An Incident of aristolochic acid again

Dr. Tiejun Tang
BBC and some newspaper had a negative news about Chinese Medicine today.

Ying "Susan" Wu, 48, of Holland-on-Sea in Essex, has been on trial at the Old Bailey for selling pills containing aristolochic acid to a civil servant.
Patricia Booth, 58, took the pills, bought at Chelmsford's Chinese Herbal Medical Centre, for over five years. She was in her mid-40‘s when she first sought help from the centre in 1997 for stubborn patches of spots on her face.
Aristolochic acid (AA) is a component from some Chinese medicine herbs. It can cause kidney damage if applied improperly in the clinic.

In Belgium, in the early 1990's many people had been diagnosed with kidney damage after taking a kind of Chinese herbal slimmimg tea for one year, which contained AA. In 1998, the UK had two case of kidney failure reported after taking herbs containing AA. Since then any herbs or patent herb products have been strictly forbidden by law in the entire world.

Every qualified Chinese Medicine practitioner should have this knowledge and such an incident should be avoidable.

Some people might simply believe AA is just contained in Aristolochia debilis (Madouling), actually it also exists in many other herbs such as Manshurian Aristolochia Stem (Guanmutong), Aristolochia fangchi (Guangfangji), and Dutchmanspipe Vine (Tianxianteng) et al.

Some herbs only contain a trace amount of AA, and it can still be used safely especially when it was   combined with other herbs. Only the herbs which the chief component is AA should be strictly banned.

Generally speaking Chinese herbal medicine is much safer compared to most chemical drugs, but it doesn’t mean it is a hundred percent safe. It still needs special training and obtaining a standard qualification before practice. Which herb can you choose? What is maximum dosage? How long can your patient take it? If a practitioner failed in answering these questions, he or she will be like a blind driver on the road.

As a TCM practitioner I think this case highlighted the urgent need for the statutory regulation of herbal medicine in the UK. The government needs to take action to speed up the process of statutory regulation of herbal medicine.

I would like to tell the media and the public that in the UK, most of the Chinese Medicine practitioners are qualified and most of the Chinese herbs are very safe. When you select Chinese Medicine treatment check your practitioner’s qualification first. Do not change your opinion about Chinese Medicine just because of one or two very rare incidents.

How to treat rheumatoid arthritis with Chinese medicine?

Tiejun Tang

Rheumatoid arthritis (RA) is a chronic, progressive and disabling auto-immune disease. Statistics show 0.8% of the UK adult population suffer from RA. More than 7 million people in the UK (15% of the population) suffer from long term health problems related to arthritis.

RA in Chinese medicine is diagnosed as Bi syndrome. Chinese medicine believes Bi syndrome is due to the invasion of exogenous pathogenic wind, cold, dampness and heat. These exogenous evils can cause meridian blockage, sluggish qi and blood flow.

Clinical symptoms are marked by pain, soreness, numbness, heaviness, burning sensation, incapability of flexion and extension in muscles, bones and joints, or even accompanied with joint swelling or joint deformity.

If Wind is in excess, patients often describe the pain as ‘moving around’ in the body or limbs / joints. If Cold is in excess, the pain is more contracted, fixed and stabbing. If Dampness is in excess, patients will experience more swelling, a sensation of heaviness, numbness and stiffness in the joints, with less pain.

The principles of treating Bi syndrome should be to expel Wind, disperse Cold, eliminate Dampness, clearing away heat and dredging the meridians.

Many Chinese herbs can effectively release the symptoms of RA.

If the joint pain is located in the upper limbs.

 Qianghuo(Rhizoma seu Radix Notopterygii), Sangzhi (Ramulus Mori), Baizhi (Radix Angelicae Dahuricae), Weilingxian (Radix Clematidis) can be selected.

If the joint pain occurs in the lower limbs, 

Duhuo (Radix Angelicae Pubesentis), Niuxi (Radix Achyranthis Bidentatae), Mugua (Fructus Chaenomelis), Xuduan (Radix Dipsaci) can be selected.

For spinal joint pain 

Duzhong (Cortex Eucommiae), Sangjisheng (Ramulus Taxilli), Gushuibu (Rhizoma Drynariae), Yinyanghuo (Epimedium) should be selected.

Practices may differ between physicians in terms of herb selection, but the intention to eliminate pathogenic factors remain the same. Professor Tietao Deng treats Bi syndrome with a preference for local Cantonese herbs, many of them are from vine category. Such as:

 Kuangjinteng (Caulis Tinosporae), Luoshiteng (Caulis Trachelospermi), Rendongteng (Caulis Lonicerae), Jixueteng (Caulis Spatholobi), Qingfengteng (Caulis Sinomenii), Haifengteng (Caulis Piperis Kadsurae) et al.

Treating disease according to syndrome differentiation is most important in Chinese medicine. Different cases may experience symptoms differently. Therefore, the prescription must be individually modified to suit the individual’s constitution. There is no one prescription that fits all.

Herbal medicine can be used in conjunction with acupuncture, which has proven to be highly effective for the treatment of arthritic pain. The acupoints selection can be local points around the affected joints or the use of distant points to target on expelling Wind,  Cold and Dampness. 

A systematic review included 13 RCTs involving the use of electroacupuncture and manual acupuncture, all showed positive treatment effects on knee osteoarthritis[1]. Another RCT report on treating peripheral joint osteoarthritis with acupuncture had significant and clinical benefits [2]. 

To conclude, as we come to understand that RA is mainly due to wind, cold and dampness, patients should, therefore, be more vigilant on preventative measures. Try to keep your joints warm in cold weather and practice safe manual handling techniques.

Reference: 

1.        Vas J．Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory review. Acupunct Med. 2007 Jun;25(1-2):29-35.

2.  Manheimer E. Acupuncture for peripheral joint osteoarthritis.Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001977.

We are practicing authentic Traditional Chinese Medicine outside of China

---- A letter to Professor Tietao Deng

Dear Professor Deng

How are you recently? Can’t imagine how time flies, I’ve already come to England for more than two years now. During these two years, I’ve been working in a Chinese Medicine Clinic affiliated with a UK university both as a doctor and a teacher and I’ve gathered much impressions. Thinking about some of the recent criticisms on the practice of Chinese Medicine in China, I feel the need to let you know my experience here and hope that you can spread the ideas to both the supporters and those who disagree. I hope my experience and impression here can exert some influence on the development of Traditional Chinese Medicine in China.

In UK, there are many practising Chinese medicine practitioners. The main difference between the practice here and that in China is that we practise the pure Traditional Chinese Medicine here. This is evidenced as follows:

1. Only Chinese medicine can be prescribed, no Western medicine can be used coherently

It is very difficult to absolutely avoid the use of Western medicine for most of TCM practitioners in China, me included before I came here. However in UK, only pure Chinese herbs can be prescribed. Decoctions, pills and powders are commonly used forms. Everything we use has to be pure Chinese herbs. This country has a very strict legislation for the control of Chinese medicine imports. No patented pills containing any Western medicine are allowed to be imported. As a Chinese medicine practitioner here, we are not allowed to prescribe any Western medicine, or use any Western medicine to treat patients. In this sense, we are compelled to use only pure Chinese herbs. Although this leaves us with no choice but to practise in total independence of Western medicine, on the other hand the therapeutic characteristics of purely using traditional Chinese medicine has fully been shown. In fact, we still can get very good effects for most diseases even without the use of any Western medicine. I personally have a lot of successful cases within my scope of practice.

2. Combining Chinese herbs with acupuncture and other non-drug therapy

In China, most TCM doctors seldom use acupuncture. The doctors of acupuncture department do not prescribe herbs very often. Chinese herbal medicine and acupuncture seem to be divided. However, in ancient time, nearly all the TCM practitioners used both therapies. In the history of Chinese medicine, before the Ming and Qing dynasty, every famous master was very good at both herbs and acupuncture. If we hope that our treatment could be as effective as our ancestors’, maybe we need to follow their way of practice. Only in this way, the real spirit of TCM can be developed. That is the approach we adopt abroad. In the treatment of most of our patients, we combine herbs and acupuncture together. Some other non-drug therapy such as moxibustion, cupping, electric acupuncture, ear seed, tuina massage, cutaneous scraping etc are also applied according to individual cases. With this multi-therapy interaction, the therapeutic effects can be seen much enhanced.

3. Extensive clinical aspect

London is a multi-cultural metropolis. People here are of different races and come from different parts of the world. Their life style, diet, and constitution are varied. The scope of disease is also very different from China. Some diseases which are rarely seen in China could be very common here. The different conditions that we come across here are very wide, including internal disease, surgery, gynaecology, paediatrics, dermatology and ENT disease. We must learn to be a good all-round general practitioner at all times. No matter what disease I encounter, I always remember two important essence of TCM ---- the holism conception and differentiation diagnosis. In my opinion, the holism conception is helpful in breaking through the demarcation of clinical classification; whilst the differentiation diagnosis is applied to analyse all the new problems. In most of the larger TCM hospitals in China, the division of clinical departments tend to be more and more refined. Each department only focuses on one of the zang-fu organs. Isolating a particular area too much may inevitably lead to overlooking other related aspects. In the long run, the holism conception will be diminished; the traditional practice of TCM is also altered. At this stage, shouldn’t we ask ourselves whether we should be developing TCM according to its original concept? Must we follow the Western clinical divisions?

4. Combining teaching with clinical treatment

The university which I’m now working for first started enrolling full time students for a 5 year TCM programme in 1997. Starting from this year, it also started enrolling for a TCM master degree programme. Our students come from all over the world, mainly from Europe. TCM education here has been greatly influenced by higher education of UK. Emphasis is being placed more on practical training. Clinic placement starts at the first term of the first year. As the term progresses, the students will have to take up more and more clinic placement, until they can treat patients independently. After 3-4 years of training, most of the students will be able to master quite skilful acupuncture techniques and will have acquired some knowledge about herbs. During the whole 5 years study, the students spend more time on clinic placement than classroom teaching. Compared to the education in China, UK students have more own time for self study. They have more paper work, case study and presentations to do. The emphasis is more on clinical practice.

Since ancient times, the Traditional Chinese medicine had been passed down from generation to generation by an individual teaching method. Teaching and treating are carried out at the same time. In fact, the students who get high marks in the exam may not necessarily turn out to be good doctors in the clinical environment. Clinic practical training is therefore very important. I feel that TCM education overseas resembles TCM teaching in ancient China more and I think that teachings in China should follow more closely with this trend.

All of the above are the impression I obtained with my work in UK. TCM is a quintessence of Chinese culture. It has been accepted by all races over the world. Many of my students have a great unbelievable enthusiasm to TCM. They are diligent and hard working. Every year, they graduate from here and go to different parts of the world. During these two years, I have treated many patients by applying the clinical experience that you taught me and many unbelievable good results have been achieved. I will report these cases to you in future.
I remember you used to take an undiscovered jade as the metaphor for TCM. I would like to tell you now that this precious gem is already glittering outside China. You can rest assured that TCM will live on forever and be even more and more widely accepted.
Best Wishes
Your student : Tiejun Tang

6th September 2007

Why and How Traditional Chinese Medicine can treat Coronary Heart Disease？

Dr Tiejun Tang
Coronary heart disease (CHD) is a common heart disease. It is caused by narrowing of the coronary arteries, resulting in blood supply insufficiency. It leads to myocardial ischemia changes or anoxic change of the heart. Clinical symptoms include sudden chest pain, an oppressive feeling in the chest and palpitations. In some severe case death will occur.

Statistical data from Department of Health shows CHD is the biggest killer in U.K. More than 1.4 million people suffer from angina. 275,000 people have a heart attack annually. CHD kills more than 110,000 people in England every year [1].

Hypertension, hyperlipidemia and diabetes are common risk factors of CHD. Some unhealthy life style factors such as smoking, alcohol, lack of exercise, stress at work can increase the chance of CHD.

CHD can be diagnosis by ECG, heart ultrasonic scan and coronary angiography.

Western medicine has many advantages in the treatment of CHD, but it still has limitations. For example: there are side effects of most antihypertensive and antilipemic drugs, some of them serious; the high restenosis rate within 6 months after percutaneous transluminal coronary angioplasty (PTCA)[2] ; the high risk and the high financial implication of surgical intervention, i.e coronary bypass.

The symptom of CHD had been firstly recorded in the Neijing (Yellow Emperor's Canon of Medicine 475B.C.-221B.C.) In this classic book angina is named as xiong bi, or xintong. Arrhythmia is named as xinji, or zhengchong. From that time our ancestors began to use Chinese herbs and acupuncture for the treatment of this disease. In modern China we combine traditional Chinese medicine (TCM) and western medicine together to treat CHD. Many clinical and laboratory research published now indicates that some Chinese herbs in addition to acupuncture may have a very good effect for treating the symptoms of myocardial ischaemia with a positive outcome for those patients affected [3,4].

Within the TCM framework the pathology of CHD may be understood to be due to deficiency in the root and excess in the branch. Deficiency of the root includes heart, kidney, spleen, yin and /or yang deficiency. Excess branch include qi stagnation, cold obstruction, phlegm blockage and blood stasis. Different cases will have individual pathology presentation. The treatment principle should vary according to the syndrome differential diagnosis.

If cold obstructing the heart, warming heart method should be selected. Where phlegm is blocking the heart, expel phlegm method should be used; if heart blood stasis, the stagnation need to removed from the heart meridian; if liver and kidney yin deficiency, nourishing yin method should be used; if heart yang deficiency, warming yang method should be selected.

Chinese medicine can prevent CHD by reducing the risk facts such as hypertension, high cholesterol, diabetes and arteriosclerosis.

Herbs functions that inhibit liver yang and nourishing kidney yin often have a good effect on lowing blood pressure. For example: Tian ma (Rhizoma Gastrodiae), Gou teng (Rmaulus Uncariae cum Uncis), Ju hua (Flos Chrysanthemi), Gou qi zi(Fructus Lycii); Herbs functions that remove blood stasis often have good effects on improving microcirculation and increase coronary circulation. For example: Dan shen(Radix Salviae Miltiorrhizae), Chi shao (Radix Paeoniae Rubra), San qi (Radix Notoginseng), Chuan xiong (Rhizoma Ligustici Chuangxiong); Some herbs can reduce cholesterol, like Shan zha (Fructus Crataegi), Ze xie (Rhizoma Alismatis), Jue ming zi (Semen Cassiae), He shou wu (Radix Polygoni Multiflori); Some herbs has function to reduce blood sugar, like Shan yao (Rhizoma Dioscoreae), Mai men dong (Radix Ophiopogonis), Tian hua fen (Radix Trichosanthis), Shu di huang (Radix Rehmanniae Praeparata).

Chinese medicine selects different herbs according to different condition. Sometimes decoction may be used and sometimes patent pills may be prescribed. Usually herbs combined with acupuncture will make the treatment more efficient.

In the treatment of CHD Chinese medicine have showed the following advantages:

Firstly, Chinese medicine has a Multi-target effect. One decoction or pills contains several different ingredients. Each ingredient acts on different pathology change. It can treat disease from the branch to the root at same time.

Secondly, it is nature therapy, nearly no side effect. You can bring your blood pressure down without getting side effect such as dry cough, headache or edema; you can reduce cholesterol without damage your liver function.

Thirdly, the effect of Chinese medicine is stable and sometimes it has a bidirectional regulating function. Compare to western medicine, it has much less rebound effect on blood pressure. Some herb pills not only simply reduce blood lipid, it has a balance or regulation function. For example, our research shows Kaixin capsule can balance among the subfractions of lipoprotein and inhibit arteriosclerosis[5].

Few years ago the UK Government had committed to reducing the death rate from CHD and stroke and related diseases in people under 75 by at least 40% (to 83.8 deaths per 100,000 population) by 2010. Can we hit this target this year? I suggest all the patients and doctors have a second idea, it maybe a better solution in fighting against CHD.

Reference
1. http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/Coronaryheartdisease/index.htm
2. Drachman DE. et.al. Restenosis: Intracoronary brachytherapy. Current Treatment Options in Cardiovascular Medicine. 2002; 4(2) :109-118.
3. Tiejun Tang, Weikang Wu. Progress of Experimental Study in Traditional Chinese Medicinal Herbs Against Myocardial Ischemia. Shenzhen Journal of Integrated Traditional Chinese and Western Medicine. 2003；13 (2):111-113,118.
4. Tiejun Tang. The prosecution and application of rat model of experimental coronary heart disease. International Journal of Cardiovascular Medicine (Chinese Edition) 1999; 1(4): 318-320.
5. Tiejun Tang et al. Effect of Kaixin Capsule on Blood Lipid and Lipoprotein Subfractions in Experimental Rats with Coronary Heart Disease. Journal of Guangzhou University of Traditional Chinese Medicine 1999; 16 (3): 223-225.