Tuesday, March 3, 2009

Give Your Patients More Herbs at a Higher Dose and See Better Results

Here's a quote from one of my favorite bloggers, Eric Brand, on one of my favorite subjects, the chronic underdosage of herbs here in the U.S. All emphasis is mine and does not appear in the original.

It could be said that the greatest overall differences in Chinese herbal medicine between the US and Asia relate to dosage. In Asia, raw herbs are generally taken by decoction at a dose of one pack per day, whereas in the Americas, one pack of raw herbs is often taken for two days. Despite the fact that North American patients tend to have a higher body weight than their Asian counterparts, they often consume Chinese herbs at a dosage that is essentially half of the traditional dose.

In a similar paradox, Taiwanese granules are often prescribed at doses that are a fraction of the doses used in Taiwan. Part of the confusion seems to lie with the labeling information, which is required by US law to state a specific dose. Given the litigious nature of American society, most companies are understandably cautious in their dosage recommendation, so the dosage listed on the label is often well-below the dosage that is regularly used by a trained practitioner. Furthermore, most loose granules have the Asian labeling on concentration ratios removed for the US market, so practitioners are often at a loss to know how the powder corresponds to the raw herbal weight.

Taiwanese granules are generally used at a dose of around 18g/day in Taiwan, but many practitioners in the US use doses as low as 4—6 g/day. Perhaps the majority of Western practitioners prescribe granules in a dose range of around 6—12g/day, but many practitioners remain uncertain about how proper granule dosing is determined. Additionally, many instructors in American schools come from China but teach in schools that stock Taiwanese granules, which are more prominent on the American market. The granule product is different than what they used in their training in China, and teachers cannot effectively educate students on granule dosage because the standard raw dose equivalent is absent from the label. Consequently, practitioners often rely on the label information, which is essentially just an overly cautious (read: “please don’t sue me”) guideline that is required by FDA laws.

As I work in the Yosan clinic, this continues to amaze me. Most of us are giving our patients less than a half dose of herbs. I have to admit I don't always insist that my patients take one bag per day of raw herbs. Whenever you see a patient there is a calculation that takes place - how committed to getting better is this person? How much are they buying what I'm saying? If they really want to get better and have trust in me as a practitioner, I'll generally prescribe five bags of herbs, one for each day, with one day off before the next weekly check-up. If they're one of these people that don't really believe Chinese medicine can help them, or they were cajoled into getting an appointment by a relative or a friend, I might give three bags of raw herbs, with the idea that some herbs is better than none.

The best patients are the ones that are ready to change their lives and just need some help doing it. I saw some amazing results with heavy smokers with life-long asthma using acupuncture and variations on 白果定喘汤 Bai Guo Ding Chuan Tang, but these people were also doing yoga every morning, going running, changing their diets, and had the support of partners and friends. Without Chinese medicine, these people might be the ones who said "I tried everything but I still need my inhaler" - their kidneys too weak, their lungs too encumbered with phlegm. For one of my patients, we got him from using his inhaler up to ten times a day down to once or twice a day within a week, and shortly after that he didn't need the inhaler at all. This patient of course took one bag of raw herbs per day. With a half dose, who knows how effective it would have been?

This is something I feel strongly about, and hopefully I've convinced a few TCM students it's an important subject that needs attention. Supervisors are another matter. Some clinical supervisors that were educated in California are so used to using one bag of raw herbs for two days that suggesting otherwise gives them a shock. "Why you brat," they seem to be thinking, "I've been doing this since 1987! I think I know what I'm doing!" Supervisors who were educated in China might be gung-ho about herbs, or they might just want to fit in and not rock the boat too much.

In either case, most supervisors I've encountered give wide latitude in dosing herb granule extracts. Using the method detailed here, you can figure the dose yourself and tell your patient just how to take it. You'll quickly find that most patients need 100 grams to last at least a week.

p.s. It almost goes without saying that a higher dose of herbs means absolutely nothing if your diagnosis is incorrect... it's just important to understand all the weapons at your disposal.

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