[St. John's wort: a pharmaceutical with potentially dangerous interactions]. / Johanniskraut: Ein Phytopharmakon mit potentiell gefährlichen Interaktionen.

Over-the-counter preparations of St. John's wort are widely used as 'natural' herbal medicine alternative to traditional antidepressants. The antidepressant effect has been shown in numerous placebo controlled studies. The mechanism of action is assumed to be at least in part, similar to conventional antidepressants, due to presynaptic serotonin reuptake inhibition as well as GABA-modulation and inhibition of monoaminoxidases. Because of its favorable safety profile compared to conventional antidepressants, the use of St. John's wort preparations has gained high acceptance with doctors and patients. However, any biologically active compound contains a certain risk of untoward effects and/or interactions which often are neither known nor recognised with the use of herbal remedies. Thus, doctors, pharmacists, and patients might feel themselves in false safety. Recently, a variety of case reports of potentially hazardous interactions due to drug combinations with St. John's wort have been published (e.g. cellular rejection of pancreas-, kidney- as well as heart transplants with ciclosporin therapy, rise of INR with oral anticoagulants, bleeding with oral contraceptives, reduction of plasma concentration of digoxin, indinavir, amitriptyline, and theophylline). We report a case of irregular bleeding with oral contraception and discuss these drug interactions and the mechanisms.

Pharmacokinetics and pharmacodynamics of clomethiazole after oral and rectal administration in healthy subjects.

Clomethiazole, a sedative-hypnotic and anticonvulsant drug, has been successfully administered orally and intravenously, but in cases where either of these methods presents complications, rectal administration may represent a practical alternative. We sought to compare the single-dose pharmacokinetics and pharmacodynamics of clomethiazole after oral and rectal administration. Ten healthy adult volunteers were given 600 mg clomethiazole edisylate (corresponding to 390 mg clomethiazole base) in 2 capsules as a single oral or rectal dose in a double-masked, double-dummy, crossover fashion. Serum concentrations were measured up to 10 hours after administration using a specific high-performance liquid chromatography method. Computerized reaction-time measurement and visual analogue scales (VAS) were used to assess drug effects. Peak serum concentrations were significantly higher after oral administration (mean +/- SEM, oral 1.76 +/- 0.47 microg/mL vs rectal 0.48 +/- 0.14 microg/mL; P = 0.03) and appeared earlier (55 +/- 12 vs 89 +/- 11 min; P = 0.04). Area under the concentration-time curve values were similar after administration by both routes (oral 116 +/- 20.6 vs rectal 105 +/- 36.0 microg x min/mL), with a relative rectal bioavailability of 90% compared with oral administration. The objective pharmacodynamic effects on reaction time (increase of 104 +/- 26 vs 66 +/- 22 ms, oral vs rectal) and working speed (decrease of 132 +/- 38 vs 97 +/- 32 ms, oral vs rectal) were not significantly different. Subjective pharmacodynamic effects, as measured on the VAS, were comparable with both routes of administration. Clomethiazole was well tolerated, with a similar adverse effect profile for both routes of administration. The effects of rectal dosing of clomethiazole were similar to those of oral dosing but appeared to occur later. Our results suggest that rectal administration of a single 600-mg clomethiazole edisylate dose bears no safety risk. Therefore, rectal administration could be considered when neither oral nor parenteral administration is possible and a later onset of effect is not critical.