More Discussion of Herbal Dosing

Carl Stimson, an American acupuncturist living and working in Tokyo, has some interesting observations on medicinal dosing - you can read part one and part two here.

Running a Chinese pharmacy, I see all different levels of dosing. Some of our practitioners use 12-15 different herbs for each prescription, with 9-15 grams for each herb. Others use as little as 4 herbs and doses of 3-9 grams maximum. Some want their patients to take one bag of raw herbs per day, others one bag every other day. If you're not getting results, dosage might be one aspect of your treatment to consider (obviously a correct diagnosis is number one).

In previous posts, I've recommended using one bag of raw herbs per day, or its equivalent in granule form. While I still feel this is the best option, I have seen many practitioners get results with varied dosage forms, and results are what matter most. Heiner Fruehauf, a member of the Fire Spirit school of Chinese medicine, uses Fu Zi in almost every formula, and in this article cites his teachers in the Fire Spirit school as saying that if a patient feels palpitations and dizziness after taking Fu Zi it's most likely because the dose was too small rather than too high (he's also very specific on the type of Fu Zi used - it must be from Jiangyou County in Sichuan province).

Here's Carl:

When I was a student I remember reading a debate on dosages between several practitioners on a TCM internet discussion group. The argument that American patients did not need as much herbs as Chinese patients because they had not developed any tolerance to herbs was being discussed. One practitioner countered that if a doctor traveled to an isolated island where the inhabitants had never been treated with aspirin or antibiotics, the doctor wouldn't reduce his dosage because of this, he would continue to dose based on weight and severity of the illness. At the time I thought this was a wonderful argument. It illustrated the fact that we are all humans with the same biology and chemistry. I still think the point is an important one, but now I wonder about a related question. I think there is no doubt that a foreign doctor arriving in a new country / culture would continue to dose using the standards he was trained in. However, if the local doctors were given this new medicine, would they continue to follow the same dosage standards after many years of practical experience? It seems, based on what we have seen with acupuncture and pain medication, that there is no guarantee the local doctors would not develop different dosage standards.

So why does this happen? After all, the human body is the human body, no matter if it is American, Chinese, or any culture. It is subject to the laws of science no matter what national borders the body is living in. I believe that differences in dosage standards across cultural lines has very little to do with science, and mostly involves differences in each culture's relationship to health and medicine. In China, many patients will not be satisfied with an acupuncture treatment that is not painful, while in the US and Japan, a practitioner is unlikely to be in practice very long if his/her treatments cause much pain. Perhaps the Chinese have more faith in the "No pain, no gain" principle. The difference in pain medication dosages between the US and Japan probably reveals the fact that being able to withstand suffering without complaint is highly valued (and expected) in Japanese society. I have also heard that US doctors start to give medication for blood pressure and cholesterol at lower levels than Japan. This could reflect a tendency of Americans to be more proactive in using outside means to control nature. It could also reflect the pervasive paranoia about liability in America.

While it is true that we are all human beings and subject to the laws of science, let's remember that the laws of science are essentially a crude way of describing the laws of nature. The Daoist tradition has a much more elegant, somewhat less exact but much more complete way of describing nature, based on the the concepts of Wu Ji, Tai Ji (yin and yang), the five phases, ba gua and so on. When you look at humans from this perspective, it helps you remember that people get sick in different ways all over the world. So when the hypothetical doctors arrive on the island, why are they giving out aspirin and antibiotics in the first place? What criteria are they using to evaluate local people and their illnesses, and are those criteria valid?

There is a trope in Chinese medicine that Northerners (northern Chinese) come from a cold climate and therefore need higher doses, take to warming tonics better, and when they catch wind (cold) need stronger exterior-releasing herbs. Southerners (southern Chinese) come from a warmer climate and therefore usually need lower doses, and when they catch wind need a different treatment strategy. So of course people in places as different as China, Japan and the U.S. need different dosages.

In a heterogeneous society like the U.S., you'll treat all different body types and all different ethnicities. Some of your patients were born in faraway places, some were born around the corner from your office. Don't get caught up in dogma, whether it relates to dosing, diagnosing, or anything else. Evaluate each patient individually and decide what's appropriate for their situation.

See also: How much is in a qian? by Eric Brand

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.