Q. Can St. John's wort be taken by pregnant women? Also, I've heard that it's dangerous to take it if you eat cheese or wine. Is that correct?
A. First of all, let me explain what St. John's wort is: It's a natural flowering plant that
grows wild in the western United States and throughout Europe. For a number of years, Europeans
have been treating depression with an extract made from the dried bright yellow flowers
and leaves of the St. John's wort plant. In fact, in Germany it's the leading antidepressant,
outselling all the available prescription antidepressants. By the way, the word "wort" is
the old English term for "plant."
What is it about St. John's wort that helps folks with depression? It's believed that
hypericin is the component that's responsible for the magic. What does hypericin do?
It appears to raise levels of several brain chemical transmitters such as serotonin,
norepinephrine and dopamine, thus affecting mood. Antidepressants such as Prozac, Paxil and
Zoloft work by raising brain levels of serotonin; the antidepressant Effexor works by
raising brain levels of serotonin and norepinephrine.
The cheese and wine dietary precautions you describe apply only to an older class
of antidepressants _ the MAO inhibitors. Drugs such as Parnate and Nardil are examples. If
you're on an MAO antidepressant, red wine, cheddar cheese and other foods rich in
something called "tyramine" can interact with the drug and cause a sudden rise in blood
pressure. There was some discussion in the early medical research that St. John's wort is a
weak MAO inhibitor, but more recent studies have not confirmed this. Furthermore, there haven't been any reports of MAO inhibitor food-drug interaction with St. John's wort.
As far as its safety profile, there have been very few side effects reported. As you
might expect, there may be a few folks who are allergic to St. John's wort. Also, some folks
may develop a rash from sun sensitivity, especially when it's taken in high doses.
Is it safe in pregnancy? There have been some reports in the medical literature that it has the
potential to induce abortion, so I wouldn't advise its use in pregnancy.
Does St. John's wort extract really work? In a number of small European studies, it does appear to be effective and generally safe.
However, there are a few things to keep in mind:
1) All preparations of St. John's wort are not alike. There needs to be a standardized
extract of the active ingredient "hypericin" at a dosage of 300mg three times a day;
2) Foods containing St. John's wort extract often have doses too small to be effective;
3) Read the labels of multivitamins that add St. John's wort to check the amount added. If it's too small a dose to be helpful, you're just wasting your money;
4) It takes up to 6 weeks to get the full benefit of St. John's wort; and
5) For serious major depression, it's best to see your doctor and not self-treat. A prescription antidepressant may be what you need.
The National Institutes of Health and the National Institute of Mental Health are studying St. John's wort in the first U.S. large scale clinical trial to assess whether it has a significant therapeutic effect in patients with clinical depression. Even though it's widely prescribed in Europe, no studies of its long-term use have been done, and published studies involved different types of patients treated at several different dosages. An important part to the trial will be to compare its effectiveness against the widely used prescription antidepressant Zoloft. The study began in December 1998 and should be complete by July or August of this year.
Q. I was recently informed by my doctor that my EKG seemed to show that I may have had a heart attack sometime in the past. How could that be? Wouldn't you think I'd know if I had a heart attack? _C.E., Columbia, S.C.
A. We're all familiar with the classic chest pain symptoms: a tightness in the center of
the chest lasting more than a few minutes; radiation of the pain into the left arm, shoulder
or the neck; and associated shortness of breath, sweating or nausea. But that's not always
the way it happens.
Sometimes instead of chest pain or pressure, a person having a heart
attack will have abdominal pain that mimics a bout of indigestion or a stomach "bug."
Sometimes there's no chest pain, but only palpitations and cold sweats. Sometimes
there's unexplained shortness of breath without an obvious cough or fever or chest
infection. Sometimes there's just an unexplained weak feeling.
As many as 30 percent of those who have heart attacks have "silent" ones, either not feeling any discomfort at all, or
simply attributing non-typical symptoms to something else. Some folks may mistakenly
treat their non-typical heart attack symptoms with antacids, pain relievers and rest. And
they may be lucky in surviving the heart attack that only becomes apparent when a
routine EKG reveals it.
By the way, it's best to follow the EKG with an
echocardiogram (sonogram) of the heart to see if there are any areas of the heart that aren't moving or move weakly.
I'm sure that you're asking yourself: "How do I know if a bout of indigestion or
weakness doesn't mean I'm having a heart attack?"
First of all, the majority of folks do have symptoms that raise doctors' suspicion of heart disease. And while a heart
attack can occur out of the blue, most folks usually have some warning symptoms of angina. For example, I recently had a patient who saw me for "heartburn" that seemed
to come on while climbing a flight of stairs. He ended up having emergency heart bypass surgery.
Heart disease doesn't just happen. There's a reason for it that, generally speaking, can be seen from miles away.
A diabetic carries a high risk of heart disease. What's more,
diabetics may develop damage to the nerve pain fibers that are designed to warn them of
angina. Diabetics are at much higher risk of silent heart attacks and silent angina. They
need to have their cholesterol aggressively lowered. The American Diabetes Association
advises that their LDL "bad" cholesterol be lowered through diet and/or cholesterol
medication to 100 or less. A non-diabetic without heart/vascular disease should have
their LDL cholesterol level 130 or less.
Smokers have two to four times the risk of heart attacks and sudden death as non-smokers.
A family history of premature heart disease, with those affected under the age of 55, is another red flag for a doctor. In those with a family history of premature heart disease, I look for other possible contributors in the blood
besides cholesterol _ particularly an elevated "homocysteine level" and an elevated "Lipoprotein A" level. A high triglyceride level (normal level is under 200) is also now felt to be a contributing factor to heart disease.
A woman who has reached menopause prematurely, either because of early ovarian failure or because of total hysterectomy, is felt to be at an increased risk of heart disease.
So what can you do?
The first thing to do is to work on risk factors you can do something about.
If your cholesterol is high, try to lower it through diet and keep it down. If that's not working, talk with your doctor about lowering it with a drug such as Lipitor or Zocor. They're remarkably safe _even long-term. I'd also recommend asking your doctor about starting an aspirin a day. It will help decrease the risk of clots and may prevent a heart attack.
If you're smoking, obviously you need to quit.
If you're a diabetic, get your sugars under as tight a control as possible.
Lastly, an annual EKG and stress test in those at high risk of having a heart attack is a good idea.
