Chinese Herbs and Pharmaceuticals – More Safety for our Patients

June 20, 2024

Many of our patients take several prescription and over-the-counter medications. This situation often challenges traditional Chinese medicine (TCM) practitioners. In 2017, 38% of Swiss people (over 15 years old) took medication every week. According to Frontiers in Pharmacology, this number is increasing every year. In Australia, an estimated nine million people (35% of the population) take a prescribed medication daily, eight million of whom even take two or more pharmaceuticals. 

Basic Pharmacology Terms 

Pharmacokinetics studies the effects of drugs in the body, from absorption to distribution, and the impact on metabolism to excretion. Pharmacodynamics deals with the results of medicines, including details on the mechanism of action, drug concentration, and doses. Pharmacological interactions describe how the drug achieves the therapeutic goal and the receptors affected by these actions. Pharmaceuticals are manufactured under controlled, low-germ or sterile conditions.  

 According to Health.gov.au, medicines are:  

“Substances that help our bodies – physically or mentally – to prevent, treat or cure diseases.” 

 The term “medicine” is different to what we refer to as: 

 

Routes of drug administration 

 

Route explanation 

 

Buccal They are held on the inside of the cheek. 
Enterally They are administered directly into the stomach or intestines using a tube. 
Inhalable Inhaled through a tube or mask. 
Infused Injected into a vein via an infusion line and gradually dripped in.  
Intramuscular Injected into the muscle with a syringe. 
Intrathecal Injected into the spine. 
Intravenous Injections into a vein or an infusion line 
Nasal Administered by spray or pump into the nose. 
Ophthalmic Administered as drops, gel or ointment into the eye. 
Oral Swallowed by mouth as a tablet, capsule, or liquid. 
Otic Drops directly into the ear.  
Rectal Introduced through the rectum. 
Subcutaneously Injected directly under the skin. 
Sublingual Held under the tongue. 
Topical  Applied to the skin. 
Transdermal Administration via a patch on the skin. 
Vaginal Inserted directly into the vagina. 

 As TCM practitioners in Western countries, we prescribe our patients pills, capsules, tablets, liquids, tinctures, granules, raw herbs, or creams. Prescribing suppositories or injecting herbs or saline solution directly into the acupuncture points is less common. Thus, we can assume that most of our prescriptions are taken orally. From my experience in practice, most patients take pharmaceuticals in this way, too. 

 The Paradigm of Chinese Herbal Medicine 

Although most patients take medicine the same way (orally), they are prescribed using different medicine systems. We remember that the first compilation of herbs was made during the Eastern Han Dynasty, around 100 BC. It was called Shen Nong Ben Cao Jing. A total of 365 herbs were identified and classified. The first category contained the “top” 120 herbs (e.g., Ren Shen and Huang Qi), which could be taken daily. The following class (also 120 substances) was that of the “middle” herbs (e.g., Dang Gui and Bai Shao), which should be taken to prevent disease, and the remaining 125 “lower” herbs (e.g., Fu Zi and Ban Xia) were considered a means of treating illness. Because of their toxicity, these substances should only be taken briefly. 

Example: Chang Pu (The first remedy of the upper category) 

  • Rhizomes of Acorus gramineous 
  • Acrid flavour, warm, non-toxic 
  • Treats wind-, cold/ and damp-related bi impediment and counterflow cough with the ascent of qi; opens the apertures of the heart; supplements the five Zang organs; unclogs the Nine Orifices; brightens the ears and eyes; and makes the sound of the voice come forth. 
  • Consumed over time, it lightens the body, staves off forgetfulness and confusion, and extends the years. 
  • Grows in ponds and marshes. 

 (Shen Nong Ben Cao Jing The Divine Farmer’s Classic of Materia Medica translated by Sabine Wilms, Ph.D.) 

 In Shen Nong Ben Cao Jing, herbs are listed with their thermal energetics and five flavours. This book continues to inspire me personally to this day. How come? Because it connects me to the origins of our medicine. Unfortunately, the other side of the coin is that our medicine speaks a language and has a philosophy that seems complex or abstract to those who do not regularly use it. Interestingly, to this day, the “compilation” of Materia Medica is maintained in China to support research in TCM. 

 In contrast to the categorisation and description of herbs, formulas combine these individual substances. Typically, formulas are divided by pattern (of the disease). Classic formulas are popular because they have been used for centuries and promise a synergistic effect. However, formulas balance many individual factors, and we cannot tell which ones. But just because “our” herbs are products of nature does not mean that they cannot be poisonous or interact with one another. Certain herbs are incompatible; some have antagonistic effects, and some inhibit others, which can also increase the impact. Chinese herbal therapy is complex in prescribing formulas and individual substances and requires ample knowledge and experience. 

 The apparent differences between pharmaceuticals and herbs 

Pharmaceuticals are manufactured synthetically, while medicinal plants are considered natural products in TCM. The quality of the substances depends on numerous factors (soil, region, weather, harvesting methods, etc.), and consequently, the composition of these plants’ “chemical compounds” also varies. As stated and discussed above, as TCM practitioners, we are not interested in the individual components, but we are focused on the overall effect of a formula on the disease pattern we diagnose. Often, the formulas we prescribe are intended to relieve multiple symptoms of a pattern. We may add herbs to a formula (constipation, dizziness, etc.). Still, we always aim to support the organism holistically and create “harmony” that the patient ultimately experiences as well-being. 

One reason our patients take a lot of medication is that conventional medicine prescribes its “remedies” so that each one treats an isolated symptom. Although drugs are “tested” for over 15 years before they are used on people, nothing says anything about the extent of their effect. An excellent example of this is Viagra, which was initially designed for use in cardiovascular problems and is now marketed for erectile dysfunction. 

 Again, I just wanted to mention that TCM and conventional medicine have fundamentally different treatment methods. This is another point that makes estimating or avoiding interactions between Chinese herbs and pharmaceuticals difficult. 

How do we make Chinese herbal therapy safe for our patients? 

That is the question we want to answer with this short article. We know that the interaction between herbs and pharmaceuticals is an important and complex issue, as both systems of medicine are used by patients worldwide. Interactions can occur between herbs and medications, but also between individual pharmaceuticals and between individual herbs. Unfortunately, such interactions between different patient medicine components are complicated to predict. 

  1. Pharmacokinetic and pharmacodynamic interactions: Chinese herbs can affect the absorption, distribution, metabolism, and excretion of pharmaceuticals. It may also be that the mechanism of action can lead to a strengthened or weakened result. 
  1. Enzyme induction and enzyme inhibition: Chinese herbs can derive or inhibit enzymes in the body, resulting in altered drug levels in the blood and thus causing suboptimal effects or side effects. 
  1. Herb-Drug Interactions: Herbs with blood-thinning properties may react with anticoagulant medications, leading to a higher risk of bleeding. 
  1. Interactions between herbs and supplements: Due to limited research, it is difficult to predict whether and how these substances will get along. 

 As you can easily see, this is a complex matter because existing databases only contain individual substances. As far as I know, there is no central place where Chinese formulas are compared to dietary supplements or pharmaceuticals. I asked a few universities and received the following sources:  https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/search?keys=Shu+di+huang&letter= 

  • You can find a database here where you can query individual herbs. 
  •  Western Sydney University (NICM) started a project (database) a few years ago, but it could not be continued due to running out of funds. However, I was informed that this project will be reopened over the next year. 

I have a rule of thumb in my practice: 

  • If the patient takes many different pharmaceuticals, I will not prescribe herbs. I believe there are not enough reliable sources to estimate possible interactions. The patient can at least benefit from acupuncture and our advice on dietary or lifestyle changes. 
  • If the patient takes many nutritional supplements (mainly if another complementary medicine practitioner prescribed them), I will not prescribe herbs and “only” offer acupuncture. How can we anticipate what herb and what supplement is causing what changes?  
  • If the patient is motivated to stop taking one or more pharmaceuticals, I will only agree if the treating doctor is informed and can carry out regular blood tests. I usually set a time frame of three to six months for such undertakings. 
  • If the patient takes three or four common medications, I will prescribe herbs after working with the person on a detailed plan for when they are taking the herbs. All Chinese medicines must be taken at least two hours before or after the pharmaceuticals. In addition, the patient must continue having regular blood tests to monitor liver and kidney function.  

 Unfortunately, it is not the case that there are precise instructions on the use of Chinese herbs in combination with pharmaceuticals. But we must protect our patients from harm, and although I don’t like to admit it when in doubt, I am very cautious about prescribing herbs because too many factors could cause injury. 

References:

  • https://www.healthline.com/health/administration-of-medication#routes 
  • https://academic.oup.com/qjmed/article/109/10/639/2440067?login=true 
  • https://www.nccih.nih.gov/health/providers/digest/herb-drug-interactions 
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9635910/ 
  • http://www.itmonline.org/safety.htm 
  • Sperber, G. (2007). Integrated pharmacology: combining modern pharmacology with Chinese medicine. Blue Poppy Enterprises, Inc. 
Brigitte Linder
Brigitte Linder was born in Zurich and has lived near Melbourne on the south coast of Australia since 2008. She operated Safflower – Chinese Herbs Expertly Dispensed until mid-2023. Safflower is an herbal dispensary business operating under the banner of the Therapeutic Goods Administration (TGA). It was issued a GMP licence. Acuneeds acquired the company in January 2024 and intended to offer all services to practitioners in Australia and New Zealand.Brigitte completed a master's degree in 2023 with NICM Health Research (Western Sydney University). Her thesis involved creating a case report guideline for Chinese herbal medicine. In 2019, she published her first book and has since mentored TCM graduates to better transition to full-fledged practitioners. She has been consulting patients for 20 years and enjoys working with children and patients with complex conditions. She is a diplomat of the Institute of Classics in East Asian Medicine (ICEAM) and prescribes Eastern Han-era herbal formulas, namely Shang Han Lun and Jin Gui Yao Lue. Brigitte has always been interested in uniting a strong, cohesive TCM community. She continues to invest time and effort to ensure practitioners and the profession receive support and recognition.
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