Prescrire international
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Prescrire international · Oct 2004
Comparative StudySt John's wort and depression: slight efficacy at best, many drug interactions.
(1) St John's wort has been widely used for centuries as a herbal remedy. Dozens of trials, of variable quality, have examined the therapeutic value of St John's wort. Published meta-analyses show that St John's wort extracts are more effective than placebo in patients with mild and moderate depression. (2) Trials show that St John's wort is about as effective as tricyclic and serotonin reuptake inhibitor antidepressants. (3) There is insufficient evidence to determine the efficacy of St John's wort in patients with more severe depression. (4) Few, mostly minor adverse effects have been reported, but there may be a small risk of serotonin syndrome and cutaneous photosensitisation. (5) Some components of St John's wort interfere with CYP3A4, one of the main cytochrome P450 isoenzymes. ⋯ St John's wort reduces the efficacy of several drug groups including: immunosuppressants (risk of graft rejection), oral contraceptives (risk of pregnancy), oral anticoagulants (risk of thrombosis), and HIV protease inhibitors. It can also reduce the bioavailability of digoxin. (6) In practice, St John's wort is an inappropriate treatment for severe depression. It is, however, an acceptable option for short-term management of transient depressed mood when there is no risk of drug interactions and when the patient is properly informed of this risk. (7) In short, the risk-benefit balance of St John's wort is no better than that of standard antidepressants, mainly because of the risk of drug interactions.
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Prescrire international · Oct 2004
Gefitinib: new preparation. Non small-cell lung cancer: stricter assessment needed.
(1) Platinum-based chemotherapy is generally used to treat advanced-stage non small-cell lung cancer (stages III and IV), but has only a modest impact on survival. There is no reference treatment. (2) Gefitinib inhibits the tyrosine kinase activity of the receptor for EGF (epidermal growth factor), which is thought to be involved in tumour growth. ⋯ The most frequent were gastrointestinal (diarrhea, nausea, vomiting) and cutaneous (rash, acne, dry skin, pruritus). (6) Interstitial pneumonitis occurred in about 1% of patients, and was fatal in about one-third of cases. (7) Gefitinib is metabolised by the cytochrome P450 isoenzyme CYP3A4, so carries a potentially high risk of interactions. (8) In practice, more thorough assessment of gefitinib is needed to determine whether this new drug is beneficial for patients with non small-cell lung cancer. Marketing authorisation is not currently justified.