St. John's wort vs. paroxetine

[Miklos]

The on-line BMJ published a study today that concluded:

"In the treatment of moderate to severe major depression, hypericum extract WS 5570 (St. John's wort) is at least as effective as paroxetine and is better tolerated."

See for the abstract: http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38356.655266.82v1

Comments?

 

[john182]

The on-line BMJ published a study today that concluded:

"In the treatment of moderate to severe major depression, hypericum extract WS 5570 (St. John's wort) is at least as effective as paroxetine and is better tolerated."

See for the abstract: http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38356.655266.82v1

Comments?

Side effects are just as common - dry mouth, nausea, consptiaption, fatigue, dizziness and headache with photosensitivity reactions due to red pigment says the Maudsley Guidelines.

One study found it to be comparable to Imipramine 150mg (standard dosing to form a comparison across species of drug) and as effective in mild-moderate depression.

None of the older trials lasted longer than 8 weeks. This one only lasted 6 weeks. So far, plenty of research says it's as effective the global 150mg imipramine (or paroxetine 20mg, e.g., and so on) in mild-moderate, this one says effective in moderate-severe. HOWEVER, we need long term studies not simply 6 weeks which sort of makes it pointless.

Major concern with HP IMHO is non-standard preparations without government control of the standards and more importantly depression should be diagnosed by trained professionals - the problem is people diagnosing themselves when the cause could be purely physical (e.g., on propranolol, hypothyroidism) or psychological (e.g., psychosocial stressors).

Evidence for SJW is inconsistent and all trials have been under 8 weeks. The notable word in the full article (in PDF on the site) is that it is effective in acute treatment. Also, the run-in was single-blinded.

Comments?

 

[mdblue]

Side effects are just as common - dry mouth, nausea, consptiaption, fatigue, dizziness and headache with photosensitivity reactions due to red pigment says the Maudsley Guidelines.

One study found it to be comparable to Imipramine 150mg (standard dosing to form a comparison across species of drug) and as effective in mild-moderate depression.

None of the older trials lasted longer than 8 weeks. This one only lasted 6 weeks. So far, plenty of research says it's as effective the global 150mg imipramine (or paroxetine 20mg, e.g., and so on) in mild-moderate, this one says effective in moderate-severe. HOWEVER, we need long term studies not simply 6 weeks which sort of makes it pointless.

Major concern with HP IMHO is non-standard preparations without government control of the standards and more importantly depression should be diagnosed by trained professionals - the problem is people diagnosing themselves when the cause could be purely physical (e.g., on propranolol, hypothyroidism) or psychological (e.g., psychosocial stressors).

Evidence for SJW is inconsistent and all trials have been under 8 weeks. The notable word in the full article (in PDF on the site) is that it is effective in acute treatment. Also, the run-in was single-blinded.

Comments?

Forgive me for being so cynical
From the article-
Funding: Dr Willmar Schwabe Pharmaceuticals, manufacturer of WS 5570.
Competing interests: AS has received consultancy fees from Dr Willmar
Schwabe Pharmaceuticals. RK is head of a contract research organisation
(IMEREM), which is engaged in several clinical trials of hypericum extract
for different pharmaceutical companies. AD and MK are employees of Dr
Willmar Schwabe Pharmaceuticals.

 

[joanithan]

Please see the following for what is arguably the final word on this issue (by virtue of the quality of the studies). Note also that in these studies, a placebo was employed.

JAMA. 2002;287:1807-1814.
JAMA. 2001 Apr 18;285(15):1978-86.

See also: J Clin Psychiatry. 2004 Aug;65(8):1114-9.

 

[serenity]

From my own experience,St John's wort works great on pre-menstrual symptoms.
Its an awesome find,atleast for me!
To all the females out there,take note

 

[PsychMD]

It appears, furthermore, that the studies which showed the lack of efficacy of St. John's Wort were funded by NIH-CAM, (not by Pharma, which could be always suspected of aggressive and frankly corrupted bias in today's climate!), which I understand is generally pro-safe CAM rather than anti-CAM, so unless one suspects too an extraordinary level of corruption or bias within NIH-CAM itself (I guess anything is possible nowadays, so one never knows!)...one can safely assume that it just doesn't work very well.

Of course, SSRI's themselves are not that extraordinarily effective, as we have all witnessed during more recent revelations...so...one may ask...what's a doc to do? Take TIME, IMHO, to both learn how to CRITICALLY read the literature, and also to unravel, as best as possible, case by case, what may be helpful and what may not in the case of each individual patient, how to prioritize and optimize the various tx. tools currently at our disposal (and we are all very aware that these are not limited to pills!), and just plain try to treat what is treatable, and improve what's improvable, as best as we can, under the traditional and perennialy worthy of supporting paradigm of "first do no harm"!

 

[bananaface]

1) St. John's Wort is considered an herbal supplement and there is no agency responsible for quality control of herbals at this time. Many times the herbal supplements have a much higher or lower dose of the product than the label indicates. Also, many are prepared in such a way that the active product never enters the body.

2) Natural =/ safe. St. John's Wort accounts for like 40% of OTC herbal interactions, by way of CYP3A4 induction. People rarely bother to tell their prescribers or pharmacists that they are taking an herbal product. It's an accident waiting to happen.

3) Use of an OTC encourages self-treatment.

As an aside, Paxil (paroxetine) bites. It has more drug interactions and side effects than the other drugs in it's class. Lexapro (escitalopram) and Zoloft (sertraline) are contenders for the best two SSRI's out there at the moment, IMO. I dunno why anyone would start out with paroxetine at this point in time.

 

[Furrball]

As an aside, Paxil (paroxetine) bites. It has more drug interactions and side effects than the other drugs in it's class. Lexapro (escitalopram) and Zoloft (sertraline) are contenders for the best two SSRI's out there at the moment, IMO. I dunno why anyone would start out with paroxetine at this point in time.

Generic drug, therefore less money and greater chance your patient can actually afford to take it.

 

[bananaface]

Generic drug, therefore less money and greater chance your patient can actually afford to take it.

Generics are not always cheaper. For example, generic ranitidine syrup costs 3 times as much as the brand name Zantac syrup.

Just for comparison here are some prices for you, at 30 tablets each, from Walgreen's website:

Lexapro
10mg - $69.99
20mg - $80.99

Paroxetine generic

10mg - $67.49
20mg - $69.99
30mg - $71.99
40mg - $71.99

If you want to save people money, the best way to do it is to write the prescription so that the patient is instructed to take a half tablet per dose, if possible. (ie: instead of one 10mg tab, write for 1/2 of a 20mg tab)