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The Annals of Pharmacotherapy: Vol. 37, No. 1, pp. 150. DOI 10.1345/aph.1C208
© 2003 Harvey Whitney Books Company.
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Suspected withdrawal syndrome after cessation of St. John's wort

Angela J Dean, BPharm(Hons)

Drug Information Pharmacist Department of Pharmacy Mater Misericordiae Health Services Raymond Terrace South Brisbane QLD 4101, Australia FAX 61 7 3840 1690 E-mail angela_dean{at}health.qld.gov.au

Geraldine M Moses, BPharm PgradDipClinPharm

Senior Pharmacist Department of Pharmacy Mater Misericordiae Health Services

Joanne M Vernon, BPharm(Hons)

Drug Information Pharmacist Department of Pharmacy Mater Misericordiae Health Services

www.theannals.com, DOI

TO THE EDITOR: St. John's wort has become popular with consumers as an herbal antidepressant. A growing body of research suggests that St. John's wort may possess modest antidepressant efficacy1,2 and that it has some pharmacologic effects similar to those of prescription antidepressants.3 Antidepressant withdrawal syndromes have been well described.4 We report a case of a suspected withdrawal reaction induced by cessation of St. John's wort.

Case Report. A 58-year-old postmenopausal woman initiated St. John's wort tablets 1800 mg 3 times daily (Herron St. John's wort, which contains Hypericum perforatum extract standardized to hypericin 0.3% and hyperforin 3%) to treat depression symptoms. She was also taking glucosamine hydrochloride (1 g/d) for osteoarthritis in her knees and a multivitamin and mineral tablet every few days; she had been taking both of these regularly for a number of years. Her typical caffeine intake was approximately 100 mg/d. She engaged in daily exercise and considered herself otherwise healthy.

After 32 days of treatment with St. John's wort, the patient stopped the agent due to a suspected photosensitivity reaction. Within 24 hours, she experienced nausea, anorexia, dry retching, dizziness, dry mouth, thirst, cold chills, and extreme fatigue. These symptoms peaked on day 3 and gradually improved until they abated on day 8. The woman also lost 4 kg of weight during this period.

Discussion. The symptoms described in this case and their temporal relationship with discontinuation of St. John's wort parallel the withdrawal syndrome associated with cessation of conventional antidepressants.4 To our knowledge, this is the first report of a discontinuation syndrome associated with St. John's wort. Given the high dose of St. John's wort used by this woman, it is possible that withdrawal reactions may be dose related. The adverse event was classed as possible according to the Naranjo probability scale.5

Although such syndromes are typically mild and transient, they can impact the quality of life of the patient and may contribute to anxiety about possible reemergence of depression symptoms. At-risk patients need to be informed about the possibility of a withdrawal syndrome, and gradual dose tapering may be recommended where appropriate. As treatment with complementary medicines is often undertaken without involvement of health professionals, this case also highlights a need for consumer-based reporting of adverse drug reactions.

References

  1. Linde K, Ramirez G, Mulrow CD, Pauls A, Weidenhammer W, Melchart D. St. John's wort for depression — an overview and metaanalysis of randomised clinical trials. BMJ 1996;313:253-8.[Abstract/Free Full Text]
  2. Gaster B, Holroyd J. St. John's wort for depression — a systematic review. Arch Intern Med 2000;160:152-6.[Abstract/Free Full Text]
  3. Di Carlo G, Borrelli F, Ernst E, Izzo AA. St. John's wort: Prozac from the plant kingdom. Trends Pharmacol Sci 2001;22:292-7.[CrossRef][Medline]
  4. Lejoyeux ML, Ades J. Antidepressant discontinuation: a review of the literature. J Clin Psychiatry 1997;58(suppl 7):11 -6.
  5. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions.Clin Pharmacol Ther 1981;30:239-45.[Medline]




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