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The Effect of St John's Wort on the Pharmacodynamic Response of Clopidogrel in Hyporesponsive Volunteers and Patients: Increased Platelet Inhibition by Enhancement of CYP3A4 Metabolic Activity

Lau, Wei C MD*; Welch, Terrence D MD; Shields, Theresa BSN, RN*; Rubenfire, Melvyn MD; Tantry, Udaya S PhD; Gurbel, Paul A MD

Journal of Cardiovascular Pharmacology: January 2011 - Volume 57 - Issue 1 - p 86-93
doi: 10.1097/FJC.0b013e3181ffe8d0
Original Article

Clopidogrel is metabolically activated by cytochrome P450 (CYP) isoenzymes. We evaluated whether St. John's wort (SJW), a CYP2C19 and CYP3A4 inducer, enhances the pharmacodynamic response of clopidogrel. Volunteers (n = 45) were screened for clopidogrel hyporesponsiveness after a 300-mg load. After a 7-day washout, hyporesponders (n = 10) received 14 days of SJW (300 mg 3 times a day) followed by a second 300-mg clopidogrel. Platelet aggregation was measured at 0, 2, 4, and 6 hours postloading; hepatic CYP3A4 activity was simultaneously determined at 0 and 4 hours by the erythromycin breath test. A prospective, randomized, double-blind pilot study was conducted in postcoronary stent patients (n = 85) on clopidogrel 75 mg/d screened for clopidogrel hyporesponsiveness. Hyporesponders (n = 20) were randomized to SJW (n = 10) or placebo (n = 10); platelet aggregation was measured before and after 14 days of therapy. In volunteers, SJW decreased platelet aggregation (59% ± 14% vs. 40% ± 15% at 2 hours, P = 0.02; 56% ± 10% vs. 44% ± 13% at 4 hours, P < 0.03; and 55% ± 14% vs. 37% ± 14% at 6 hours, P = 0.01) and increased CYP3A4 activity (2.1% ± 0.4% 14CO2 exhaled per hour before vs. 2.9% ± 0.6% 14CO2 exhaled per hour after SJW, P = 0.002). In patients, SJW decreased platelet reactivity (226 ± 39 vs. 185 ± 49 P2Y12 reactivity units, P = 0.0002) and increased platelet inhibition (23% ± 11% vs. 41% ± 16%, P = 0.002). SJW may be a future therapeutic option to increase CYP metabolic activity and antiplatelet effect of clopidogrel in hyporesponders.

From the *Cardiovascular Center, Department of Anesthesiology, and †Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; and ‡Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD.

Received for publication September 9, 2010; accepted October 1, 2010.

Supported by General Clinical Research Center, #M01-RR00042, University of Michigan, McKay Cardiovascular Center Grant, University of Michigan, Cardiovascular Inaugural Center Grant, University of Michigan CVC.

The authors report no conflicts of interest.

Reprints: Wei C. Lau, MD, Department of Anesthesiology, University of Michigan Health System, University of Michigan, 4172 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5861 (e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.