# St. John's Wort Implicated in Kidney Transplant Rejection



## JeanG (Oct 20, 1999)

The URL for this article is: http://www.medscape.com/reuters/prof/2000/...016clin015.html St. John's Wort Implicated in Kidney Transplant Rejection --------------------------------------------------------------------------------TORONTO (Reuters Health) Oct 17 - Two cases of kidney transplant rejection associated with use of St. John's Wort were described at the annual meeting here of the American Society of Nephrology. The first case was that of a 44-year-old woman who underwent a living renal transplant in February 1996. She was referred to a specialty clinic in December 1999 after experiencing acute rejection, Dr. Sameh R. Abul-Ezz, from the University of Arkansas, in Little Rock, reported. The patient had been receiving maintenance doses of cyclosporine, but recently had been prescribed higher doses because of a sudden drop in blood levels of the drug. Even with the increased dosage, her whole blood levels of the drug remained low, and had been low for 6 months, Dr. Abul-Ezz reported. Her physicians discovered that the patient had been taking St. John's Wort daily at the same time that she took her oral cyclosporine. She stopped taking the herb, and within 2 weeks her whole blood cyclosporine trough levels increased to a normal range of 275 ng/mL. After 4 weeks, physicians were able to reduce her cyclosporine dose, and the whole blood drug concentrations remained at the therapeutic range of 200 to 350 ng/mL. The second patient did not fare as well, Dr. Abul-Ezz said. This was a 29-year-old woman who had undergone a combined cadaveric kidney and pancreas transplant in July 1994. This patient had two early episodes of rejection, which clinicians were able to stabilize. Her whole blood cyclosporine trough stayed in the therapeutic range until November 1998. "Over the next 30 days, her CSA trough concentrations dropped to 155 ng/mL, although she remained on the same dose of CSA," Dr. Abul-Ezz said. Three weeks after that, the levels dropped to 97 ng/mL, and her serum creatine levels increased. Dr. Abul-Ezz' team found that this patient was taking St. John's Wort. When she discontinued taking the herb and Dr. Abul-Ezz increased the dosage of oral cyclosporine, her blood levels jumped to 530 ng/mL. The dose was quickly adjusted, and blood levels dropped to a normal range. The patient eventually developed acute rejection, and underwent another renal transplant in January 2000. Reports in the medical literature show that regular use of St. John's Wort can induce the activity of CYP3A4 and P-glycoprotein expression, and has the potential to interact with other medications. It now appears that it interferes with cyclosporine metabolism, Dr. Abul-Ezz noted.


----------



## Guest (Oct 19, 2000)

Jean,It's not just kidney transplants...---------------------------------------------Lancet 2000 Feb 12;355(9203):548-9 Acute heart transplant rejection due to Saint John's wort.Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll GWe report here acute rejection in two transplant patients due to a metabolic interaction of St John's wort and cyclosporin.Publication Types: Letter Comments: Comment in: Lancet 2000 May 27;355(9218):1912 ---------------------------------------------This just illustrates the danger of *not* telling one's doctor about self-medication with herbs. Any substance with biological activity is a *drug*, regardless of its source. St. John's Wort also inactivates the HIV drug class called protease inhibitors; furthermore, it's not even clear how St.John's Wort works yet. However, people who are taking SSRI antidepressants or MAOinhibitors are strongly urged not to use St. John's Wort at the same time, for fears it may negatively interact with these drugs.Companies who sell herbal preparations are not required to demonstrate their products are safe or effective. They are not even required by law to guarantee their products are free of impurities. It's definately buyer beware...


----------



## Guest (Oct 19, 2000)

Jean,Here's another one...---------------------------------------------: Arch Intern Med 2000 Sep 11;160(16):2548 St John's wort interaction with digoxin.Cheng TOPublication Types: Letter ---------------------------------------------


----------



## Guest (Oct 19, 2000)

Jean,Yet more drug interactions with St. John's Wort...---------------------------------------------Presse Med 2000 Jul 1;29(23):1285-6 [St. Johns wort-venlafaxine interaction].[Article in French]Prost N, Tichadou L, Rodor F, Nguyen N, David JM, Jean-Pastor MJPublication Types: Letter ---------------------------------------------Lancet 2000 Feb 12;355(9203):547-8 Indinavir concentrations and St John's wort.Piscitelli SC, Burstein AH, Chaitt D, Alfaro RM, Falloon JSt John's wort reduced the area under the curve of the HIV-1 protease inhibitor indinavir by a mean of 57% (SD 19) and decreased the extrapolated 8-h indinavir trough by 81% (16) in healthy volunteers. A reduction in indinavir exposure of this magnitude could lead to the development of drug resistance and treatment failure.Publication Types: Clinical trial Letter ---------------------------------------------: Lancet 2000 Jan 8;355(9198):134-8 Published erratum appears in Lancet 2000 Mar 18;355(9208):1020Herb-drug interactions.Fugh-Berman AGeorge Washington University School of Medicine and Health Sciences, Department of Health Care Sciences, Washington, DC 20037, USA. fughberman###aol.comConcurrent use of herbs may mimic, magnify, or oppose the effect of drugs. Plausible cases of herb-drug interactions include: bleeding when warfarin is combined with ginkgo (Ginkgo biloba), garlic (Allium sativum), dong quai (Angelica sinensis), or danshen (Salvia miltiorrhiza); mild serotonin syndrome in patients who mix St John's wort (Hypericum perforatum) with serotonin-reuptake inhibitors; decreased bioavailability of digoxin, theophylline, cyclosporin, and phenprocoumon when these drugs are combined with St John's wort; induction of mania in depressed patients who mix antidepressants and Panax ginseng; exacerbation of extrapyramidal effects with neuroleptic drugs and betel nut (Areca catechu); increased risk of hypertension when tricyclic antidepressants are combined with yohimbine (Pausinystalia yohimbe); potentiation of oral and topical corticosteroids by liquorice (Glycyrrhiza glabra); decreased blood concentrations of prednisolone when taken with the Chinese herbal product xaio chai hu tang (sho-salko-to); and decreased concentrations of phenytoin when combined with the Ayurvedic syrup shankhapushpi. Anthranoid-containing plants (including senna [Cassia senna] and cascara [Rhamnus purshiana]) and soluble fibres (including guar gum and psyllium) can decrease the absorption of drugs. Many reports of herb-drug interactions are sketchy and lack laboratory analysis of suspect preparations. Health-care practitioners should caution patients against mixing herbs and pharmaceutical drugs.Publication Types: Review Review, tutorial Comments: Comment in: Lancet 2000 Mar 18;355(9208):1019-20 ---------------------------------------------


----------



## JeanG (Oct 20, 1999)

Thanks, Guy. That last article you posted here was quite sobering. We have to remember that herbs are potent, and can cause reactions to other medications.JeanG


----------

