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Decreased Plasma Levels of Amitriptyline and Its Metabolites on Comedication With an Extract From St. John’s Wort (Hypericum perforatum)

Johne, Andreas MD*; Schmider, Jürgen MD*; Brockmöller, Jürgen MD*; Stadelmann, Andreas M. MD; Störmer, Elke PhD*; Bauer, Steffen PhD*; Scholler, Gudrun MD; Langheinrich, Matthias MD§; Roots, Ivar MD*

Journal of Clinical Psychopharmacology: February 2002 - Volume 22 - Issue 1 - p 46-54

Extracts of St. John’s wort (Hypericum perforatum) became increasingly popular as easily available remedies for mild to moderate depression. Comedication with hypericum extract was recently shown to drastically reduce plasma concentration of ciclosporin, digoxin, and indinavir. We investigated the possible interaction of hypericum extract LI160 with amitriptyline. Both antidepressants have a high probability of concomitant use. Twelve patients requiring amitriptyline treatment received a single dose of hypericum extract (900 mg) at day 1, continued by a 12-to 14-day treatment with retarded amitriptyline (75 mg twice daily). Then hypericum (900 mg/day) was added for another 14 to 16 days. Steady-state pharmacokinetics of amitriptyline were compared before and after multiple-dose treatment with hypericum extract. Furthermore, comparisons were made for single-dose kinetics of hypericum-extract ingredients hypericin, pseudohypericin, and hyperforin between the first day of concomitant treatment and LI160 alone. Multiple-dose comedication with LI160 led to a statistically significant decrease in the area under the plasma concentration–time curve within one dosing interval of amitriptyline by 22% (p = 0.03) and nortriptyline by 41% (p = 0.002), as well as of all hydroxylated metabolites, except for 10-E-hydroxynortriptyline. Plasma levels of amitriptyline and hydroxylated metabolites gradually decreased, whereas nortriptyline concentrations were already markedly decreased after 3 days of cotreatment with hypericum. Cumulative urinary amounts of amitriptyline and metabolites decreased to the same extent as plasma concentrations upon hypericum comedication. Induction of cytochrome P-450 enzymes or drug transporters (P-glycoprotein) by St. John’s wort extract may explain this pharmacokinetic interaction. Physicians should be aware of this interaction when treating patients with amitriptyline.

*Institute of Clinical Pharmacology, †Department of Psychiatry, and ‡Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Charité, Humboldt University of Berlin, Germany; §Lichtwer Pharma AG, Berlin, Germany

Received May 31, 2000; accepted after revision February 12, 2001.

Address requests for reprints to: Ivar Roots, MD, Institute of Clinical Pharmacology, Charité, Humboldt University of Berlin, Schumannstr. 20/21, D-10098 Berlin, Germany. Address e-mail to: ivar.

© 2002 Lippincott Williams & Wilkins, Inc.