The letter from A Breckenridge and Factsheets give advice for specific interactionsbetween medicines and St John's wort where evidence exists or the clinicalimplication of that interaction may be serious. Interactions between St John's wort andother medicines are possible, although direct evidence for these interactions is not yetavailable.
The information below can be used as a guide to medicines that may interact with StJohn's wort.
1. Topical medicines with limited systemic absorption (inhalers, creams,ointments, eye and ear drops, enemas etc) are unlikely to be affected.
Non-psychotropic medicines, which are not metabolised by the liver, areunlikely to be affected.
St John's wort has a number of effects on the central nervous system (CNS). Itis therefore likely that pharmacodynamic (additive or potentiating) interactionsmay occur with other medicines that act on the CNS. These interactions arelikely to result in a greater frequency of adverse effects due to excessivestimulation of receptors in the brain.
The table below lists drugs known to be metabolised by the pathways, whichare affected by St John's wort. If interactions occur with the medicines listedbelow, they would tend to lower blood levels and the therapeutic effect of thatmedicine. However, there is no direct evidence to suggest that theseinteractions will be clinically significant.
This is not a complete list; other drugs may be added to the list in the future as furtherinformation is obtained.
Potential mechanism Drugs which may potentially interact with SJW
of interaction
Dexamethasone, domperidone, erythromycin, fexofenadine, ivermectin, ketoconazole, loperamide,morphine (6-glucuronide), nelfinavir, nifedipine,ondansetron, paclitaxel, quinidine, rifampicin, ritonavir,saquinavir, tamoxifen, terfenadine, verapamil, vinblastine,vincristine.
Clozapine, imipramine, oestradiol, olanzapine,paracetamol, ropinirole, tacrine, theophylline Dapsone, diclofenac, glibenclamide, glimepride, glipizide,flurbiprofen, fluvastatin, ibuprofen, losartan, NSAIDs,phenytoin, piroxicam, sulphamethoxazole, tamoxifen,tolbutamide.
Alfentanil, alprazolam, amiodarone, amitriptyline,amlodipine, atorvastatin, bepridil, budesonide,carbamazepine, cisapride, clarithromycin, clonazepam,corticosteroids, cyclophosphamide, dapsone, delavirdine,diazepam, diltiazem, disopyramide, doxyrubicin,erythromycin, ethinyloestradiol, etoposide, felodipine,fentanyl, finasteride, flutamide, granisetron, ifosfamide,isradipine, itraconazole, ketoconazole, lignocaine,loratadine, lovastatin, methadone, methylprednisolone,mibefradil, miconazole, midazolam, nefazodone,nicardipine, nifedipine, nimodipine, nisoldipine,nitredipine, ondansetron, paracetamol, pimozide,quinidine, quinine, rifabutin, ritonavir, retinoic acid,saquinavir, sertraline, sidenafil, simvastatin, sufentanil,tacrolimus, tamoxifen, taxol, temazepam, teniposide,terbinafine, terfenadine, troleandomycin, verapamil,vinblastine, vincristine, zolpidem, zonisamide.



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