A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 1 9 9 9 309

S c i e n t i f i c F o r u m

Redefining St John’s Wort

To the Editor:

I am writing in response to the November/December 1998 Editorial, “DietarySupplements: Safe..., at Certain Speeds,” by Alan Matarasso, MD (Aesthetic Surg J1998;18:442-3). I was especially interested in the editorial because some of our productscontain St John’s wort. Dr Matarasso states that St John’s wort has a mild monoamineoxidase (MAO) inhibitory effect, “[t]herefore, use of these supplements should be dis-continued 2 weeks before surgery, and they should not be used simultaneously withmeperidine, as with other MAO inhibitors.” His reference is “Danger Alert—St John’sWort is Monoamine Oxidase Inhibitor,” by Stephen H. Jackson, MD, published in theCalifornia Society of Anesthesia (CSA) Bulletin’s March/April 1998 issue.1 This would bean excellent recommendation if St John’s wort was in fact an MAO inhibitor.

Dr Jackson observes that MAO inhibitors can interact detrimentally with meperidine,which is frequently used as a postsurgical analgesic and is also used in the recoveryroom to treat postanesthesia shivering. His warning is based on his belief that St John’swort is an MAO inhibitor: “The potential concern with St John’s wort is that thehypericum extract, hypericin, has been identified by the German equivalent of our FDAas a monoamine oxidase inhibitor.”1 The agency to which he refers is the GermanCommission E. Dr Jackson states that much of his information is from two sources:The American Medical Association’s (AMA’s) Council on Scientific Affairs report,“Alternative Medicine,”2 and an article and editorial from the British MedicalJournal.3

The British Medical Journal editorial to which Dr Jackson refers mentions the 1984monograph on St John’s wort, The German Commission E Monographs: TherapeuticGuide to Herbal Medicines, which stated: “According to experimental observation,hypericin [a key component of St John’s wort] can be categorized among the MAOinhibitors.” The monograph, however, was revised in 1990 and 1998. The most recentedition (1998) includes the following update: “The research suggesting MAO activitywas experimental and not conducted in animal systems. Subsequent research has indicat-ed either no or very slight MAO activity in St John’s wort or its preparations.”4

The British Medical Journal editorial also states, “So far, its [St John’s wort] extensiveuse in Germany has not resulted in published case reports about serious drug interac-tions or toxicity after overdosage.”3 The British Medical Journal article and editorialand the AMA’s alternative medicine report mentioned in Dr Jackson’s “Danger Alert”examine the efficacy of St John’s wort in supporting mood and a sense of well-being.3,5,6

No mention is made in any of these articles of dangerous interactions between anesthe-sia/meperidine and St John’s wort. It seems Dr Jackson based his concerns solely on themention of St John’s wort as a potential MAO inhibitor in a monograph whose contentwas subsequently revised.

Letter to the Editor

I also contacted Varro Tyler, PhD, ScD, Dean andDistinguished Professor Emeritus at Purdue University.Dr Tyler is a recognized authority on plant drugs, andthe author of more than 200 scientific publications andseveral books, including The Honest Herbal and Herbsof Choice. His response (written communications,January and February 1999) follows:

Early in vitro studies attributed weak MAOI[monoamine oxidase indicator] activity to hypericinand to extracts of St John’s wort (SJW). However, asnoted by Bladt and Wagner in the J GeriatricPsychiatry Neurology, 1994;7:S57-S59, such activityhas never been demonstrated in vivo. With normaldosage of the extract, the plasma level of hypericinwould be far below that needed to inhibit MAO. Asimilar failure to confirm MAOI activity was reportedby Thiede and Walper in the same issue of the samejournal, pages S54-S56. Following these reports, theherb was classified as an “atypical” antidepressantand remains in that category today.

In addition, one must recognize that although SJW hasbeen used by scores of thousands of people, no reportsof interactions with tyramine-rich foods haveappeared in the medical literature. Such reactionswould surely have occurred with some frequency if theherb had any significant MAO activity.

An interesting recent reference describes the mode ofaction of SJW as influencing the reuptake of cerebralneurotransmitters as well as affecting their receptorsites. The article begins: “New investigations haveshown that the...effects of St John’s Wort extractLI160 (Jarsin® 300 from Lichtwer) are not due to theinhibition of mono-amine oxidase (MAO) A andMAO-B as had been believed for a long time.7

Therefore, recent research and the opinion of expertsindicate that St John’s wort should not be considered inthe same class as MAO inhibitors, and MAO precautionsand potential interactions do not apply to this herb.

I hope this information alleviates some of your readers’concerns regarding this widely used herbal product. Itwould be unfortunate if patients were caused undue anxi-ety in an already stressful presurgical situation.

Cheryl L. MyersManager of Medical Communications and EducationPhytoPharmicaGreen Bay, WI

PhytoPharmica is a natural medicine company that pro-duces St John’s wort supplements.

References

1. Jackson SH. Danger alert—St John’s wort is monoamine oxidase

inhibitor. California Society of Anesthesia Bulletin. March-April 1998;53.

2. American Medical Association Council on Scientific Affairs. Alternative

medicine. Council on Scientific Affairs Report 12-A-97.

3. De Smet PAGM, Nolen WA. St John’s wort as an antidepressant (editori-

al). Br Med J 1996;313:241-2; 253-8. Available at:

http://www.bmj.com/cgi/content/full/313/7052/241. Accessed

February 1, 1999.

4. St John’s wort. In: Blumenthal M, editor. The Complete German

Commission E Monographs. Austin, Tex: American Botanical Council,

Integrative Medicine Communications; 1998:214-5.

5. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidennnhammer W, Melchart

D. St John’s wort for depression—an overview and meta-analysis of ran-

domised clinical trials. Br Med J 1996:313:253-8. Available at:

http://www.bmj.com/cgi/content/full/313/7052/253. Accessed

February 1, 1999.

6. American Medical Association Council on Scientific Affairs: Report 12.

Alternative Medicine. Available at: http://www.ama-assn.org/med-

sci/csa/1997/r12full.htm. Accessed February 4, 1999.

7. Neary JT, Bu Y. Hypericum LI 160 inhibits uptake of serotonin and nor-

epinephrine in astrocytes [abstract]. Brain Res 1999;816:358-63.

70/8/100006

Dr. Matarasso’s reply:

Several important points were made in my editorial inwhich a brief, well-referenced mention of potential MAOinhibitor effects of St John’s wort was also reported. Letme reiterate some of the concerns I expressed.

1. Patients need to alert their surgeons to all pills andproducts they use, even if they are not prescriptionagents.

2. Physicians need to become more familiar with theeffects of dietary supplements.

3. Additional research is needed to clarify the mecha-nism of action of these supplements.

4. Product purity and recommended dosage vary wide-ly, and no standardization exists.

5. Unlike prescription drugs, dietary supplements arenot required to be proven safe and effective beforethey enter the marketplace. The Dietary SupplementHealth and Education Act of 1994 stipulates that, toremove a product from the market, usually as aresult of consumer harm or injury, the Food andDrug Administration (FDA) has to prove it unsafe.Moreover, the product can remain available until theFDA finishes its testing and proves its allegations incourt.

310 A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 1 9 9 9 Volume 19, Number 4

S c i e n t i f i c F o r u m

6. Often, the users of these products are the samehealth-conscious individuals who would be mostwary of taking “prescription drugs,” and they maynot recognize that if these natural dietary supple-ments are effective, they are in fact drugs—albeitunregulated ones

Enough concern and uncertainty exist that a recent arti-cle in the Aesthetic Society News1 addressed the sameissues raised in my editorial.

Furthermore, health food store salespeople, by advisingtheir patrons about the products they sell, have in effectbecome the pharmacist, drug representative, and physi-cian all rolled into one, and without any formal training.

Finally, I would like to conclude by reiterating a state-ment made by Susan Shoaf, the acting chief ofPharmacokinetic Studies, National Institutes of Health,

Bethesda, MD. The following comment by Ms Shoaf is inresponse to a German physician who asserts that heavoids prescribing “drugs” for a patient diagnosed withborderline schizophrenia, and instead substitutes StJohn’s wort:

To say you are not prescribing drugs because they areherbs is absurd. Herbal preparations contain chemicalcompounds that would be called pharmaceuticals ifisolated, purified, and put in a pill. We should regulatethe therapeutic claims that can be made for herbs pre-cisely because they are drug preparations.2

References

1. American Society for Aesthetic Plastic Surgery. Herbal and dietary sup-plements. 1999;3.

2. American Health for Women. May 1999.

70/8/100007

A E S T H E T I C S U R G E R Y J O U R N A L ~ J U L Y / A U G U S T 1 9 9 9 311Redefining St John’s Wort

S c i e n t i f i c F o r u m

Don’t miss a single issue of the journal! To ensure prompt service when you change your address,please photocopy and complete the form below.

Please send your change of address notification at least six weeks before your move to ensure continued service.We regret we cannot guarantee replacement of issues missed due to late notification.

JOURNAL TITLE:Fill in the title of the journal here.

OLD ADDRESS:Affix the address label from a recent issue of the journal here.

NEW ADDRESS:Clearly print your new address here.

Name

Address

City/State/ZIP

COPY AND MAIL THIS FORM TO: OR FAX TO: OR PHONE:Journal Subscription Services 314-432-1158 1-800-453-4351Mosby, Inc Outside the USA, call11830 Westline Industrial Dr 314-453-4351St Louis, MO 63146-3318

Send us your new address at least six weeks aheadON THE MOVE?