|Michael Arnold, MD, Chinese herbal medicine practitioner, Pacific Grove, CA. |
NEW ORLEANS—Chinese herbal medicine can offer your patients many clinical benefits, but it must not be approached casually, said Michael Arnold, MD, at the annual meeting of the American Academy of Medical Acupuncture.
Many of the widely reported problems with Chinese herbs—including the incidents of nephrotoxicity in a Belgian clinic that resulted in a recent FDA ban of all herbs containing aristolochic acid—result from improper use of these herbs outside the context of the Chinese diagnostic system, and without supervision from a trained Chinese herbalist.
Dr. Arnold, a pediatrician in Pacific Grove, CA, who now practices Chinese herbal medicine exclusively, said too many American physicians (and patients) take a naive or overly-simplistic approach to what is a highly sophisticated diagnostic and therapeutic canon.
"To say, for example, that astragalus (Huang Qi), 'boosts the immune system' is a vast over-simplification which respects neither the subtleties of when to use the herb nor the potential problems with the herb's action. The statement that, 'Ginseng (Ren Shen) is good for fatigue,' has about the same level of sophistication as the statement that, 'Cimetidine is good for coughs.'"
Indeed, cimetidine is good for certain coughs—those tied to gastroesophageal reflux. Likewise, ginseng improves some types of fatigue, and astragalus can increase certain immune functions. But the effects are quite specific. Chinese medicine is definitely not a one-size-fits-all system.
In the Chinese approach, fatigue may be due to an energy deficiency in one or more of the psychophysiologic systems defined by the Chinese medical construct. But it could also be due to excesses—of "phlegm" or of "damp heat" for example.
Ginseng, considered an energy tonic or strengthener, works well when there are particular deficiencies. But when symptoms reflect some sort of excess, use of a strong tonic like ginseng could make matters worse.
The key point is, Chinese herbal therapies evolved out of Chinese—not Western allopathic—diagnostic criteria. Problems arise when one uses them without understanding the patterns they are intended to treat. This is an important message to relay to patients interested in Chinese herbs. Dr. Arnold offered the following suggestions to physicians wishing to explore the potential of traditional Chinese herbal medicine:
• Be Honest with Yourself and Your Patients: There is nothing wrong with admitting you do not know something, and there is no 11th Commandment obliging you to become an expert on Chinese herbs. What you must know is your limits. Be open to people who have greater expertise. If a patient asks if a particular Chinese formula is safe or effective, answer honestly. Do not avoid discussion simply because you do not want to appear ignorant.
• Make Friends with an Herbalist: The vast majority of serious adverse effects occur when people use Chinese herbs without guidance of a knowledgeable herbalist. Friendly relations with one or more herbal practitioners can be a tremendous asset. As far as training, the standard in the US is a master's level degree in Chinese or Oriental medicine, but Dr. Arnold said many excellent herbalists practice under acupuncture licenses (L.Ac).
Begin by simply calling people in your area who advertise herbal practices and asking questions about how they use various herbs or view certain symptom patterns. Make an office visit and experience herbal treatment yourself. Dr. Arnold recommends looking for someone with years of experience, who primarily practices herbal medicine—those with very broad practices may not have sufficient mastery. After a while, you'll sense who will be a good herbal colleague to whom you can refer.
• Don't Let Degrees Get in the Way: Though it evolved from "folk" tradition, Chinese herbal medicine is highly sophisticated. It is based on a coherent and extremely rational system of diagnosis that takes years to master. The absence of an "MD" or "DO" next to someone's name is not an invitation for condescension. Approach TCM practitioners with collegial respect and open-mindedness and you will benefit your patients and learn quite a bit yourself.
• Follow Classical Guidelines: Many adverse events with Chinese herbs are due to excessive doses or prolonged use. These consequences are often described in the classical Chinese texts. Dr. Arnold cited a number of recent cases, including one of neonatal androgenization that resulted from a mother's self-medication with Siberian ginseng at twice the recommended dose for a year and a half.
With the exception of certain tonic formulas which can be used every day for indefinite periods, most Chinese herbs should only be used in short courses. "I was taught not to 'refill' an herbal prescription beyond two weeks." said Dr. Arnold. "The patient's clinical situation may have changed and you need to re-evaluate."
• All Herbs Are Not Created Equal: Allopathic pharmacology recognizes some compounds as generally safe for sale over-the-counter, while others must be carefully regulated. Chinese herbal medicine has similar distinctions, though US regulators don't recognize them. Some herbs are unlikely to cause harm even in large doses; others, like ephedra or aconite have narrow therapeutic windows, and should never be used for self-medication. "In China, some herbs are only administered in hospitals."
• All Patients Are Not Created Equal: As with foods, idiopathic reactions occasionally occur after administration of Chinese herbs. Patients with multiple food allergies are probably not good candidates for Chinese herbs. People with significant hepatic or renal disease are also not good candidates, since their abilities to metabolize and excrete herbal medicines is compromised. Elderly patients may also have problems processing herbs, owing to age-related metabolic changes.
While nearly all Chinese herbal formulas are safe for children, doses must be carefully tailored. A few herbs like rhubarb are specifically contraindicated in pregnancy. In China, it is common for pregnant women to take herbs. But given the medicolegal climate in this country, Dr. Arnold urged extreme caution.
• Learn a Few Basics: Only a handful of Chinese herbs are in wide use in the US: learn their basic properties and how they should and should not be used (see related story).
• Know the Botanical Suppliers: Like all medicines, Chinese herbs must be prepared properly. Some are toxic in their raw state and require specific processing to detoxify them. In general, Chinese herbals should be tested for purity, absence of heavy metals and microbial contaminants, and prepared in accordance with stated formulas.
Unless you are very familiar with Chinese, Taiwanese or Hong Kong-based manufacturers and know which companies apply stringent quality control, Dr. Arnold said it is better to stick with US, European, or Japanese suppliers. There are many good ones, he said, but he is most familiar with the following: K'an Herb Co.; Health Concerns; Three Treasures; East-West Herbs; Golden Flower (for loose herbs); KPC, and Brion/Sun Ten.