Acupuncture Vancouver - Rheumatoid Arthritis

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IMeG Health Clinical Report, 2009, No.5

- Traditional Chinese Medicine ClinicSuite 300 1177 West Broadway, Vancouver, BC V6H 1G3 604-736-8928 [email protected]

Platinum Link Health Management Inc. 2009 All Rights Reserved.

Traditional Chinese Medicine Treatment ofRheumatoid Arthritis (RA)

Keywords: arthritis, OA, osteoarthritis, RA, rheumatoid arthritis, Traditional Chinese Medicine, TCM,

Acupuncture, Herbal medicine, IMeG HealthTM Clinic, Vancouver, Canada, joint pain, inflammatory

pain, CAM, phlegm, blood stasis, herb-drug interactions

Introduction

There are more than 100 kinds of arthritis, themost common of which are osteoarthritis (OA) and

rheumatoid arthritis (RA). Of the two, osteoarthritis is

the most common form, affecting approximately three

million Canadians, mostly over the age of 45. While

both forms involve the typical joint pain associated

with arthritis, they are in fact completely different

diseases.

Osteoarthritis is commonly caused by hard

repetitive activity, and joint injury. The condition is

normally limited to the joint capsule, and is the result

of the gradual deterioration of the cartilage that lines

the bone surfaces. As it wears away, the synoviallining in the joint capsule becomes inflamed. When

severe, the bone ends will touch, and begin to wear

away, resulting in jointdeformity.

On the other hand, in rheumatoid arthritis, the

inflammation is the result of an autoimmune illness.

Autoimmune conditions result when the body

recognizes some of its own cells as being harmful and

in turn begins to attack itself.

Like OA, RA affects the joints, but in addition it canalso result in inflammation of the tendons, lungs, and

blood vessels. Over the years, there has been

speculation as to its causes, but as yet its cause

remains unknown.

Conventional treatment for rheumatoid arthritis

employs the use of pain killers, anti-inflammatory

medications (which includes the COX-2 inhibitors

such as Vioxx and Celebrex), and a category of

medications known as disease modifying anti-

rheumatic drugs, or DMARDS (which includes

medications such as methotrexate). Reports over the

last year have resulted in several of the commonly-used COX-2 inhibitors being pulled off the market.

In addition to these conventional treatments,

more and more patients are seeking out different

treatment options, and in many cases seeing multiple

practitioners for the same condition. One of the most

highly sought treatment options is traditional Chinese

medicine (TCM).

TCM Treatment of Rheumatoid

Arthritis

Traditional Chinese medicine classifies allarthritis as a syndrome called Bi, or Painful

Obstruction Syndrome. This syndrome is further

differentiated on the basis of the presenting signs and

symptoms, resulting in names such as Wind Bi, Pain

Bi, Hot Bi, Damp Bi, Bone Bi, and others. Many

studies have been conducted over the years as to the

efficacy of TCM in the treatment of this disease, many

reporting success rates of over 80%. However, in

Clinical practice at the IMeG Health TCM

Clinic is supported by research at some of the finest

universities in the world. This platform enablespractitioners to achieve the mission of patient-

focus health care delivery. IMeG Health Clinical

Report is a community service provided by IMeG

Health. For all enquiries on this report, please

contact the editor: Professor Steve C. F. Au-Yeung,

email: [email protected]. Other clinical

resource materials are available on the IMeG

Healths website atwww.imeghealth.com.
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Platinum Link Health Management Inc. 2009 All Rights Reserved. 2

many of those studies very little information is

provided regarding outcome measures.i

Still, there

are many studies that are noteworthy, and they do

point to the efficacy of TCM in arthritis.

In their paper Arthritis and Acupuncture: The

Evidence for Effectiveness, which was published by

the British Acupuncture Council in October 1998,

authors Saunders, Gould, and MacPherson reviewed

a total of 18 papers, and regarding rheumatoid

arthritis, they reached this conclusion:

Acupuncture has been shown to give some pain relief

in rheumatoid arthritis and an anti-inflammatory

response may also be present. Treatment early in the

disease is preferable but age and duration of the

disease should not be seen as barriers to treatment.

There are also countless studies regarding the

efficacy of Chinese herbal medicines. Some of these

studies examined the effects of a single herb, whileothers examined the effects of herbal formulas. In one

such study, a team of researchers from the University

of Texas and the National Institutes of Health

analyzed the effect of the herb Tripterygium wilfordii

Hook F, or lei gong teng as it is known in Chinese.

Thirteen patients with long-standing rheumatoid

arthritis participated in the trial over a 12-18 month

period. Nine of the patients went through the wholeprogram, all experienced marked improvement and

one went into complete remission on a dose of 390

mg/day. ESR (erythrocyte sedimentation rate) went

from 55 mm/hour to 22 mm/hour on a dose of 480

mg/day.

ii

Fuelled by the results of this small trial,researchers are currently conducting a much larger,

double- blind, controlled study to confirm the benefits

of lei gong tengextracts.

Clinical Experience

In my own experience, I have found arthritis to be

one of the most commonly-encountered clinical

conditions, and one that responds very favourably to

treatment. Based upon my own clinical experience

using acupuncture, I have devised a treatment

protocol that divides the treatment into different

phases (Table 1). I recommend treatment initially at 2-

3 times per week for several weeks. Depending on a

patients reaction to treatment, this will be reduced to

1-2 treatments per week (perhaps for several weeks

or more), then 1 per week, then every 2 weeks, then

3, and eventually tapering to a maintenance schedule

of one treatment per month (plus or minus).

Table 1. Acupuncture: General Treatment Protocol for RA

Treatment

Phase

Duration (# of

weeks)

Treatment Frequency

(times/week)

Receptivity to

Treatment

Total Treatments

I 2 - 4 2 -3 Good 4-12

II 4 - 8 1 - 2 Good 4-16

III 8 - 20 1 Good 8-20

IV 20 - 30 1 per 2 weeks Good 10-15

V 30 - 40 1 per 3 weeks Good 10-13

Maintenance Continuous 1 per month Good 10-12 per year

Like the above acupuncture protocol, herbal

therapy is also of longer duration, and patients can

expect approximately one month of herbal therapy for

every year they have had the condition. Therefore, if a

patient has had RA for 10 years, they can reasonably


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expect to be taking herbal medicines for at least 10

months.

Case Example: Rheumatoid Arthritis

(62-year-old Female Accountant)

The case history of a 62-year-old female

accountant is summarized in Table 2.

Table 2. Case History - Rheumatoid Arthritis of the

Hands

Chief Complaint Joint pain of hands

MD Diagnosis Rheumatoid arthritis

Treatment anti-inflammatory medication -

Methotrexate (DMARD)

A 62-year-old female sought help for her joint

pain due to rheumatoid arthritis. She had been

diagnosed several years earlier, and was prescribed

methotrexate, (a disease modifying anti-rheumatic

drug DMARD). Her pain was considerable and joint

deformity in the metacarpophalangeal (MCP) joints as

well as the thumbs of both her hands was evident.Her right hand was somewhat more painful, but both

were at times intolerable. Her hands were especiallystiff in the morning, and could remain so for several

hours or more. She was an accountant, and the pain

made doing her job impossible at times.

The TCM diagnosis confirmed that she was

suffering from Bi Zheng due to Wind-Cold-Damp

(considered to be the main etiological factors in

arthritic conditions). In accordance with the

discussion presented above, the recommendation for

this patient was a comprehensive treatment of

acupuncture and herbal medicine (Table 3). The

acupuncture treatment focussed on invigorating

circulation and stopping the pain, while the herbalmedicine treatment focussed on resolving the Wind-

Cold-Damp condition, clearing the stagnation of

Phlegm and blood, tonifying the Kidneys,

strengthening qi, and clearing heat-toxins.

Table 3. TCM Diagnosis and Recommended Concomitant Treatment Modalities

Diagnosis:

TCM Disease: Bi Zheng

TCM Pattern: Wind-Cold-Damp Bone Bi

Acupuncture: Initial treatment frequency of weekly acupuncture, gradually decreased over

the course of one year

Herbal Medicine: Herbal formula was modified periodically, with focus on

Clearing Wind-Cold-Damp

Clearing stagnation of Phlegm

Invigorating Blood

Strengthening Kidneys

Boosting Qi

Clearing Heat-Toxins

Other Recommendations: The patient was also encouraged to participate in stress-reducing

activities such as meditation, and to ensure she was getting adequate rest.


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for the same condition, and often not informing their

practitioners of other treatments they might be

receiving. This is especially true for chronic and

enduring conditions like arthritis, and represents a

potentially hazardous situation. As the above Case

Example illustrated, some understanding of potential

herb-drug interactions is imperative in order tomediate the risks of herb-drug complications. This fact

requires and demands more open communication

between different disciplines of heath service

providers (interdisciplinary communication).

In modern clinical practice, the prudent

practitioner will make himself aware of the potential

risks and benefits of such therapies as herbal

medicine. As an example, certain herbs have shown

an effect in enhancing the circulating levels of

corticosteroids by slowing their metabolism. This

action will not only increase the amount of natural

corticosteroids (hormones produced by the adrenalcortex), but also any steroids administered as drugs.

When the steroid levels administered for treating

inflammation are high enough to cause some side

effects, elevation of the drug level by herb action

could increase the side effects.v

At the same time,

due to this very interaction, conventional steroid

therapy could be reduced. This has been exactly the

case in Japan, where an herbal formula called ChaiLing Tang (Bupleurum and Hoelen Combination) has

been used in cases of rheumatoid arthritis and found

that the result is a reduction in the dose of steroids by

up to two-thirds. It was also shown to be helpful in

reducing arthritic inflammation.vi

Studies such as this would indicate that there can

be a positive effect for the use of herbs in combination

with corticosteroids, but it also presents a potential

problem: if a medical doctor is administering high

(rather than low) doses of steroids to a patient who is

also taking herbal medicine, the effects can be

adverse

vii

. Other examples of potentially negativedrug-herb interactions are summarized in Table 5.

Table 5. Summary of some Drug-Herb Interactions

Latin Name Chinese Name DrugHerb Interaction

Glycyrrhizin - a compound in licorice gan cao may prolong the biological half-life of the systemic

corticosteroids

Radix Ligustici Wallichii chuan xiong may interfere with Anti-Coagulating drugs

Radix Saviae Miltiorrhizae dan shen may interfere with Anti-Coagulating drugs

Radix Angelicae Sinensis dang gui may interfere with Anti-Coagulating drugs

Magnoliae Officinalis hou po contains magnolol, a mild anticoagulant. Caution should be

used in patients taking antiplatelets or anticoagulants

including; aspirin, dipyridamole, clopidogrel(plavix), heparin,

warfarin, and enoxaparin(Lovenox)

Ligustri Lucidi nu zhen zi lowers plasma glucose levels. Combining this herb with anti-

diabetic medication such as insulin or sulfonylureas may result

in hypoglycaemia

Ginseng ren shen may reduce fasting blood glucose levels. Hypoglycemia may

occur when this herb is combined with drugs for diabetes

mellitus.

Anemarrhenae Asphodeloidis zhi mu may interfere with Anti-Diabetic drugs

Finally, immunostimulants such as echinaceaand

zinc should not be given with immunosuppressants

such as corticosteroids (prednisone, etc.) and

cyclosporine, and are contraindicated in patients


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suffering from rheumatoid arthritis and systemic lupus

erythematosus.This list is far from exhaustive, and

while it remains true that we still do not know all

possible interactions, steps can be taken to ensure

that those situations that could be problematic are

understood. Inherent in this understanding is the very

real need for open communication amongst thepractitioners, and between practitioners and patients.

Statistics point to the fact that patients will explore

other treatment options, and only by encouraging

open dialogue will practitioners be armed with all of

the information necessary to the formulation of

effective, safe treatment.

SUMMARY

Acupuncture and traditional Chinese medicine (TCM)

have been safely used for thousands of years. My

clinical experiences would corroborate with many

studies that point to the benefits of acupuncture andherbal medicine in the treatment of arthritis. In some

cases treatment might only involve acupuncture, and

other times a comprehensive therapy of acupuncture

and herbal medicine is employed. In almost all cases,

patients will also be taking conventional medications

for their condition. Those medications typically include

NSAIDS, DMARDS, COX-2 inhibitors, and

corticosteroids. Statistics show that when properly

prescribed, herbal medications and conventional

medications can work well together. Unfortunately,

statistics also show that many patients are not

informing their doctors of the other therapies they are

using. This fact is disturbing at best and potentiallyhazardous at worst. Medical doctors, rheumatologists,

and doctors of traditional Chinese medicine must

begin open and clear dialogue and communication in

order to ensure our patients are receiving the highest-

possible level of care, in order to most effectively treat

these very common conditions.

At the IMeG HealthTM

Clinic, traditional Chinese

medicine doctors are supported by up-to-date

knowledge of herb-drug interactions, and current

research studies in the field of TCM by some of the

finest TCM universities in the world. These materials

are available on our website atwww.imeghealth.com.

contributed by Bradley Matthews, Dr. TCM

iSaunders, Gould, MacPherson. Arthritis and Acupuncture:The Evidence for Effectiveness. Edited and produced by theAcupuncture Research Resource Centre. Published by theBritish Acupuncture Council, October 1998.

iiXuelian Tao, Jean Younger, Fred Z. Fan, Betty Wang,

Peter Lipsky. Benefit of an extract of Tripterygium WilfordiiHook F in patients with rheumatoid arthritis: A double-blind,

placebo-controlled study.

iiiEsmail, Nadeem. The Fraser Institute, Complementary

and Alternative Medicine in Canada: Trends in Use andPublic Attitudes, 1997-2006.

ivIbid.

vSubhuti Dhamananda. The Interactions of Drugs and

Herbs. Institute for Traditional Chinese Medicine, Portland,Oregon.

viIbid.

vii Ibid.
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Acupuncture Vancouver - Rheumatoid Arthritis