Etiology and Pathology of Bone Bi (16)
TREATING ADVANCED ARTHRITIS
WITH CHINESE HERBS
During the past year, serious concerns have been raised about one of the most important pharmaceutical therapies for persistent arthritis, the selective COX-2 inhibitor drugs. These non-steroidal anti-inflammatory drugs (NSAIDS) are potent analgesics that were developed specifically to avoid the gastrointestinal and renal side effects common to previously used drugs by focusing on a particular pathway: reducing the prostaglandins produced by the action of COX-2 enzyme (cylooxygenase-2) without inhibiting the COX-1 enzyme. The COX-2 metabolites have functions other than contributing to pain, such as the beneficial effects of limiting thrombosis and promoting vasodilation. As a result, when COX-2 is strongly inhibited by high doses of the drugs used over an extended period of time in the absence of simultaneous COX-1 inhibition, they can increase the risk of vascular events such as heart attack and stroke (1). Some of these drugs were pulled off the market abruptly, though a return to market with significant warnings is likely because of the symptomatic relief the drugs have provided to people with advanced arthritis.
A number of arthritis sufferers who have been on these drugs are likely to seek alternative remedies, looking to natural therapies that might have less risk. Although great progress has been made in recent years towards making the herbal therapies safer, ancient remedies are not themselves inherently safe. So, when examining traditional medicine approaches to treating advanced arthritis, some herbs listed in potentially useful formulas have to be avoided. For example, an herb that had been widely used in Chinese arthritis remedies, stephania, had to be removed from the market a few years ago because its most common source material, a species of Aristolochia, contains aristolochic acid, a substance that could, in rare cases, cause renal damage and renal failure (2). In an attempt to avoid herbs that might sometimes have Aristolochia as a source, other Chinese herbs frequently used for arthritis, such as clematis and sinomenium (which are rarely substituted by Aristolochia), and herbs in the Aristolochiaceae family that may contain aristolochic acid (e.g., asarum), have been removed from most products and are only available from a few suppliers who are willing to go through the steps necessary to assure absence of aristolochic acid.
Other Chinese materials included in arthritis formulas might be safe to use in their traditional form, but are classified as toxic and should not be used; examples are scorpion and scolopendra (which are toxic as live animal stings, but far less toxic when ingested orally) and strychnos (the processed seeds used in Chinese formulas contain 1/10 the strychnine of the toxic raw seeds). Adverse cardiac effects have been associated with ephedrine from ma-huang, an herb that is traditionally used in some arthritis treatments; the reactions have not been associated with complex Chinese herb formulas. Some Chinese prescriptions specify use of raw aconite, which is toxic; processed aconite is safe to use and is the only aconite referred to in this article.
With these herbs left out, the formulas are safe for most users. Nonetheless, prolonged reliance on high dosage of herbs for arthritis should be accompanied by adequate monitoring, as is often done with drug therapies. Thus, for example, one should be alert to warning signs of rare adverse reactions.
A potential advantage of using herbs is that, in addition to alleviating arthritis pain, they may provide some positive effects that are not attained from drugs aimed solely at reducing pain due to inflammation. For example, there is an established herbal benefit of improved circulation, just the condition that could be impaired by the COX-2 inhibitor drugs. In fact, improving circulation to the limbs may be one of the important therapeutic approaches for alleviating arthritis pain. Persons with advanced arthritis often have limited capability for physical exercise, which contributes to worsening circulation in the limbs, which might be partly countered by herbs. The authors of an investigation into blood flow in arthritis patients noted (3):
The results revealed that the disorder of limb blood circulation clearly exists in patients with rheumatoid arthritis. This disorder was closely related to endovasculitis and increased blood viscosity, which interact and facilitate thrombosis of the microvenous system to bring about a series of clinical manifestations. Rheumatoid arthritis belongs to the category of stubborn rheumatism in traditional Chinese medicine….The authors lay stress on the application of blood activating and stasis removing drugs in treating rheumatoid arthritis.
In a previous article by the current author, numerous traditional and modern formulas for arthritis were analyzed to reveal the most commonly used ingredients (4). Generally, those formulas were especially suitable for treating newly diagnosed cases of arthritis or cases of mild to moderate severity in which "external pathological factors" affecting a person with deficiency syndrome is the dominant etiology. A tablet formulation called Chiang-huo 13 was produced to follow the common approach, and has been in use for many years with no adverse effects reported. A feature of this type of formulation is reliance on herbs that are categorized as dispelling wind-chill or wind-damp, such as chiang-huo, siler, cinnamon twig, chin-chiu, and tu-huo.
Persistent severe arthritis is more difficult to treat and usually involves a focus on different therapeutic principles and herbs, particularly those that fit the Chinese therapeutic categories of vitalizing blood and resolving "hidden phlegm" or "phlegm turbidity" that obstructs the channels. It was pointed out in another article by the current author that the "hidden phlegm" syndromes often correlate with what we think of as blood stasis syndromes (5).
This article briefly reviews the work with four sample formulations based on a new approach to treatment: Wangbi Chongji; Shuguan Wenjing Chongji and Shuguan Qingluo Chongji; and Fengshi Xiandan. The term "chongji" in the first three formula names refers to the form of preparation: these are instant tea granules, produced by making the extract of the herbs and then combining it with sugar and forming into large granules that will dissolve when hot water is applied; the fourth formula is made into pills (dan).
This formula was developed by the famous physician Jiao Shude, who is widely known for his work in the treatment of arthritis. Western practitioners may know of him through the popular work Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shude (6). Jiao was born in Hebei Province in northeastern China in 1922. He began studying medicine as a child with his grandfather. In 1941, at the age of 19, Dr. Jiao opened a medical practice in his hometown and simultaneously entered the Tianjin Medical College. In 1946 he passed his medical examinations and was officially licensed. In 1950 he began to work in Beijing as a doctor of internal medicine and in 1958, Jiao joined the Beijing Chinese Medical College faculty where he taught and practiced for the next 27 years. In 1984 he began working at the newly established China-Japan Friendship Hospital in Beijing, where he continues to practice. He is also a visiting lecturer and practitioner at other facilities in Beijing.
Jiao further developed traditional ideas in the diagnosis and treatment of rheumatic joint disease (bi syndrome; literally: obstruction syndrome) in the light of modern knowledge. Working from the traditional categories of gubi (bone bi or, as commonly used, bony bi; see etiology diagram) and wanbi (stubborn bi), both of which often involve joint deformity and is understood to involve phlegm obstruction of the meridians, he described a new type, which he calls wangbi (the character used for wang is similar to one used to denote crooked, bent or distorted). The disorder is characterized by changes in the joint's physical form, along with deterioration of the bone and difficulty extending the limbs. Its basis is blood stasis that is worsened by kidney yang deficiency (which also contributes to weakness of the bones) along with the usual factors that induce bi syndrome, such as cold, damp, and wind. The etiology is similar to that clearly presented for wanbi (which can include deforming rheumatoid arthritis, gout, and ankylosing spondilitis) in the text Rheumatology in Chinese Medicine (7):
When painful obstruction is chronic, the channels' blood and qi are slowed down and obstructed by the presence of external pathogenic influences. This causes stasis of blood and [accumulation of] turbid phlegm, which settle deeply in the joints. At this point they are very difficult to eradicate. Phlegm and blood stasis meld together, further aggravating the blockage…the pain becomes stabbing and excruciating.
Jiao emphasized the blood stasis aspect, and considered that by warming the kidney yang, the flow of qi and blood would be restored. In 1983, the China National Chinese Internal Medicine Association chose wangbi, along with Dr. Jiao's methodology for treating it, to be investigated nationwide at numerous provincial hospital sites. The patent formula used to treat this pattern, Wangbi Chongji, has received national awards. Following five years of study, in 1986, a second generation of formulas was created on the basis of Jiao's model, called Wangbi Health Restoring Formula 1 and 2. These formulas also received national awards for excellence (8). Dr. Jiao has published articles about his concepts of arthralgia, such as Personal Experience in the Diagnosis and Treatment of Rheumatoid Arthritis and Pattern Identification and Treatment Differentiation as Applied to Wangbi.
The precise formulation for Wangbi Chongji has not been published, and this is a common procedure when the manufacturer wishes to protect their special formulations from being copied. Also, at least three formulations are mentioned above: the original and two modifications. The following ingredients have been listed for the formula; they are presented here divided into therapeutic categories for ease of interpretation (not all ingredients are in a single formulation):
The dominant therapeutic approaches here are tonifying the kidney, warming the body, and vitalizing blood; some of the standard herbs for dispelling wind-chill and wind-damp, used in the anti-arthralgia formulas designed for early and intermediate stage arthritis, are also included. Of the items listed, ingredients that are usually avoided in Western practice are ma-huang, clematis, and scolopendra; pangolin scales are sometimes not available due to endangered species concerns (in China there is a plentiful supply because the animals are raised on farms). The formula is produced by the Benxi Third Pharmaceutical Factory. It comes in packets of 10 grams, and is taken 1-2 packets each time, three times a day.
In clinical work, the formula is mainly used for arthritis and gout. For arthritis, data for 332 patients collected from the medical units in China suggest its effectiveness (some degree of improvement in symptoms) for about 70.8% of those who use it (9). A report on use of a similar formulation for treating wangbi involved an extract of epimedium, curculigo, morinda, cibotium, dipsacus, rehmannia, pine node, carthamus, and sparganium (10). These herbs were extracted and dried, and put into capsules; patients took 4 capsules, three times daily for 60 days. It was claimed that all but 4 of 43 patients so treated had improvement in their clinical condition, especially for pain, swelling, and morning stiffness.
The potential role of phlegm obstruction in advanced rheumatoid arthritis is still important to consider. Wei Song wrote an article on treating wanbi, emphasizing this aspect (11). He noted that:
Invisible stubborn phlegm plays an important role in the pathogenesis of wanbi. If stubborn phlegm isn't eliminated, wanbi won't be healed. Based on the principle of warming transformation (wenhua), the author treated the disease with sinapis, typhonium, silkworm, arisaema, etc. This approach can markedly improve the curative effect of treatment and restrain the condition of wanbi.
This method of therapy, based on resolving phlegm with these herbs, is briefly described by Yang Yifan in her book comparing the effects of various Chinese medicinals (12):
The herbs that transform wind-phlegm are arisaema, typhonium, sinapis, silkworm, gastrodia, pinellia, bamboo sap, and bamboo silica. These herbs are used in clinical practice to treat cramp, numbness, tingling, heaviness and pain in the limbs, facial paralysis, facial spasm, epilepsy, hemiplegia, migraine, neuralgia, and arthritis. They are often used together with herbs that regulate the qi and blood, expel wind-dampness, and extinguish internal wind.
In the above list, the last four herbs are primarily given for the problems of facial paralysis and spasm, epilepsy, and hemiplegia. The Wangbi Chongji formula includes one herb specifically for resolving phlegm, gleditsia (see photos). In the book on his lectures, Jiao mentions use of gleditsia for arthritis:
When I am treating enduring and severe illnesses such as arthritis, wind strike with hemiplegia, or rheumatoid arthritis, I often add gleditsia to the formula prescribed for the pattern, whether it be in pill, powder, or other forms. Adding an appropriate amount of gleditsia spine not only increases the formula's ability to quicken the blood and channels, it also guides the medicinals "directly to the site of disease," which definitely increases the effectiveness of the formula.
Of all the yang tonifying herbs that are used for this condition, Jiao emphasizes the use of epimedium, pointing out that "it is warm in nature and acrid in flavor, dispels wind-cold, supplements the liver and kidney, and strengthens the sinew and bone." By eliminating the external pathogenic factors and supplementing the weakened organs and bone, epimedium is ideal for the treatment of wangbi (and the conditions of gubi and wanbi) when combined with herbs that resolve phlegm (e.g., gleditsia) and vitalize blood (e.g., red peony, carthamus, and achyranthes).
The Shuguan formulas (shuguan means to clear away the obstacles) were mentioned in articles by a research group about a single study published both in the Journal of Traditional Chinese Medicine (13) and the Chinese Journal of Integrated Traditional and Western Medicine (14). The formulas were given to advanced arthritis patients; the matched control group received the already well-established Wangbi granules. The ingredients mentioned in the articles for these two formulations were:
Shuguan Wenjing: epimedium, dipsacus, aconite, rehmannia, clematis, sinapis, eupolyphaga, scolopendra, and millettia
Shuguan Qingluo: rehmannia, ho-shou-wu, photinia, chin-chiu, campsis, euonymus, arisaema, wasp nest, earthworm
The first formula was given to patients diagnosed primarily as having yang deficiency, while the second was given to those with yin deficiency. Since the patients were specifically selected for having advanced arthritis, the level of response to treatment was less than that reported above, but was in the range of 36-44%, with the Wangbi formula having the higher total effective rate, though on some categories of symptom evaluation, the Shuguan formulas performed somewhat better than Wangbi granules.
While Shuguan Qingluo includes several ingredients not commonly found in the other formulas for arthritis, Shuguan Wenjing has characteristics similar to the Wangbi formula, in tonifying kidney, warming the body, and vitalizing blood (for information on unique ingredients, see table). The use of sinapis and arisaema illustrates the approach of resolving hidden phlegm to treat advanced arthritis.
The Shuguan formulas were manufactured for the clinic conducting the study and are not commercial products. It was reported that 16.5 grams of crude herbs were extracted for each packet of the granules, and the dosage used was one packet each time, three times a day; this corresponds to the decoction of about 50 grams of herbs per day. A course of treatment was three months, which was the observation period. Outside China, the ingredients scolopendra and wasp nest are usually avoided due to concerns for toxicity.
Formulation principles along the lines outlined above continue to be advocated, even for earlier stages of arthritis. In a 2003 article in the Journal of Traditional Chinese Medicine (15), a formula called Fengshi Xiandan was evaluated for rheumatoid arthritis (fengshi means wind-damp and is the ancient designation of arthritis; xiandan is the ancient term for special pills of the immortals, indicating a highly-valued remedy). The formula ingredient list given was:
epimedium, curculigo, morinda, cibotium, rehmannia, scrophularia, peony, anemarrhena, carthamus, sappan, viola, taraxacum, scorpion, scolopendra, arisaema, and sinapis.
Here, both arisaema and sinapis are included, along with yang tonics and blood vitalizing herbs; the formula is warming in nature. Its unique feature is adding two "antitoxin" herbs, viola and taraxacum, which are mainly used in cases of early stage arthritis (13 of the 53 patients treated had cases of recent onset, and only 4 had late stage arthritis). Anemarrhena and scrophularia are examples of herbs that help nourish the yin and prevent the strong warming and dispersing herbs from further weakening the kidney yin; the formula reportedly produced no side effects.
Fengshi Xiandan was produced by grinding the herbs to powder and forming them into pills. The pills were administered orally, 10 grams each time, three times per day, with three months as a course of therapy; the patients were treated for two courses. A control group was given indomethacin, and the result of treatment outcome was claimed to show that the herb treatment provided significantly better results than the drug, with fewer adverse reactions (all the adverse reactions reported for the herbs involved gastro-intestinal responses, and these occurred only about only about 1/4 as frequently as with the drug, which also produced other types of side effects). The herb formula's benefits were especially noted in reducing the duration of morning rigidity (from an average of 49 minutes to about 19 minutes), greatly reducing the tenderness of the joints, and improving both walking speed and grip strength of the hands.
Sinapis is commonly used in the formulas for advanced arthritis. In an extensive article on treatment of bi syndrome (16), the functions of this herb were described:
Sinapis is spicy and warm; it disperses cold, dissolves wetness, opens the meridians, and reaches the luo vessels; it reduces swellings and relieves pain; it is the essential herb for reducing swelling and for analgesia in the treatment of rheumatoid arthritis.
Of the numerous yang tonics employed along with the key herb epimedium, the frequently used ingredients are dipsacus, morinda, curculigo, and cibotium. Yang Yifang compares these ingredients and notes that
Morinda is an excellent herb for tonifying the kidney yang because its warm-sweet nature will not bring about harsh, drying, or cloying side effects. Comparing morinda to curculigo and epimedium, it is the best one for tonifying the kidney yang and treating weakness of the legs and knees, chronic bi syndrome, and sexual disorders….Cibotium's function is similar to that of dipsacus, but it is stronger in expelling wind, dampness, and cold, and regulating the qi and blood. It is used for pain and stiffness of the joints and muscles in chronic bi syndrome.
She notes that curculigo is slightly toxic and should not be used for a prolonged treatment (however, a literature review of curculigo fails to reveal toxic components, so this issue is worthy of further investigation). Cibotium is currently restricted for importation due to endangered species concerns for the ferns, of which this is one. Dipsacus, which is stronger at vitalizing blood circulation might be used as an alternative to cibotium for the late stage of arthritis. For persons who suffer from evident coldness, addition of aconite and/or psoralea will increase the warming effect of the treatment.
Rheumatoid arthritis is often described in the traditional Chinese system as stubborn bi (wanbi) or bone bi (gubi) and the advanced cases are characterized by deformity of the joints with deterioration of the bone structure, which Jiao Shude has dubbed wangbi. Though wangbi-and the herb therapy used to treat it- overlaps with osteoarthritis, it is a description aimed at patients with rheumatoid arthritis. Treatment of these rheumatic conditions is addressed through nourishing the kidney (and liver) to strengthen the bones and tendons and to relax the stiffness, warming the meridians and dispersing hidden phlegm and stagnant blood to reduce swelling and alleviate pain, and by dispersing wind-damp and wind-chill which represent the external influence that aggravates the disease. Key herbs in the treatment include epimedium (with a variety of other yang tonics, such as dipsacus), rehmannia, peony, carthamus, and sinapis. In China, it is common to incorporate animal materials (which are thought to penetrate more readily the obstructed meridians) with reliance on scolopendra, scorpion, pangolin scales, earthworm, and eupolyphaga; the last two are still commonly used outside of China, being non-toxic and plentiful in supply. The effect of the therapies may be to reduce the inflammatory processes while also invigorating the circulation, and this may be a potential solution to those who try Chinese herbs as an alternative to the COX-2 or other anti-inflammatory drugs.
Herbs mentioned in formulas that are infrequently used (see reference 4 for commonly used ingredients)
| Herb | Main Actions | Comments |
| Campsis lingxiaohua | vitalizes blood, breaks up stagnation, cools blood, dispels wind | Campsis is used for blood stasis syndromes combined with invasion of wind; it is not commonly used for treating arthritis. |
| Euonymus weimao | regulates blood, removes stagnation, alleviates pain | Euonymus is used for pain associated with blood stasis, and is applied in cases of postpartum abdominal pain and arthritis. |
| Lycopodium shenjincao | eliminates wind and dampness; relaxes tendons and unblocks luo vessels | Lycopodium is used in cases of arthralgia in which there is tightness of the fingers or limbs associated with contraction of the tendons. It is also used for trauma that causes or worsens the disorder. Gleditsia is in the same plant Family. |
| Photinia shinanye | eliminates wind, nourishes kidney | Photinia is used in arthritis associated with kidney deficiency, typically used for low back and leg pain, and when there is weakness of the tendons and bones. Often Piper puberulum, or other Piper species are used in place of photinia. |
| Pine node songjie | dispels wind and dries dampness, analgesic | Pine node is given for severe pain, usually associated with cold blockage and advanced arthritis. It is also used for pain due to trauma. |
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| Gleditsia sinensis Gleditsia spine, zaojiaci, is used by Jiao Shude for resolving phlegm obstruction in treatment of advanced arthritis. Other physicians may rely instead on arisaema or sinapis for that purpose. | |
May 2005