailing opinion is positive. Nevertheless, the quality of therapeutic trials vary so greatly that definitive conclusions are not possible. Both the source and mode of St. John's Wort's therapeutic effect are unclear. We need further controlled studies of effectiveness, safety, and mode of action. In addition to its use in depression, there are reports suggesting possible therapeutic effects in other conditions such as certain malignancies and infections, but these are far too preliminary to permit any conclusions.

Perioperative considerations for the patient taking herbal medicines

There has been a significant increase in the proliferation and use of dietary supplements known as neutraceuticals. Since 1994, herbal products have been regulated by the Dietary Supplement Health and Education Act (DSHEA), which does not require burden of proof to demonstrate premarketing safety and efficacy studies. Scientific literature and government policies have not adequately addressed this fast-emerging group of more than 20,000 health supplements. Lack of purity and standardization of these agents, combined with minimal education in traditional homeopathic medical education, has led to serious health-related problems including arrhythmias, cardiovascular compromise, strokes, and deaths. Even though 30% of our traditional medicines are derived from botanicals, most physicians are either unfamiliar or unwilling to develop any level of expertise with neutraceuticals. A review emphasizing perioperative considerations is provided of the history of herbal medicines, governmental policies, and specific herbal agent-drug interactions.

Efficacy and safety of St. John's wort for the treatment of major depression

OBJECTIVE

Extracts of St. John's wort have been widely used in the treatment of depression. Our aim was to review information related to the efficacy and safety of St. John's wort as an antidepressant.

DATA SOURCES

Primary and review articles were identified by a search of Medline (1960 to February 2000) and through secondary sources.

STUDY SELECTION

All the articles identified from the data sources were evaluated and all relevant information was included in this review. The pharmacokinetics, mechanism of action, efficacy, side effects and drug interactions of St. John's wort have been examined in various studies.

CONCLUSION

St. John's wort is a promising investigational antidepressant, but the data are not yet sufficient to accept hypericum as a first line antidepressant preparation for treatment of depression. Besides the need for dose standardization and adequate trial lengths, there is a need for studies in severely depressed patients and long-term studies to assess the risk of relapse and recurrence.

Hypericum perforatum extracts as potential antidepressants

Extracts of Hypericum perforatum have been used in the treatment of mild to moderate depression for many years in Europe. More recently, these extracts have become available in the USA as dietary supplements and have been popularly used to improve mood. In support of this practice, data from several controlled clinical studies suggest that Hypericum perforatum is better than placebo and as effective as established antidepressant drugs. These data have, however, several limitations that should temper our enthusiasm and argue for more research before accepting Hypericum perforatum extracts into our pharmacopoeia of established antidepressants. Extant data on the possible effects of Hypericum perforatum extracts in depression are here critically reviewed and plans for further research presented.