Integrating Chinese Medicine into everyday practice: 8 herbal formulas to start using now

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1 Integrating Chinese Medicine into everyday practice: 8 herbal formulas to start using now Lara K. Day, DVM CVA, DAAPM, CCRP, CVCH Using Chinese Herbs If you are thinking about using Chinese herbal formulas in practice, you most likely have already had some exposure to Chinese medicine theory. You may have read a book, gone to a lecture, been prescribed some yourself, or are trained in acupuncture. It is very easy to get weighed down by theory and odd terms such as yin, yang, qi, 5 element, 8 principals, etc. While it is very important to study theory, just as it is in conventional medicine, it is easier to understand once you start practicing. My recommendation is to start with the simple and work your way up to more complex. I simplify theory to the following four statements: If it is hot, cool it If it is cold, heat it If it is dry, moisten it If it is wet, dry it Then I add more complex ideas: If it is deficient, tonify it If it has excess, sedate/drain it If it is stagnant, move it The most complex part of practice of Chinese Medicine is learning how to look at the patient and seeing the possible layers of a disease process. This has been compared to peeling an onion. It will take some time to understand how a lifetime of poor diet can lead to Spleen Qi Deficiency, which can lead to Lung Qi Deficiency, then Kidney Qi Deficiency and in turn Kidney Yang Deficiency. Continual studying and practicing will get you there. Don t get too bogged down with Chinese theory and forget the conventional side. Do a Pub Med search, there are 1,000s of articles on acupuncture and Chinese herbs. It is harder to do a double blind study with Chinese Medicine as we are treating individuals not a disease, but it is important to know there is research out there. To begin practicing Chinese Medicine, I recommend learning the organs and channels. Look at tongue and feel pulses on every patient whether you plan on using Chinese Medicine or not. Do a quick body scan for hot, cold, damp or dry spots. If you know acupuncture, check for active points. Attempt to name a Chinese diagnosis and include this in your medical record.

2 In Chinese Medicine you are treating the whole patient, not just the disease. Western medicine does such a great job getting down to the cellular level to treat disease, which is wonderful when it works, but sometimes misses the forest for the trees. If there is a conventional medicine that works great for a condition, ie antibiotics, insulin, I use that first. But sometimes, those medicines do not completely cure or even manage a condition, so I turn to Integrative medicine in order to attack from both angles. Chinese Medicine is often an answer when a client asks if there is anything else that can be done for a patient. Chinese medical diagnosis Here is a quick summary (oversimplification) of the most common Chinese medical diagnosis seen in Veterinary Medicine. Kidney Qi Deficiency Kidney Qi Deficiency manifests as a general weakness and poor stamina, which tends to improve with rest. This weakness is especially noted in the lower back and rear legs. Increased thirst and urination occur. The pulse is weak and the tongue tends to be pale lavender and moist. The Kidneys lose their balance of Yin and Yang, becoming more Yin and thus cold, leading to Yang Deficiency. These patients have the same symptoms as Qi Deficiency, but also have a weak slow pulse, are chilly and often incontinent. Kidney Yin Deficiency Patients with Kidney Yin Deficiency have signs of empty heat because the weak Kidney Yin allows the Heart Yang to swing out of balance. These patients have a fast weak pulse (thready) and red dry tongues. They seek dark, cool places and will often pace and yowl or cry at night. These patients tend to have weight loss and muscle wasting despite a good appetite. It is confusing, but these patients can also have low back and rear leg weakness and pain and be incontinent, which is similar to Qi and Yang Deficiency. To help determine whether it is Qi, Yin or Yang deficiency, look for heat or cold signs. If still unsure, Kidney Qi deficiency is the best diagnosis until temperature signs predominate. Spleen Qi Deficiency The Chinese Spleen is a confusing organ because it really isn t the spleen as we know it. It is a more digestive organ in Chinese Medicine. These patients are weak and have signs of malabsorption, i.e. muscle wasting, small bowel diarrhea. Spleen Qi signs are similar to Kidney Qi Deficiency signs, but tend to be more digestive in nature. The Spleen is damaged by a diet with excessive carbohydrates, so look for a history of a diet of poor quality kibble. The tongue and pulse are variable, but often have a weak pulse with a pale, swollen, moist tongue. Damp Heat Damp is a Pathologic substance produced by a malfunctioning Spleen. It is an unusable fluid that can be discharged as mucous, exudate and skin oil, or trapped fluids such as edema or ascites, or it can be inert tissue such as excess body fat or congealed (Phlegm) as warts or lipomas. Damp in the tissues causes friction during the circulation of Blood and Qi, which leads to Heat. Damp Heat is exactly what it sounds like, red oozing often odiferous lesions. The tongue is often red, swollen and moist with tenacious saliva, while the pulse is swollen, wide and fast. Blood Deficiency Blood Deficiency is impaired peripheral circulation and may include anemia. Signs include dry itchy skin and hair coat, timid behavior that can include fear aggression, and crying and twitching during sleep. The ear tips and paws are often cooler that the rest of the body due to the decreased circulation. The tongue is small, pale and dry while the pulse is thin and slow.

3 Blood Heat Blood Heat appears in a patient as heat intolerance, agitation, severe itch, thirst and even hemorrhage. Unlike Damp Heat, these patients have dry lesions, although they could have been damp in the past, as Blood Heat can be a sequella to Damp Heat. The tongue tends to be brick red or dark purple and the pulse is fast and wiry. Stagnation Both Qi and Blood can stagnate and affect the organs (Liver) or the channels (Gall Bladder, Triple Burner). When Blood or Qi stagnate, pain results. This stagnation can lead to abnormal muscle and nerve function resulting in coughing and/or vomiting. It can lead to organ obstruction such as hepatomegally or splenomegally. This stagnation can affect movement of the limbs resulting in ataxia or hind limb paralysis. Qi stagnation generally occurs first and tends to have fleeting, variable pain. It will progress to Blood Stagnation, which tends to have fixed pain and visible lesions such as tumors or fibrosis. The tongue tends to be purple and swollen; the sublingual vasculature can especially be swollen and tortuous. The pulse tends to be wiry and hard to compress with an irregular rhythm. Great books to get you started: Four Paws Five Directions by Cheryl Schwartz Manual of Natural Veterinary Medicine by Susan G. Wynn and Steve Marsden Veterinary Acupuncture by Allen Schoen Veterinary Herbal Medicine by Susan G. Wynn and Barbara Fougere The book I can t live without: Chinese Medical Herbology & Pharmacology by Chen & Chen Classes: IVAS: online Chinese Herbal certification course Chi Institute: tcvm.com offers both on site and online in modules, certification available National meetings of AHVMA, AAVA, AVMA and regional and state meetings often include some lectures on Chinese Herbal Medicine VIN has offered herbal classes and has an alternative medicine forum (and has a Monthly acupuncture journal club) Herbal suppliers: Natural Path Herb Company: available in the US through A Time to Heal Herbs (Dr. Mona Boudreaux) Jing Tang Herbal (Dr. Xie) tcvmherbal.com Kan Herb Company Evergreen Herbs (Drs. Tina and John Chen)

4 Classic Herbal Formulas Ba Wei Di Huang Wan (Rehmannia Eight Combination) This is the quintessential kidney failure formula. This formal can be started in any case of canine or feline renal azotemia, although it is possible with differentiation of kidney disease to find a better fitting formula. This formula includes the following herbs: prepared Rehmannia root, Chinese Yam rhizome, Cornus fruit, Poria, Alisma tuber, Moutan bark, Cinnamon bark, prepared Aconite root. The patient this formula fits best is a chilly deficient dog or cat with renal azotemia and normal serum cholesterol (Kidney Qi or Yang Deficiency). The pulse tends to be weak and slow, and the tongue pale lavender and swollen. This combination of herbs warms the patient while nourishing Kidney Yin, Yang, Essence and Liver Yin and Blood. There are some great studies of using rehmannia increasing renal blood flow in patients with renal azotemia: Rehmannia glutinose ameliorates renal function in the ischemia/reperfusion-induced acute renal failure rats. Kang DG et al; Biological and Pharmaceutical Bulletin 2005 Sep;28(9): Protective effect of Hachimi-jio-gan against renal failure in a subtotal nephrectomy rat model Yamabe N et al; The Journal of Pharmacy and Pharmacology 2005 Dec; 57(12): In addition to chronic renal failure, patients that may benefit from using Rehmannia Eight Combination may have the following conditions: hypothyroidism, degenerative myelopathy, infertility, diabetes mellitus, and asthma. Si Miao San (Four Marvels Powder) This is the main formula I use in patients with Damp Heat. These are the dogs that constantly pant, have red swollen tongues, greasy skin and ears with an odor. These dogs do worse on warm, damp days. The ingredients are as follows: Atractylodes rhizome, Achryanthes root, Coix seed, Phellodendron bark. This formula supports the Spleen, as a weak Spleen is the primary source of Damp. Diseases that may respond to the use of Four Marvels Powder include inflammatory conditions such as: colitis, cystitis, arthritis, suppurative vaginitis, yeast otitis externa, moist pyoderma, allergic dermatitis, seborrhea oleosa, recurrent pancreatitis, glomerulonephritis, pododermatitis, immune thromobocytopenia, and anal sacculitis. It may also benefit in cases with hyperadrenocorticism, degenerative myelopathy, epilepsy, lymphoma, and vestibular syndrome. San Ren Tang (Three Seeds Decoction) This is another formula that I use in patients with Damp Heat. I tend to use this one for patients that show more signs of damp and Four Marvels Powder for ones with more heat. This formula is mild tasting unlike Four Marvels because it does not include the very bitter tasting Phellodendron, so it is much easier to give to cats. This formula includes the following herbs: Apricot seed, Coix seed, Talc, Pinellia rhizome, Round Cardamon, Lopatherum, Magnolia bark, Rice Paper pith. Patients with the following conditions may benefit from the use of Three Seeds Decoction: asthma, urolithiasis, inflammatory bowel disease, gastritis, constipation, inappropriate urination, cystitis, allergic dermatitis and yeast otitis externa. Si Wu Tang (Four Materials Decoction) This formula can be used in all cases of Blood Deficiency. These are the dogs that have dry skin and hair, pale gums, cry and run while dreaming, and possibly anemic. Dogs with Liver Blood deficiency are the ones who bark yet run away, bite when you turn your back, and bully smaller pets. This formula contains

5 the following herbs: Cooked Rehmannia, Angelica sinensis, White Peony, Ligusticum. These herbs nourish the Blood and have a mild warming effect to quicken the flow. Avoid use in patients with Damp Heat. Conditions that may respond to treatment with Four Materials Decoction include: seborrhea sicca, keratoconjunctivitis sicca, allergic dermatitis, otitis externa, recurrent superficial pyoderma, separation anxiety, noise phobias, and fear aggression. Xiao Chai Hu Tang (Minor Bupleurum Combination) This is one of the world s oldest still used herbal formula as it was published in the Shang Han Lun around 200 AD. It was developed to treat Stagnation of the Triple Burner. This stagnation will lead to Yang energy entrapment in the upper burner leading to Qi deficiency and a cool lower burner. These patients often have a painful abdomen, coughing and/or vomiting, and a weak hind end. They appear to have a mixture of Yin Deficiency, Qi Deficiency and Stagnation. Their tongue and pulse are variable but often have a lavender tongue with a wiry pulse. I use this formula for patients in kidney failure that have an elevated serum cholesterol in addition to azotemia. I also use it for patients with hind limb ataxia or paralysis if I notice an improved pulse when needling acupuncture points GB 30 or 34, which is a sign of Stagnation in the Gall Bladder channel. The formula has the following herbs: Bupleurum root, Scutellaria root, Pinellia rhizome, Licorice root, Ginger rhizome, Jujube, Ginseng root. Patients with the following conditions may respond to treatment with Minor Bupleurum Combination: hypoadrenocorticism, encephalitis, lymphoma, chronic active hepatitis, pneumonia, pyelonephritis, glomerulonephritis, lyme disease, hip dysplasia, partial ACL tear, hind limb paralysis, and flank pain. Xue Fu Zhu Yu Tang (Persica and Carthamus Decoction) This formula was developed to treat Qi and Blood Stagnation in the Upper Burner (chest). It is the first herbal formula I grab when I have a coughing patient. The patient tends to have a lavender tongue and thin tense pulses and will be hot around the head and cool on the lower back and feet. This formula includes the following herbs: Persica seed, Chinese Angelica root, Carthamus flower, Cyathula root, Rhemannia root, Red Peony root, Bitter Orange, Ligusticum rhizome, Platycodon root, Bupleurum root, Licorice root. Diseases that may respond to treatment with Persica and Carthamus Decoction include: congestive heart failure, canine infectious tracheobronchitis (kennel cough), pulmonary hypertension, thoracic tumors, and cutaneous mast cell tumors of the upper body. Qing Ying Tang (Clear the Ying Decoction) This formula was developed to clear Heat pathogens than had descended into the Ying and Xue (plasma and blood) layers. Blood Heat is an extreme situation. It causes severe itch and hemorrhage. The tongue will be very red and the pulse will be rapid and wiry with possible irregular rhythm. This formula contains the following herbs: Rehmannia root, Honeysuckle flower, Scrophularia root, Red Peony root, Gardenia fruit, Rhubarb root and rhizome, Coptis rhizome, Forsythia fruit, Salvia root, Lopatherum, Ophiopogon root. Patients with the following conditions may benefit from the use of Clear the Ying Decoction: profound chronic allergic dermatitis, demodectic mange, deep pyoderma, masticatory myositis, vaccine reaction,

6 immune mediated hemolytic anemia, immune mediated thrombocytopenia, encephalitis, and leptospirosis. Yunnan Bai (Pai) Yao Yunnan Bai Yao is the formula that got legendary status during the Viet Nam war. The North Vietnamese soldiers carried the concentrated red pill into battle to take if they were shot. The formula was developed to treat blood stasis, but it also acts as a hemostatic agent. Notoginseng is the main ingredient and has clinical actions as follows: hemostatic, CNS stimulant and suppressant, immunostimulant, decreases blood pressure, decreases heart rate, increases blood perfusion to the coronary artery, decreases oxygen consumption by the cardiac muscle. This is a proprietary formula so the exact ingredients and quantities differ, but the main ingredient is always Notoginseng. Other substances in Yunnan Bai Yao formulations may include myrrh, ox bile, Chinese yam, sweet geranium, lesser galangal root, and possibly other antiseptics or astringent substances in a starch base. This formula can also be used topically making it a good choice for wounds or dental procedures. Patients with the following conditions may respond to treatment with Yunnan Bai Yao: hemorrhage from any cause, bleeding tumors, diabetes mellitus, bone fractures, liver disease, open pyometras. Dosing herbal medicines Chinese herbal formulas come in tea pills, loose granular herbs, capsules and tinctures (alcohol or glycerite). You may want to try different suppliers to see which preparation works best in your hands. Dosing herbal medicines is more of a guideline than with conventional drugs. Tablets are generally started at one tablet twice daily per pounds of body weight. Granular herbs are started at 1 gram twice daily per 20 pounds of body weight. Tinctures are often dosed at 0.2mls twice daily per pounds of body weight. For patients with acute disease states, I will use 1-2 gram of granular herb four times daily, or 0.2ml tincture per 5 pounds body weight four times daily. Once I get a positive response, I ease down the dose to maintenance. Some herbal formulas can be stopped altogether once clinical signs are gone, and some are continued indefinitely. Rehmannia Eight, Four Marvels, Three Seeds and Four Materials are formulas I often use for the long term, whereas I tend to stop the other formulas once clinical signs are gone, but this may be months depending upon chronicity of the disease. Getting the herbs into the patient is always a trick especially when cats are involved. Chinese Herbal formulations are not flavored other than with the herbs used. If it is a heat clearing formula, it can be very bitter tasting indeed. I have had several canine patients eat granular herb sprinkled over their regular food. One of my dogs eats in with her dry food and licks her bowl clean. Often times you can give herbal medicines however you give conventional medicines using pill pockets, canned food meatballs, etc. Rice paper can be used instead of a capsule but you have to get it in the back of the throat as it dissolves quickly when wet. Unless you have a rare cat patient like my Toonces who will eat herbs mixed in her food, you will probably want to stick to tinctures as the pills and capsules can be quite large. Tinctures can be mixed with a good tasting liquid such as clam juice or pet tinic and given with a oral syringe. If you are using alcohol tinctures, I highly recommend placing the dose in a small amount of hot water and letting the alcohol evaporate over 5 10 minutes first, as it tastes horrible. Cases Bear is a 14 year old M/N Yorkie/Shih Tzu Cross weighing 14 pounds. He was referred by his rdvm for alternative treatment after unsuccessful treatment of chronic sinusitis and for acute back pain and ataxia.

7 Bear has a 1 year history of copious clear to cloudy bilateral nasal discharge and goose honk cough. Chest radiographs taken by his rdvm reveal a mild interstitial lung pattern and a normal looking trachea. Bear has been treated with Temaril P, Allegra, Zyrtec, Albuterol, and hydrocodone. The owners believe that only the hydrocodone has helped, but they have also continued the Temaril P and Allegra. The cough and sinusitis seem to be worse on damp days, whether hot or cold outside, and better on dry days. About 4 months ago, the owners noticed Bear seemed to be weak on his left hind leg and occasionally miss a step. This has progressed to Bear not wanting to walk much at all, and will often fall over. He was referred to a Veterinary Neurologist when his back became painful and he wouldn t use his hind legs at all. The Neurologist suspects a bulging intervertebral disc near the thoraco-lumbar junction. Unfortunately Bear experienced severe cardiac and respiratory depression when under anesthesia, so his MRI was cancelled. He eats a mixture of grocery store kibble and canned food, with occasional table food. Until last year, he has been very healthy other than rare bouts of colitis and anal sacculitis. On presentation, Bear is nervous, and has good body condition with a score of 3/5. No cough is elicited on tracheal palpation. He has decreased conscious proprioception on both hind legs, with left worse than right. His epaxial muscles spasm when palpated alongside vertebral bodies T10 to L1. His hair coat is slightly thin, with fine powdery white dander. He has multiple cutaneous papilloma-like masses. Bear s tongue is pale lavender, small and dry. His pulse is thin, fast and wiry. The acupuncture point BL 17 was active. Western diagnosis is chronic sinusitis and bulging intervertebral disc at thoraco-lumbar junction. TCM diagnosis is blood deficiency (small tongue, thin pulse, thin hair coat with fine dander) leading to blood (muscle spasm) and qi stagnation (weak hind end, wiry pulse, cough). Treatment included adding organ meat, fish and steamed vegetables to diet, with a recommendation to discontinue dry kibble. Laser treatment was recommended twice weekly to treat the epaxial muscle spasm and possible bulging IV disc. Xue Fu Zhu Yu Tang was started at 1/8 teaspoon twice daily. I chose this formula for its ability to resolve blood stasis by nourishing blood and moving blood and qi. Tao Ren and Hong Hua invigorate blood, while Chi Shao, Chuan Xiong, and Dang Gui Shen move the blood. Sheng Di Huang tonifies the blood. Chuan Niu Xi descends blood to the lower jiao. Chai Hu and Zhi Ke move Qi. Jie Geng and Chai Hu guides the formula to the upper burner. After one month of treatment, Bear s ataxia is unchanged, but he is coughing less and no longer has muscle spasms. Cinnamon is an 11 year old F/S Golden Retriever weighing 85 pounds. She was referred by her rdvm for alternative treatment after a lung mass was discovered on thoracic radiographs in the right caudal lung field. The owner declined biopsy or further diagnostics as she doesn t want to do anything invasive due to her bad experience with observing her sister s dog going through chemotherapy and radiation treatment. The owner wishes to try herbal and nutritional treatment to maintain quality of life as long as possible. Cinnamon has a history of a non-productive cough of 4-month duration. She was initially treated with Clavamox, which seemed to improve the cough for a few weeks. She is fed a dry kibble grocery store diet with plenty of people food snacks. She has been healthy her whole life other than a few minor skin and ear infections, and occasional gastric upset.

8 On presentation, Cinnamon is obese with a body condition score of 5/5. She is outgoing and happy. She has reduced lung sounds in the caudal right lung field. She has a 2 soft moveable deep subcutaneous mass on the left side of abdomen just past the rib cage. The rest of the physical exam was unremarkable. Cinnamon s tongue is pale, small and dry. The underside of her tongue has purple swollen blood vessels. Her pulse is superficial and wiry. No assessment of acupuncture points were done. Western diagnosis is thoracic mass of unknown origin. TCM diagnosis is blood deficiency (pale, small, dry tongue) leading to blood and qi stagnation (wiry pulse, cough). The root is likely due to Spleen Qi Deficiency (obese, skin/ear infections, GI upset) from lifelong high processed, high carbohydrate diet. Treatment included transitioning the diet to a raw diet (high protein/low carbohydrate). Owner doesn t want to prepare the diet, so a commercially available diet, Primal, was recommended. Xue Fu Zhu Yu Tang with added E Zhu + San Leng was started at 2 teaspoons four times daily. I chose this formula for its blood tonification and qi moving effects to eliminate blood stasis. Tao Ren and Hong Hua invigorate blood, while Chi Shao, Chuan Xiong, and Dang Gui Shen move the blood. Sheng Di Huang tonifies the blood. Chai Hu and Zhi Ke move Qi. Jie Geng and Chai Hu guide the formula to the upper burner. San Leng and E Zhu are added to the formula for their additional blood moving and antineoplastic effects. Cinnamon continued to do well other than cough for 5 months. She lost 12# on her new diet, and had lots of energy. She came in for rechecks weekly for a month, than monthly. Just prior to her 5 month recheck visit, Cinnamon had a bad coughing fit, vomited mucus and bright red blood, and lost her appetite. She didn t improve after 4 days, so her owner took Cinnamon to her rdvm for euthanasia. The owner was pleased with giving Cinnamon 5 months of good quality life after her initial diagnosis.