Hypericum perforatum

"St John's wort" redirects here. For other uses, see St John's wort (disambiguation).

Hypericum perforatum
File:Saint johns wart flowers.jpg
Scientific classification
Kingdom:	Plantae
(unranked):	Angiosperms
(unranked):	Eudicots
(unranked):	Rosids
Order:	Malpighiales
Family:	Hypericaceae
Genus:	Hypericum
Species:	H. perforatum
Binomial name
Hypericum perforatum L.

Hypericum perforatum, known as Perforate St John's-wort, Common Saint John's wort and St John's wort, is a flowering plant in the family Hypericaceae. The common name "St John's wort" may be used to refer to any species of the genus Hypericum. Therefore, Hypericum perforatum is sometimes called "Common St John's wort" or "Perforate St John's wort" in order to differentiate it. It is a medicinal herb with antidepressant activity and potent anti-inflammatory properties as an arachidonate 5-lipoxygenase inhibitor and COX-1 inhibitor.

Botanical description

Translucent dots on the leaves

Hypericum perforatum is native to Europe and Asia but has spread worldwide as an invasive species, including to temperate regions of India, China, Canada and the United States.

The herb's common name comes from its traditional flowering and harvesting on St John's day, 24 June. The genus name Hypericum is derived from the Greek words hyper (above) and eikon (picture), in reference to the plant's traditional use in warding off evil by hanging plants over a religious icon in the house during St John's day.

Peforate St John's wort is a herbaceous perennial plant with extensive, creeping rhizomes. Its stems are erect, branched in the upper section, and can grow to 1 m high. It has opposite, stalkless, narrow, oblong leaves that are 1–2 cm long. The leaves are yellow-green in color, with conspicuous translucent dots, giving them a 'perforated' appearance, to which the plant's Latin name refers. Its flowers measure up to 2.5 cm across, have five petals, and are colored bright yellow with conspicuous black dots. The flowers appear in broad cymes at the ends of the upper branches, between late spring and early to mid summer. The sepals are pointed, with black glandular dots. There are many stamens, which are united at the base into three bundles. The pollen grains are ellipsoidal.

When flower buds (not the flowers themselves) or seed pods are crushed, a reddish/purple liquid is produced.

Ecology

St John's wort reproduces both vegetatively and sexually. It thrives in areas with either a winter- or summer-dominant rainfall pattern; however, distribution is restricted by temperatures too low for seed germination or seedling survival. Altitudes greater than 1500 m, rainfall less than 500 mm, and a daily mean January (in Southern hemisphere) temperature greater than 24 degrees C are considered limiting thresholds. Depending on environmental and climatic conditions, and rosette age, St John's wort will alter growth form and habit to promote survival. Summer rains are particularly effective in allowing the plant to grow vegetatively, following defoliation by insects or grazing.

The seeds can persist for decades in the soil seed bank, germinating following disturbance.

Invasive species

Although Hypericum perforatum is grown commercially in some regions of south east Europe, it is listed as a noxious weed in more than twenty countries and has introduced populations in South and North America, India, New Zealand, Australia, and South Africa. In pastures, St John's wort acts as both a toxic and invasive weed. It replaces native plant communities and forage vegetation to the dominating extent of making productive land nonviable or becoming an invasive species in natural habitats and ecosystems. Ingestion by livestock can cause photosensitization, central nervous system depression, spontaneous abortion, and can lead to death. Effective herbicides for control of Hypericum include 2,4-D, picloram, and glyphosate. In western North America three beetles Chrysolina quadrigemina, Chrysolina hyperici and Agrilus hyperici have been introduced as biocontrol agents.

• 

  Full plant

• 

  Seedlings

• 

  Fruit

• 

  Blossom

Medicinal uses

Major depressive disorder

Studies have supported the efficacy of St John's wort as a treatment for depression in humans. A 2015 meta-analysis review concluded that it has superior efficacy to placebo in treating depression; is as effective as standard antidepressant pharmaceuticals for treating depression; and has fewer adverse effects than other antidepressants. The authors concluded that it is difficult to assign a place for St. John's wort in the treatment of depression owing to limitations in the available evidence base, including large variations in efficacy seen in trials performed in German-speaking relative to other countries. It is proposed that the mechanism of action of St. John's wort is due to the inhibition of reuptake of certain neurotransmitters. A 2008 Cochrane review of 29 clinical trials concluded that it was superior to placebo in patients with major depression, as effective as standard antidepressants and had fewer side-effects. According to the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health, it "may help some types of depression, though the evidence is not definitive"; can limit the efficacy of prescription medicines; and psychosis can occur as a rare side effect. The NCCIH notes that combining St John's wort with certain prescription antidepressants can lead to a "potentially life-threatening increase of serotonin," a brain chemical targeted by antidepressants. In horses, sheep and cattle, the plant can be toxic when ingested in large quantities.

In Germany, it is sometimes prescribed for mild to moderate depression, especially in children and adolescents.

Side effects

St John's wort is generally well tolerated, with an adverse effect profile similar to placebo. Commonly reported adverse effects include gastrointestinal symptoms (nausea, abdominal pain, loss of appetite, and diarrhea), dizziness, confusion, fatigue, sedation, dry mouth, restlessness, and headache. The organ systems associated with adverse drug reactions to St John's wort and fluoxetine (a SSRI) have an analogous incidence profile; most of these reactions involve the central nervous system. St John's wort also decreases the levels of estrogens, such as estradiol, by speeding up its metabolism, and should not be taken by women on contraceptive pills as it upregulates the CYP3A4 cytochrome of the P450 system in the liver.

St John's wort may rarely cause photosensitivity. This can lead to visual sensitivity to light and to sunburns in situations that would not normally cause them.

St John's wort is associated with aggravating psychosis in people who have schizophrenia.

Interactions

Consumption of St. John's wort is discouraged for those with bipolar disorder. There is concern that people with bipolar depression taking St. John's wort may be at a higher risk for mania.

St. John's wort has interactions with medications such as SSRI antidepressants, warfarin, and birth control. Combining both St John's wort and SSRI antidepressants could lead to increased serotonin levels causing serotonin syndrome. Combining estrogen containing oral contraceptives with St John's wort can lead to decreased efficacy of the contraceptive and eventually unplanned pregnancies. These are just a few of the drug interactions that St John's wort possesses. It is also known to decrease the efficacy of HIV medications, cholesterol medications, as well as transplant medications. It should be noted, however, that traditional SSRI antidepressants such as fluvoxamine carry similar contraindications.

Pharmacokinetic interactions

St John's wort has been shown to cause multiple drug interactions through induction of the cytochrome P450 enzymes CYP3A4 and CYP1A2 (females only). This drug-metabolizing enzyme induction results in the increased metabolism of certain drugs, leading to decreased plasma concentration and potential clinical effect. The principal constituents thought to be responsible are hyperforin and amentoflavone.

St John's wort has also been shown to cause drug interactions through the induction of the P-glycoprotein efflux transporter. Increased P-glycoprotein expression results in decreased absorption and increased clearance of certain drugs, leading to lower plasma concentration and potential clinical efficacy.

Examples of drugs whose effectiveness may be reduced by St. John's wort

Class	Drugs
Antiretrovirals	Non-nucleoside reverse transcriptase inhibitors, protease inhibitors
Benzodiazepines	Alprazolam, midazolam
Hormonal contraception	Combined oral contraceptives
Immunosuppressants	Calcineurin inhibitors, cyclosporine, tacrolimus
Antiarrhythmics	Amiodarone, flecainide, mexiletine
Beta-blockers	Metoprolol, carvedilol
Calcium channel blockers	Verapamil, diltiazem, amlodipine
Statins (cholesterol-reducing medications)	Lovastatin, simvastatin, atorvastatin
Others	Digoxin, methadone, omeprazole, phenobarbital, theophylline, warfarin, levodopa, buprenorphine, irinotecan
Reference: Rossi, 2005; Micromedex

For a complete list, see CYP3A4 ligands and CYP2C9 ligands.

Pharmacodynamic interactions

In combination with other drugs that may elevate 5-HT (serotonin) levels in the central nervous system (CNS), St John's wort may contribute to serotonin syndrome, a potentially life-threatening adverse drug reaction.

Drugs that may contribute to serotonin syndrome with St John's wort

Class	Drugs
Antidepressants	MAOIs, TCAs, SSRIs, SNRIs, mirtazapine
Opioids	Tramadol, pethidine (meperidine), Levorphanol
CNS stimulants	Phentermine, diethylpropion, amphetamines, sibutramine, cocaine
5-HT1 agonists	Triptans
Psychedelic drugs	Methylenedioxymethamphetamine (MDMA), LSD, Dimethyltryptamine (DMT), MDA, 6-APB
Others	Selegiline, tryptophan, buspirone, lithium, linezolid, 5-HTP, dextromethorphan
Reference:

Mechanism of action

St. John's wort, similarly to other herbs, contains a whole host of different chemical constituents that may be pertinent to its therapeutic effects. Hyperforin and adhyperforin, two phloroglucinol constituents of St John's wort, are TRPC6 receptor agonists and, consequently, they induce noncompetitive reuptake inhibition of monoamines (specifically, dopamine, norepinephrine, and serotonin), GABA, and glutamate when they activate this ion channel. In humans, the active ingredient hyperforin is also an inhibitor of PTGS1, arachidonate 5-lipoxygenase, SLCO1B1 and an inducer of cMOAT. Hyperforin is also a anti-inflammatory compound with anti-angiogenic, antibiotic, and neurotrophic properties. Hyperforin also has an antagonistic effect on NMDA receptors, a type of glutamate receptor. Moreover, St John's wort is known to downregulate the β₁ adrenoceptor and upregulate postsynaptic 5-HT_1A and 5-HT_2A receptors, both of which are a type of serotonin receptor. Other compounds may also play a role in St John's wort's antidepressant effects such compounds include: oligomeric procyanidines, flavonoids (quercetin), hypericin, and pseudohypericin.

Comparison of selected active chemical constituents of Hypericum perforatum

Compound	Conc.	log P	PSA	pKa	Formula	MW	CYP1A2	CYP2C9	CYP2D6	CYP3A4	PGP	t1/2 (h)	Tmax (h)	Cmax (mM)	CSS (mM)	Notes/Biological activity
Phloroglucinols (2-5%)
Adhyperforin	0.2-1.9	10-13	71.4	8.51	C36H54O4	550.81	?	?	?	?	?	?	?	?	?	Inhibits reuptake of: 5-HT, DA, NE, GABA and Glu via TRPC6 activation
Hyperforin	2-4.5	9.7-13	71.4	8.51	C35H52O4	536.78	+	+/-	-	+	+	3.5-16	2.5-4.4	15-235	53.7	Serves as a TRPC6 and PXR agonist. Reuptake inhibitor of 5-HT (205nM), DA (102nM), NE (80nM), GABA (184nM), Glu (829nM), Gly and Ch (8.5μM). Angiogenesis, COX-1 (300nM), 5-LO (90nM), SIRT1 (15μM), SIRT2 (28μM) and MRSA (1.86μM) inhibitor.
Naphthodianthrones (0.03-3%)
Hypericin	0.003-3	7.5-10	156	6.9±0.2	C30H16O8	504.44	0	- (3.4 μM)	- (8.5 μM)	- (8.7 μM)	?	2.5-6.5	6-48	0.66-46	?	Is a topoisomerase II, PKA (10μM), PKC (27nM), CK1 (3μM), CK2 (6nM), MAPK (4nM), EGFR (35nM), InsR (29nM), PI3K (180nM), DBH (12.4μM), DNA polymerase A (14.7μM), HIV-1 RT (770nM), COMT, MAOA (68μM) and MAOB (420μM), succinoxidase (8.2μM), GSR (2.1nM), GPx (5.2μM), GST (6.6μM) and CuZnSOD (5.25μM) inhibitor. Binds to the NMDA receptor (Ki=1.1μM), μ-opioid, κ-opioid, δ-opioid, 5-HT6, CRF1, NPY-Y1, NPY-Y2 and σ receptors. Exhibits light-dependent inhibitory effects on HIV-1 and cancers.
Pseudohypericin	0.2-0.23	6.7±1.8	176	7.16	C30H16O9	520.44	?	?	?	?	?	24.8-25.4	3	1.4-16	0.6-10.8	Photosensitiser and antiretroviral like hypericin. PKC inhibitory effects in vitro.
Flavonoids (2-12%)
Amentoflavone	0.01-0.05	3.1-5.1	174	2.39	C30H18O10	538.46	?	- (35 nM)	- (24.3 μM)	- (4.8 μM)	?	?	?	?	?	Serves as a fatty acid synthase (FASN) inhibitor, kappa opioid antagonist, and a negative allosteric modulator at the benzodiazepine site of the GABAA receptor.
Apigenin	0.1-0.5	2.1±0.56	87	6.63	C15H10O5	270.24	?	?	?	?	?	?	?	?	?	Benzodiazepine receptor ligand (Ki=4μM) with anxiolytic effects. Also has anti-inflammatory, anticancer, cancer-preventing and antioxidant effects.
Catechin	2-4	1.8±0.85	110	8.92	C15H14O6	290.27	?	?	?	?	?	?	?	?	?	Anticancer, antioxidant, cardioprotective and antimicrobial. Cannabinoid receptor CB1 ligand.
Epigallocatechin	?	-0.5-1.5	131	8.67	C15H14O6	290.27	?	?	?	?	?	1.7±0.4a	1.3-1.6a	?	?	Found in higher concentrations in Green tea. Antioxidant. CB1 receptor ligand (Ki=35.7 μM).
Hyperoside	0.5-2	1.5±1.7	174	6.17	C21H20O12	464.38	?	?	- (3.87μM)	?	?	?	?	?	?	Has anti-fungal effects in vitro (against the plant pathogens P. guepini and Drechslera), neuroprotective effects via the PI3K/Akt/Bad/BclXL signalling pathway in vitro, anti-inflammatory effects via NF-κB inhibition in vitro, D2 receptor-dependent antidepressant-like effects in vivo, and antiglucocorticoid-like effects in vitro.
Kaempferol	?	2.1±0.6	107	6.44	C15H10O6	286.24	?	?	?	+/-	?	?	?	?	?	Inhibits the following: inflammation (via NF-κB and STAT1 inhibition), cancer, HDAC, bacteria, viruses, protozoa and fungi. It is also known to prevent cardiovascular disease and cancer.
Luteolin	?	2.4±0.65	107	6.3	C15H10O6	286.24	-	?	?	?	?	?	?	?	?	Has anti-inflammatory, anticancer, anti-allergic and antioxidant effects. May also have positive effects on people with autism spectrum disorders. Potent non-selective competitive inhibitor of PDE1-5.
Quercetin	2-4	2.2±1.5	127	6.44	C15H10O7	302.24	- (7.5 μM) b	- (47 μM) b	- (24 μM) b	- (22 μM) b	-	20-72c	8c	?	?	Has anti-cancer, anti-inflammatory, anti-allergic, anti-asthmatic, antihypertensive, analgesic, neuroprotective, gastroprotective, anti-diabetic, cardiovascular disease-preventing, antioxidant, antidepressant-like (in rat models of depression), anxiolytic-like, sedative, antimicrobial and athletic performance-promoting effects. Non-selective PDE1-4 inhibitor that is slightly selective for PDE3/4 over PDE1/2.
Rutin	0.3-1.6	1.2±2.1	266	6.43	C27H30O16	610.52	?	?	?	?	?	?	?	?	?	Has anticancer, cardioprotective, nephroprotective, antioxidant, anti-inflammatory, antidiabetic, procognitive and antilipidaemic effects.
Phenolic acids (~0.1%)
Caffeic acid	0.1	1.4±0.4	77.8	3.64	C9H8O4	180.16	?	?	?	-	?	?	?	?	?	Anticancer, hepatoprotective, antibacterial and antioxidant effects reported.
Chlorogenic acid	<0.1%	-0.36±0.43	165	3.33	C16H18O9	354.31	0	0	0	0	?	?	?	?	?	Antibacterial, anticancer and antioxidant effects have been demonstrated.

Acronyms and symbols

Acronym/Symbol	Meaning
MW	Molecular weight in g•mol−1.
PGP	P-glycoprotein
t1/2	Elimination half-life in hours
Tmax	Time to peak plasma concentration in hours
Cmax	Peak plasma concentration in mM
CSS	Steady state plasma concentration in mM
$\log{P}$	Partition coefficient. These values are experimental values taken from ChemSpider and (the access dates are both 13–15 December 2013) where available or, if they are not available approximations are taken from [www.chemaxon.com/download/marvin/for-end-users/ ChemAxon MarvinSketch] 6.1.4 &
PSA	Polar surface area of the molecule in question in square angstroms (Å2). Obtained from PubChem (the access date is 13 December 2013).
Conc.	These values pertain to the approximation concentration (in %) of the constituents in the fresh plant material
-	Indicates inhibition of the enzyme in question.
+	Indicates an inductive effect on the enzyme in question.
0	No effect on the enzyme in question.
5-HT	5-hydroxytryptamine — synonym for serotonin.
DA	Dopamine
NE	Norepinephrine
GABA	γ-aminobutyric acid
Glu	Glutamate
Gly	Glycine
Ch	Choline
a	Pharmacokinetic data for ECG comes from a study of its pharmacokinetics after oral administration of green tea.
b	Comes from this source.
c	Pharmacokinetic data for quercetin comes from a study using pure oral quercetin, not a St John's wort extract.

Notes:

Livestock

Poisoning

In large doses, St John's wort is poisonous to grazing livestock (cattle, sheep, goats, horses). Behavioural signs of poisoning are general restlessness and skin irritation. Restlessness is often indicated by pawing of the ground, headshaking, head rubbing, and occasional hindlimb weakness with knuckling over, panting, confusion, and depression. Mania and hyperactivity may also result, including running in circles until exhausted. Observations of thick wort infestations by Australian graziers include the appearance of circular patches giving hillsides a 'crop circle' appearance, it is presumed, from this phenomenon. Animals typically seek shade and have reduced appetite. Hypersensitivity to water has been noted, and convulsions may occur following a knock to the head. Although general aversion to water is noted, some may seek water for relief.

Severe skin irritation is physically apparent, with reddening of non-pigmented and unprotected areas. This subsequently leads to itch and rubbing, followed by further inflammation, exudation, and scab formation. Lesions and inflammation that occur are said to resemble the conditions seen in foot and mouth disease. Sheep have been observed to have face swelling, dermatitis, and wool falling off due to rubbing. Lactating animals may cease or have reduced milk production; pregnant animals may abort. Lesions on udders are often apparent. Horses may show signs of anorexia, depression (with a comatose state), dilated pupils, and injected conjunctiva.

Diagnosis

Increased respiration and heart rate is typically observed while one of the early signs of St John's wort poisoning is an abnormal increase in body temperature. Affected animals will lose weight, or fail to gain weight; young animals are more affected than old animals. In severe cases death may occur, as a direct result of starvation, or because of secondary disease or septicaemia of lesions. Some affected animals may accidentally drown. Poor performance of suckling lambs (pigmented and non-pigmented) has been noted, suggesting a reduction in the milk production, or the transmission of a toxin in the milk.

Photosensitisation

Most clinical signs in animals are caused by photosensitisation. Plants may induce either primary or secondary photosensitisation:

• primary photosensitisation directly from chemicals contained in ingested plants
• secondary photosensitisation from plant-associated damage to the liver.

Araya and Ford (1981) explored changes in liver function and concluded there was no evidence of Hypericum-related effect on the excretory capacity of the liver, or any interference was minimal and temporary. However, evidence of liver damage in blood plasma has been found at high and long rates of dosage.

Photosensitisation causes skin inflammation by a mechanism involving a pigment or photodynamic compound, which when activated by a certain wavelength of light leads to oxidation reactions in vivo. This leads to lesions of tissue, particularly noticeable on and around parts of skin exposed to light. Lightly covered or poorly pigmented areas are most conspicuous. Removal of affected animals from sunlight results in reduced symptoms of poisoning.

Chemistry

Detection in body fluids

Hypericin, pseudohypericin, and hyperforin may be quantitated in plasma as confirmation of usage and to estimate the dosage. These three active substituents have plasma elimination half-lives within a range of 15–60 hours in humans. None of the three has been detected in urine specimens.

Chemical constituent

Chemical structure of hypericin

The plant contains the following:

• Flavonoids (e.g. epigallocatechin, rutin, hyperoside, isoquercetin, quercitrin, quercetin, amentoflavone, biapigenin, astilbin, myricetin, miquelianin, kaempferol, luteolin)
• Phenolic acids (e.g. chlorogenic acid, caffeic acid, p-coumaric acid, ferulic acid, p-hydroxybenzoic acid, vanillic acid)
• Naphthodianthrones (e.g. hypericin, pseudohypericin, protohypericin, protopseudohypericin)
• Phloroglucinols (e.g. hyperforin, adhyperforin)
• Tannins (unspecified, proanthocyanidins reported)
• Volatile oils (e.g. 2-methyloctane, nonane, 2-methyldecane, undecane, α-pinene, β-pinene, α-terpineol, geraniol, myrcene, limonene, caryophyllene, humulene)
• Saturated fatty acids (e.g. isovaleric acid (3-methylbutanoic acid), myristic acid, palmitic acid, stearic acid)
• Alkanols (e.g. 1-tetracosanol, 1-hexacosanol)
• Vitamins & their analogues (e.g. carotenoids, choline, nicotinamide, nicotinic acid)
• Miscellaneous others (e.g. pectin, β-sitosterol, hexadecane, triacontane, kielcorin, norathyriol)

The naphthodianthrones hypericin and pseudohypericin along with the phloroglucinol derivative hyperforin are thought to be among the numerous active constituents. It also contains essential oils composed mainly of sesquiterpenes.

Selected chemical constituents of Hypericum perforatum

• 

  Hypericin

• 

  Pseudohypericin

• 

  Adhyperforin

• 

  Hyperforin

• 

  Amentoflavone

• 

  Hyperoside

• 

  Rutin

• 

  Kaempferol

• 

  Myricetin

• 

  Quercetin

• 

  Quercetrin

• 

  Isoquercitrin

• 

  Luteolin

• 

  Catechin

• 

  Epicatechin

• 

  Epigallocatechin

• 

  Chlorogenic acid

• 

  Caffeic acid

• 

  Kielcorin

• 

  Norathyriol

Research

St John's wort is being studied for effectiveness in the treatment of certain somatoform disorders. Results from the initial studies are mixed and still inconclusive; some research has found no effectiveness, other research has found a slight lightening of symptoms. Further study is needed and is being performed.

A major constituent chemical, hyperforin, may be useful for treatment of alcoholism, although dosage, safety and efficacy have not been studied. Hyperforin has also displayed antibacterial properties against Gram-positive bacteria, although dosage, safety and efficacy has not been studied. Herbal medicine has also employed lipophilic extracts from St John's wort as a topical remedy for wounds, abrasions, burns, and muscle pain. The positive effects that have been observed are generally attributed to hyperforin due to its possible antibacterial and anti-inflammatory effects. For this reason hyperforin may be useful in the treatment of infected wounds and inflammatory skin diseases. In response to hyperforin's incorporation into a new bath oil, a study to assess potential skin irritation was conducted which found good skin tolerance of St John's wort.

Hypericin and pseudohypericin have shown both antiviral and antibacterial activities. It is believed that these molecules bind non-specifically to viral and cellular membranes and can result in photo-oxidation of the pathogens to kill them.

See also

• Dietary supplement
• EU Food supplements directive
• List of plants poisonous to equines

Further reading

• British Herbal Medicine Association Scientific Committee (1983). British Herbal Pharmacopoeia. West Yorkshire: British Herbal Medicine Association. ISBN 0-903032-07-4.

External links

• Species Profile — St. Johnswort (Hypericum perforatum), National Invasive Species Information Center, United States National Agricultural Library. Lists general information and resources for St John's wort.