St John’s wort — an ethical dilemma

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                   Broad spectrum                      (

St John’s wort — an ethical dilemma?
By Alison Blenkinsopp, professor of the practice of pharmacy at the department of medicines management, Keele University

     t John’s wort poses a dilemma to com-                 tions of interacting drugs may increase, lead-     ■ Are there any ethical conflicts in stocking

S    munity pharmacists in their everyday
     practice. It is a dilemma for several rea-
sons: it is not a licensed medicine; there is a
                                                           ing to toxicity. Antidepressants should not be
                                                           used with St John’s wort because of the po-
                                                           tential for interaction.”
                                                                                                                this product?
                                                                                                              ■ Is it ethical to sell a product in response to
                                                                                                                a request but not be prepared to advise on
debate about its clinical effectiveness and                    Thus the BNF highlights the safety issues        the use of that product?
about which constituent might be responsible               and directs readers to its section on interac-
for any clinical effect; there is evidence of risk         tions. A Royal Pharmaceutical Society fact-            It could be argued that if community phar-
from interactions with other medicines; and                sheet for pharmacists on St John’s wort also       macies do not stock and advise on St John’s
there are issues about pharmaceutical quality              summarises safety issues and makes sugges-         wort the potential risks to the public would be
of products containing St John’s wort, so that             tions about appropriate questions to ask peo-      increased. Unlike pharmacies, health food
obtaining dose accuracy and consistency is                 ple who request St John’s wort.                    shops are not subject to requirements of train-
difficult. Finally, but importantly, if there is               A Cochrane review of St John’s wort states:    ing or ethics and their advice is unregulated.
evidence of clinical effectiveness for St John’s           “There is evidence that extracts of hypericum      There is no British research on the quality of
wort, should a pharmacist attempt to “diag-                are more effective than placebo for the short-     advice about St John’s wort from staff in health
nose” depression, or to confirm a customer’s               term treatment of mild to moderately severe        food shops but a US study2 concluded:“Their
self-diagnosis? Or is the treatment of depres-             depressive disorders.The current evidence is in-   comments could cause significant harm to cus-
sion something which only doctors should                   adequate to establish whether hypericum is as      tomers.” The internet is a key vehicle for the
advise on? Despite all of this St John’s wort              effective as other antidepressants.”               supply of St John’s wort and the quality of in-
has a powerful lay reputation as a “natural” al-               Finding authoritative information about        formation supplied is unknown. As the “ex-
ternative to “chemical” antidepressants.                   active constituents and appropriate doses is       perts on medicines” and public health
                                                           more challenging. The PRODIGY guideline            advocates on the high street, should pharma-
Requests for St John’s wort                                on depression summarises the evidence, safety      cists not be ready to provide decision support
So how, when faced with a request relating to              and pharmaceutical quality issues but does         and help the public navigate a path through
St John’s wort, should a community pharma-                 not comment on dosage. Furthermore there           areas where the evidence is not clear and de-
cist react? Should a community pharmacist                  remains the issue about how a pharmacist           finitive? Barnes suggests: “Pharmacists are well
even be stocking St John’s wort given the is-              would differentiate between mild to moder-         placed to advise patients on the safe, effective
sues surrounding it?                                       ate depression (for which evidence indicates       and appropriate use of St John’s wort and other
    Pharmacists or medicines counter assistants            St John’s wort may help) and severe depres-        herbal products, and to assist patients in select-
might be asked for St John’s wort by name, for             sion (for which the evidence is clear that St      ing products of suitable quality.”3 Or is it unac-
an opinion on its effectiveness, or about                  John’s wort does not help). Suggesting that a      ceptable to use risk minimisation as a reason
whether they would recommend it for depres-                person might consult their GP is one option        for doing things that are less than ideal?
sion. Research has shown that pharmacists are              but some people do not want to seek medical            Pharmacists also need to think about how
indeed asked about all of these.1 The research             advice, particularly for mild depression.          they might be judged if things go wrong or a
findings indicate that pharmacists’ attitudes to-                                                             complaint is made, not just in relation to St
wards, and their knowledge about, potential                Ethical obligations                                John’s wort but to any medicine sold to the
therapeutic benefits and risks from St John’s              So can community pharmacists fulfil their          public. It would be important for a pharmacist
wort are variable. Pharmacists showed aware-               ethical obligations in relation to advice on,      to be able to show that a decision-
ness of the symptoms and signs of depression               and sales of, St John’s wort? A possible frame-    making process had been undertaken rather
and how these differed in severe depression.               work for considering a policy on St John’s         than a sale by default, and for that process to be
    A Consumers’ Association study criticised              wort for your pharmacy might be:                   transparent. It would also be important to show
the advice given by five of 21 pharmacists                                                                    that they had assessed the possible risks and for-
about St John’s wort and potential interaction             ■ Am I prepared and competent to advise            mulated appropriate responses to customer re-
with the combined oral contraceptive pill.                   on St John’s wort?                               quests, and ensured staff were familiar with
Although the design of the scenario used has               ■ Is it appropriate for my medicines counter       these.These are the principles of clinical gover-
been criticised the study nevertheless raised                assistants to deal with St John’s wort re-       nance as applied to over-the-counter medicine
issues about consistency of approach and ad-                 quests? (If yes, are they prepared and com-      sales. How does your pharmacy measure up?
vice about St John’s wort.                                   petent to do so?)
    Pharmacists have an ethical responsibility             ■ Does my pharmacy’s process for dealing           ACKNOWLEDGEMENT I am grateful to
for currency of knowledge about any medi-                    with St John’s wort systematically min-          Michelle King (see p302), Kristian Pollock,
cines that they offer for sale or supply to the              imise risk to individuals who purchase it?       Janet Grime and Zuzana Deans for discussions
public. As BNF No 28 points out: “St John’s                ■ Can I (and my staff) recognise severe de-        about issues and concepts raised here.
wort (Hypericum perforatum) is a popular                     pression to provide a basis for referral?
herbal remedy for treating mild depression.
However, preparations of St John’s wort can                   More fundamental questions when con-            References
induce drug metabolising enzymes and a                     sidering whether to stock and supply certain       1. Landers M, Blenkinsopp A, Pollock K, Grime J. Community
number of important interactions with con-                 products might be:                                    pharmacists and depression: the pharmacist as
ventional drugs have been identified, see                                                                        intermediary between patient and physician. International
                                                                                                                 Journal of Pharmacy Practice 2002;10:253–65.
Appendix 1 (St John’s wort). The amount of                 ■ If I do not know, or do not believe, that
                                                                                                              2. Glisson JK, Rogers HE, Abourashed EA, Ogletree R, Hufford
active ingredient can vary between different                 this product works, should I stock it?              CD, Khan I. Clinic at the health food store? Employee
preparations of St John’s wort and switching               ■ How should I respond to individuals who             recommendations and product analysis. Pharmacotherapy
from one to another can change the degree of                 ask for my opinion about whether this               2003;23:64–72.
enzyme induction. Furthermore, when a pa-                    product works or whether it is worth pur-        3. Barnes J. St John’s wort is hypericum (letter). The
tient stops taking St John’s wort, concentra-                chasing?                                            Pharmaceutical Journal 2001;266:538.

296   The Pharmaceutical Journal (Vol 274) 12 March 2005                                                                            

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