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Interactions between Esomeprazole and St. john's wort

1 drug interaction and 7 additional warnings found for the following 2 drugs:

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Drug interactions

Moderate drug interactions

Moderate:

St. John's wort esomeprazole

Applies to: st. john's wort and esomeprazole
Generally avoid

Coadministration with potent inducers of CYP450 2C19 and/or 3A4 may significantly decrease the plasma concentrations of omeprazole, which is primarily metabolized by these isoenzymes. In a study consisting of 12 healthy male subjects, administration of omeprazole in combination with St John's wort (300 mg three times daily for 14 days) decreased omeprazole peak plasma concentration (Cmax) and systemic exposure (AUC) in CYP450 2C19 poor metabolizers by 37.5% and 37.9%, respectively, and in extensive metabolizers by 49.6 % and 43.9%, respectively. The interaction is likely to also occur with esomeprazole, an enantiomer of omeprazole.

Management

The concomitant use of omeprazole or esomeprazole with St. John's wort or rifampin should generally be avoided.

References (3)
  1. (2022) "Product Information. PriLOSEC (omeprazole)." Merck & Co., Inc
  2. (2001) "Product Information. Nexium (esomeprazole)." Astra-Zeneca Pharmaceuticals
  3. Cerner Multum, Inc. "Australian Product Information."

Food/lifestyle interactions

Moderate food/lifestyle interactions

Moderate:

St. John's wort Food/Lifestyle

Applies to: st. john's wort
Generally avoid

An isolated case report suggests that foods containing large amounts of tyramine may precipitate a hypertensive crisis in patients treated with St. John's wort. The mechanism of interaction is unknown, as St. John's wort is not thought to possess monoamine oxidase (MAO) inhibiting activity at concentrations achieved in vivo. The case patient was a 41-year-old man who had been taking St. John's wort for seven days prior to presentation at the emergency room with confusion and disorientation. The patient recalled last eating aged cheese and having a glass of red wine approximately 10 hours prior to admission. No other cause of delirium or hypertension could be identified. In addition, alcohol may potentiate some of the pharmacologic effects of St. John's wort. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

Management

Until further information is available, patients treated with St. John's wort should consider avoiding consumption of protein foods in which aging or breakdown of protein is used to increase flavor. These foods include cheese (particularly strong, aged or processed cheeses), sour cream, wine (particularly red wine), champagne, beer, pickled herring, anchovies, caviar, shrimp paste, liver (particularly chicken liver), dry sausage, figs, raisins, bananas, avocados, chocolate, soy sauce, bean curd, yogurt, papaya products, meat tenderizers, fava beans, protein extracts, and dietary supplements. Caffeine may also precipitate hypertensive crisis so its intake should be minimized as well. Patients should also be advised to avoid or limit consumption of alcohol.

References (1)
  1. Patel S, Robinson R, Burk M (2002) "Hypertensive crisis associated with St. John's Wort." Am J Med, 112, p. 507-8
Moderate:

esomeprazole Food/Lifestyle

Applies to: esomeprazole
Adjust dosing interval

Food may interfere with the absorption of esomeprazole. The manufacturer reports that the area under the concentration-time curve for esomeprazole following a single 40 mg dose was 33% to 53% lower when administered after food intake as opposed to during fasting conditions.

Management

Esomeprazole should be taken at least one hour before meals. When administered to patients receiving continuous enteral nutrition, some experts recommend that the tube feeding should be interrupted for at least 1 hour before and 1 hour after the dose of esomeprazole is given.

References (2)
  1. (2001) "Product Information. Nexium (esomeprazole)." Astra-Zeneca Pharmaceuticals
  2. Wohlt PD, Zheng L, Gunderson S, Balzar SA, Johnson BD, Fish JT (2009) "Recommendations for the use of medications with continuous enteral nutrition." Am J Health Syst Pharm, 66, p. 1438-67

Disease interactions

5 potential interactions Applies to: 5 conditions, including Osteoporosis, Diarrhea, Liver Disease, Pseudomembranous Colitis, and Magnesium Imbalance.

Diarrhea

Major:

esomeprazole

Esomeprazole has a major potential interaction with Diarrhea.

Published observational studies suggest that proton pump inhibitor (PPI) use may be associated with an increased risk of Clostridium difficile-associated diarrhea (CDAD), especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve. It is recommended that patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Close monitoring is recommended in patients with diarrhea and in those taking antibacterial agents as CDAD has been reported with the use of nearly all these agents. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

Liver Disease

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Liver Disease.

Esomeprazole is primarily metabolized by the liver. In patients with mild to moderate hepatic impairment (Child Pugh Class A and B), little drug accumulation has been observed following once-daily, multiple-dose administration. No dosage adjustments are necessary in these patients. In severe hepatic impairment (Child Pugh Class C), however, substantial increases in plasma drug concentrations have been demonstrated. The manufacturer recommends a maximum dosage of 20 mg once daily in patients with severe liver disease.

Magnesium Imbalance

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Magnesium Imbalance.

Symptomatic and asymptomatic hypomagnesemia has been reported rarely in patients treated with PPIs for at least 3 months, in most cases after a year of therapy. Serious adverse events can include tetany, seizures, and arrhythmias. Caution should be used in patients prone to magnesium imbalances such as patients taking other medications that can cause hypomagnesemia (e.g., diuretics). Regular monitoring is recommended.

Osteoporosis

Moderate:

esomeprazole

Esomeprazole has a moderate potential interaction with Osteoporosis.

Various published observational studies have reported that PPI therapy may be associated with an increased risk for osteoporosis related fractures of the hip, wrist or spine. The risk was increased in patients who received high doses (multiple daily doses), and long term treatment (a year or longer). Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Caution should be used in patients at risk for osteoporosis related fractures and should be managed according to established treatment guidelines.

Pseudomembranous Colitis

Major:

esomeprazole

Esomeprazole has a major potential interaction with Pseudomembranous Colitis.

Published observational studies suggest that proton pump inhibitor (PPI) use may be associated with an increased risk of Clostridium difficile-associated diarrhea (CDAD), especially in hospitalized patients. This diagnosis should be considered for diarrhea that does not improve. It is recommended that patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated. Close monitoring is recommended in patients with diarrhea and in those taking antibacterial agents as CDAD has been reported with the use of nearly all these agents. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

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More resources

esomeprazole

A total of 236 drugs are known to interact with esomeprazole.

st. john's wort

A total of 674 drugs are known to interact with st. john's wort.

Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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