Interactions Between SSRIs and Herbal Supplements

Critical Contraindications

The American Heart Association recommends that patients taking SSRIs should avoid St. John's wort due to documented cases of life-threatening serotonin syndrome 1, 2
St. John's wort inhibits serotonin, norepinephrine, and dopamine reuptake while also being a strong CYP3A4 inducer, creating both pharmacodynamic and pharmacokinetic interactions with SSRIs 1, 2
The American College of Cardiology/American Heart Association hypertension guidelines recommend that patients on SSRIs should avoid Ma Huang (ephedra) and yohimbine 3
L-tryptophan supplements increase serotonin syndrome risk when combined with SSRIs and should be held for 24 hours perioperatively 4
SAM-e (S-adenosylmethionine) increases serotonin turnover and should be avoided or held for 24 hours before procedures 1, 2

Turmeric inhibits platelet aggregation via thromboxane metabolism and should be held for 2 weeks perioperatively 1, 2
Policosanol has antiplatelet effects equivalent to 100 mg aspirin at 20 mg doses 1, 2
Saw palmetto may increase bleeding time 1, 2

Valerian can be considered for continuation as it works through GABA mechanisms rather than serotonin, though it lacks strong efficacy data 1, 2
Melatonin can be continued and may reduce perioperative anxiety without significant SSRI interactions 4
Lavender has shown safety in perioperative settings without potentiating serotonergic effects 4
Passionflower can be continued for anxiety with a good safety profile 2, 4

The American College of Cardiology recommends directly asking about all herbal supplements, over-the-counter products, and dietary supplements at every visit 6, 7
If patients are taking St. John's wort, Ma Huang/ephedra, yohimbine, L-tryptophan, or SAM-e with SSRIs, discontinue immediately 1, 2, 3, 4
Assess patient's baseline bleeding risk for supplements with bleeding risk (ginkgo, garlic, ginger, turmeric) 1, 2
Consider discontinuation if patient has additional bleeding risk factors 1, 2
Hold supplements with bleeding risk for 2 weeks before any surgical procedures 1, 2

If serotonin syndrome develops, immediately discontinue all serotonergic agents including the SSRI and any herbal supplements 6, 7
Provide hospital-based supportive care with continuous cardiac monitoring 7
Administer IV fluids and manage hyperthermia 6
Consider cyproheptadine (serotonin antagonist) in severe cases 7
Monitor for 2 weeks after discontinuation of offending agents 4