Get to know your patients, St. John’s Wort(s) and all
What they don’t know can hurt them
Today, nearly one in every three Americans use herbal remedies as part of regimens to treat various illnesses and to help maintain good health.1 Most of them self-prescribe and self-medicate. However, the information they use to make their choices often lacks scientific rigor. Many people rely on information found on the Internet, which is not verified by peer-reviewed literature. Furthermore, the potential for side effects, drug-drug interactions, and drug-food interactions is very real and not typically considered by patients.
One of the commonly used herbal remedies is St. John’s Wort (SJW). Stephanie Beckman, PharmD, BCCP, a pharmacist with CVS Pharmacy in Greenville, SC, tells Drug Utilization Review that, among health care professionals, "Pharmacists are the best equipped to advise patients on the use of St. John’s Wort. Information gets disseminated well to pharmacists through journals and CE [continuing education] programs." In addition, the University of Florida now offers a certification program to pharmacists. "One of the biggest dangers in using herbal medications," says Beckman, "is lack of knowledge on the part of consumers. They go to nonscientific resources such as the Internet, put all their faith in those sources, then don’t follow up with physicians or pharmacists about incorporating the herbs into their routines. Patients are often frustrated with traditional medical care. They’re frustrated with physicians, and they’re frustrated with prescription medications that don’t seem to work or that are difficult to tolerate."
The Food and Drug Administration’s recent advisory on how St. John’s Wort reduces the effectiveness of certain HIV drugs is a reminder that herbal remedies are not always harmless ways to promote health or placebos that can be ignored. It also means clinicians must be more diligent in finding out what over-the-counter supplements their patients take and whether those products could have adverse interactions with other medications.
Beckman was lead author of a study, published in the May 2000 Pharmacotherapy, that reported results of a survey of consumers who used SJW for self-treatment of depression. The results showed that 47% of patients polled experienced side effects ranging from insomnia and other sleep difficulties, which are the most common side effects, to restlessness, anxiety, gastrointestinal upset, photosensitivity, dizziness, agitation, and irritability. Ten patients experienced more than one side effect, and six of the 43 patients polled (14%) stopped taking SJW due to such side effects. Withdrawal syndromes also occurred for some during the first week of drug cessation.
Many patients fall prey to marketing strategies of herbal manufacturers, she points out. "Self-treatment can be dangerous. It postpones more effective, safer treatment with known results. With St. John’s Wort and depression, this is a potentially lethal practice, especially for patients with severe depressive disorder."
Those patients are at greater risk to do harm to themselves, and postponing effective treatment can leave them in a position to carry out such acts, she notes. "It’s very important for patients to let their physicians know what kind of herbs they’re taking." Physicians who are not familiar with herbal products used by their patients use can refer those patients to other sources for advice regarding herbal use.
"It’s imperative," she adds, "that patients let their pharmacists know, since pharmacists have a better knowledge base regarding herbs and have access to a lot more resources. The notion that natural is safer’ can be a dangerous misconception. In the study, we found that 67% of patients surveyed were not aware of any side effects associated with use of St. John’s Wort, and 88% weren’t concerned about them."
Clinicians need to be more careful about the risks associated with herbal products and the risks of delaying proven pharmacologic treatment. Beckman encourages all pharmacists to offer to sit down with patients and talk with them about herbal medications they are taking. Additionally, "directing patients to scientific, peer-reviewed information can make them better informed patients and lead to better care."
With the resurgence in use of herbs as medicine, many schools of pharmacy are supplementing their curricula to teach skills necessary to advise patients about herbal medicine. Cydney E. McQueen, PharmD, natural product research fellow at the University of Missouri-Kansas City (UMKC), tells DUR, "Textbooks that have been used for pharmacognosy classes contain a lot of chemistry and very little clinically applicable information. Our goal is to provide clinically applicable information to teach students to determine when and which herbal products are effective, to be familiar with the side effects of specific remedies, and to know the potential drug-drug and drug-food interactions patients face.
"We have already included class periods on herbal medicinals in the pharmacology and therapeutics classes at UMKC," McQueen says. "We are also proposing the addition of two elective classes for students. One is an Introduction to Complementary and Alternative Medicine’ that would give students an idea of the natural products and the processes used in alternative medicine. The other is a Natural Products’ class that would cover the key 20 products used in the U.S. and how they are used in therapy."
McQueen agrees that pharmacists are in a better position to advise patients on herbal therapies. "Pharmacists are at the point of sale in community pharmacy and are involved in patient history in both community and hospital settings. We are more available to patients in general and are happy to talk with them about their medications. We are also accustomed to looking for contraindications and interactions in the drugs our patients take. However, not all pharmacists have the same knowledge base regarding natural products. There is a difference between helping patients avoid problems, such as drug interactions, and using herbal products therapeutically to elicit an effective response. I see this kind of discussion with patients as the pharmacist’s responsibility. If we’re going to provide pharmaceutical care, we need to know about herbs and how they interact. We need to continue to work to get all pharmacists up to speed on what they need to know."
McQueen recommends a couple of references as good sources of information for health care professionals and consumers (see box, p. 50). About references, she adds, "Always check more than one source. Research as much as you can to determine which is the best product, when that information is known. And check to see if the product your patient is considering matches the product used in the trials.
"Once well-grounded," McQueen continues, "pharmacists need to question the patient just as we would if recommending an over-the-counter medication. We need to ask about concomitant diseases, concomitant medications, how long the patient has been ill to determine if the remedy in question will be effective. Then we need to discuss specific products, doses, expectations of when to start feeling better, [and] how long to use the product, and potential side effects — the same counseling we’d give for an OTC."
The new guidelines for drug treatment of depression, recently released by the American College of Physicians-American Society of Internal Medicine, state that SJW may be effective in treating mild depression, short term. About SJW, McQueen says, "When patients take St. John’s Wort for depression, it needs to be done under the guidance of a physician. As pharmacists, we need to participate in patient care by being able to provide the patient with information that they can then take to their physician about the appropriate product, therapeutic dose, contraindications, drug interactions. Our provision of that information will help the physician and patient in the decision-making process."
Reference
1. Beckman SE, Sommi RW, Switzer J. Consumer use of St. John’s Wort: A survey on effectiveness, safety, and tolerability. Pharmacotherapy 2000; 20:568-574.
• Stephanie Beckman, PharmD, BCCP, CVS Pharmacy, Greenville, SC. Telephone: (846) 240-7421.
• Cydney E. McQueen, PharmD, Fellow in Natural Product Research, University of Missouri-Kansas City, Kansas City, MO. Telephone: (816) 235-1000.
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