Q134] A 55 year-old woman comes to your office complaining of sweating, headache, nausea and vomiting. This happened shortly after her lunch. She had some grape fruit juice and redwine with her lunch. She had She has a long history of depression but she does not believe in conventional antidepressants. She is not being medically treated for depression and anxiety however, she has been using over the counter herbal medicine for her depression. Which of the following is the most likely medication she has been using ?
a] Ginkgo biloba
b] Kava – Kava
c] St.johns wort
d] Ephedra
e] Yohimbine
Archer USMLE Step 3 Blog 
good one
ephedra?
c- 100%
E, Yohimbe ,not Yohimbine (this is used to reverse xyalzine)
Yohimbe–Yohimbe blocks monoamine oxidase (MAO), dopamine and serotonin. Blocking MAO can help with depression. here combine with “RED WINE” then……
c, grapefruit juice inhibit cyp350 and reacts with st john’s wort
c
this question is genius . hahaha
Yohimbine and st john’s wort can cause the same effect
red wine and P450 inhibitor via grapefruit juice .
But the twist that St john’s wort is most commonly used as herbal anti depression compared to yohimbine( most commonly used to tx male impotence)
So i guess the answer should be st john’s wort . hahah
Gud logic. St.J. w.
Dr.Red please explain
cc
This is quite a tricky question indeed. So, there are 2 scenarios, and we can look from 2 perspectives:
From Pharmacological perspective:
1. The Grapefruit juice, acts as a P450 inhibitor -> Increases the toxicitiy of St.John’s Wort.
2. The Redwine, releases tyramine -> Yohimibine is an MAOI, so increased NE in the synaptic clefts -> Sympathetic stimulation (kinda like a mild HTN crisis)
From the most commonly used herb perspective:
1. St John Wort is used commonly to treat depression.
2. Yohimbine is commonly used to treat erectile dysfunction, and can be given safely with SSRI.
My answer is Yohimbine(E). There are 2 reasons:
1. The question actually is “Which of the following is the most likely medication she has been using”. Its not “Which of the following medication is used to treat depression”.
2. St john Wort in itself is an INDUCER of P450. Grapefruit juice is an INHIBITOR of P450. I think if you put both an Inducer and Inhibitor of P450 at the same time, the result will be unequivocal. There shouldnt be a net effect.
Hope it helps, and any comments are appreciated.
References:
First Aid Step 1, Pharmacology chapter.
Wikipedia, on the effects of Yohimbine and St John Wort interactions.
From the question: she has been using over the counter herbal medicine for her depression.
Therefore, the answer should be C.
Yohimbine –used for erectile dysfunction BUT this is a female –incorrect answer
St. John’s wort commonly used for Depression as in this Patient may increase the risk of serotonin syndrome. Cognitive effects: headache,
Autonomic effects: shivering, sweating, hyperthermia, nausea and vomiting.
C- st john wort
Unlikely due to Yohimbine because unlikely SHE needs it for erectile dysfunction and she never was MEDICALLY treated for depression and anxiety, so where did she get the Rx for Yohimbine?
My diagnostic suspicion: Tyramine toxicity (MAO toxicity), early onset Serotonin Syndrome
My answer is C. The most common non conventional antidepressant is St John’s wort. It is a serotonin uptake inhibitor and also a weak mono amine oxidase inhibitor.
(http://www.ncbi.nlm.nih.gov/pubmed/11155494)
Tyramine in Redwine can elevate serotonin activity in the brain.
St John’s wort elevates serotonergic activity like conventional antidepressants.
This patient needs IV hydration, close monitoring, sedation and counseling.
Question 1. Should we stop St John’s wort right now? Yes? No?Depends? No, I would not have to if she gets better. I would prefer to tapper it down (if neccessary), not stop it completely. She has been sensitized at central receptor level, therefore she has been on St John’s wort for at least 2 weeks. (Her withdrawal symptoms can overlap with her current presentation and this can make it difficult to some of here symptoms like anxiety, restlessness, nausea).
Why is St John’s wort a big issue among clinicians?
1. It causes graft rejection in patients on cyclosporin treatment.
2. It causes unwanted pregnancies in patients on oral contraceptives.
3. It causes HIV treatment failure or elevation of HIV Viral Load on HAART treatment.
4. It causes cancer treatment failure and remission.
Thank you.
Some interesting reads;
Serotonin-
http://www.ncbi.nlm.nih.gov/books/NBK27940/
Cytochrome P450s- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312247/#!po=78.5714
Herb-drug interactions with St. John’s wort- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782080/#!po=10.0000