AN ANALYSIS OF CHINESE HERB
PRESCRIPTIONS FOR RHEUMATOID ARTHRITIS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

INTRODUCTION

Arthritis is a general term for joint (Greek: arthron) inflammation (Greek: itis). The main symptoms are pain, swelling, and stiffness. The cause of the disorder is an immune-based disturbance primarily affecting the joint fluids. There are several types of arthritis, but there are two basic forms mentioned in modern literature that occur frequently: rheumatoid arthritis and osteoarthritis. Rheumatoid arthritis is characterized by autoimmune attacks that usually come and go, and it may be influenced by numerous factors that alter the immune functions, including infections, dietary components, and stress. Osteoarthritis also involves some autoimmune responses, but is characterized by a gradually worsening degradation of the joint spaces, leading to sharp, fixed pain that persists. Although both disorders can begin at any of the joints, rheumatoid arthritis most often affects the upper body first (fingers are frequently the first site), while osteoarthritis most often affects the lower body first (hips and knees are commonly affected). Rheumatoid arthritis tends to be felt for the first time at a somewhat earlier age than osteoarthritis, with rheumatoid arthritis usually starting before age 50 and osteoarthritis usually starting after age 50. Women are more likely than men to suffer from arthritis of both types.

Arthritis has been a recognized medical condition since ancient times, and the Chinese had developed numerous formulas for its treatment. Chinese herbal formulas were not specifically designed for either of the two major types of arthritis defined today. The basis for Chinese doctors differentiating arthritis into subgroups was not the microscopic details of the pathology. Instead, arthritis was divided into traditional medicine categories: hot and cold types, upper and lower body involvement, deficiency or excess syndrome, pain characteristics (such as variability and severity), and whether the site of the arthritis was fixed or "moving." Both rheumatoid arthritis and osteoarthritis fall under the heading of bi syndrome, a disorder of qi and blood circulation that leads to symptoms of pain, numbness, swelling, and stiffness. Rheumatoid arthritis fits most closely those syndromes characterized by the Chinese as wind-damp invasion affecting the joints. Osteoarthritis more closely fits the syndrome of liver/kidney deficiency syndrome causing weakness and stiffness in the legs with painful joints.

In China, syndromes similar to rheumatoid arthritis were an area of special concern, generating considerable literature on the subject, since the condition could arise suddenly and could rapidly become severely debilitating. Osteoarthritis, on the other hand, tended to be lumped together with other disorders of aging, in which stiffness and pain, especially of the legs, was considered just one part of the gradual deterioration of body functions that occurs with old age. As such, it is usually not the subject of much discussion separate from antiaging therapies. The formulas described in this article mainly fit the category of rheumatoid arthritis treatments.

There are three key pathological factors addressed by the formulas: wind, damp, cold:

• Wind (feng) refers to the sudden onset of the disease, mobility of the affected site (mobile bi syndrome), variability of the manifestation of symptoms, and sensitivity to changes in the environment (see: Drawing a concept: feng). Wind-dominant arthralgia most often affects the upper body and corresponds to the early stage of rheumatoid arthritis. Deficiency of qi and blood allows wind to more easily penetrate the body and cause pain.
• Damp (shi) refers to the worsening of the symptoms in damp weather, the initiation of the disease or worsening of symptoms after spending time working in a wet environment (such as wading in water or sleeping on damp ground), and the accumulation of fluid in the joints and/or nearby areas of the limbs (see: The six qi and six yin). Dampness-dominated arthralgia most often affects the lower part of the body and is characterized by swelling and stiffness of the joints, and accompanying sensations of numbness; it may correspond to a middle stage of rheumatoid arthritis (that is, after the disease has become chronic, with less variability of affected joints). Disorders of fluid metabolism, especially a weakness of spleen function, will aggravate dampness and the resulting joint dysfunction.
• Cold (han) refers to the worsening of symptoms with exposure to cold, improvement by applying heat (including liniments that cause increased local circulation), and impaired circulation associated with declining kidney yang that most often occurs with aging (see: Exploring yin/yang #6: cold and heat). Cold-dominated arthritis especially affects the extremities (hands and feet) where circulation is poorest, as well as the lower back-the site of the kidneys. The kidney yang, if deficient, is unable to dispel chilliness. Exposure to cold may initiate arthritis; however, the more common association is with advanced arthritis in which the internal metabolism (qi and yang aspects) are debilitated by chronic disease and aging, yielding a cold syndrome. More rarely, there can be a hot type arthralgia, initiated perhaps by excess exposure to the hot sun during the summer, and manifesting with redness of the joints.

The closest traditional Chinese medicine term to rheumatoid arthritis is fengshi bing which literally means wind-damp disease. The wind and damp factors can complex with either cold or heat factors to yield arthralgia. Almost all of the traditional approaches apply to the complex involving cold factors rather than heat. Gout, which has some characteristics in common with arthritis, usually fits the cold-dominated category or the cold-damp category of bi syndromes.

Cold, wind, and dampness cause stagnation of circulation within the channels (meridians; blood vessels). According to the Chinese medical concept, when these pathological factors are dispelled, the circulation returns to normal and the disease goes into remission. If the disease has been experienced for a long period of time, the blood becomes static (a more severe condition than poor circulation). Eventually, the initiating factor (wind) becomes less prominent and the stagnation dominates, with blood stasis an increasing concern. Therefore, in the treatment of the chronic and advanced disease, there is more emphasis on overcoming static blood than when treating an earlier and more variable phase of the disease.

BASIS OF THE ANALYSIS

One can use the traditional Chinese description of arthritis to suggest herbs and formulas to use for each patient. However, rather than devising unique formulations for each patient, it is common practice throughout the Orient to make use of a relatively small group of arthritis formulas that are believed be very successful. In this article, 31 such formulas that are in the current literature and based on the traditional approach are analyzed to reveal their commonly used ingredients and the patterns of formulation that have been relied upon. The sources of the prescriptions were as follows:

1. Two publications of the Oriental Healing Arts Institute (OHAI): the compendium Commonly Used Chinese Herb Formulas with Illustrations (1) and the journal articles in OHAI Bulletin devoted to rheumatism and gout and their Chinese herb treatment (2).
2. The English-language rheumatology books Bi Syndromes (3) and Rheumatology in Chinese Medicine (4) based on traditional Chinese herb prescriptions.
3. The formula reference books Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine (5) and Chinese Herbal Medicine Formulas and Strategies (6).
4. The books on patent remedies available in English, Chinese Herbal Patent Formulas (7), Handbook of Prepared Chinese Herbal Formulas (8), and Chinese Patent Medicines (9). In addition, one Japanese patent remedy based on a popular Chinese patent and approved by the Japanese Ministry of Health, was also included in the listing (10).

Formula selection was based on two main factors:

• The indications for the prescription suggest that it could be used in the treatment of arthritis associated with any combination of wind, damp, and cold factors. Formulas specifically designed for unusual cases of arthralgia, such as heat-dominated arthritis, were not included.
• The presence of common Materia Medica items in the prescriptions, with non-toxic ingredients being the dominant components of the formulas.

The selection of formulas will have some influence on the outcome of the analysis, so an effort was made to include formulas that were described in several different texts, indicating their importance to the study of traditional Chinese medicine.

Table 1: Arthritis Formulas. This table displays the names of the formulas, the list of ingredients, and some comments about each of the formulas. In the first column, the pinyin transliteration of the Chinese formula name is given first, followed by the common name (OHAI system) if available, and then the references to the source texts (which have been listed above). In the ingredients column, the herbs have been listed in order from the most frequently used to the least frequently used (see Tables 2 and 3), followed by a short list of some rarely used items (after "plus"). The final column gives the Chinese traditional source text (STNA denotes source text not available) and some comments about the use and application of the formulas.

MAIN HERBS IN THE SELECTED FORMULAS

Table 2 lists 8 herbs as "standard herbs" for arthralgia syndromes. They are broadly used in constructing arthralgia formulas and were included in at least half of the formulas listed in Table 1. There were another 21 herbs, listed in Table 3, that serve as adjunctive therapies; they each were present in at least 4 of the formulas. Each of these 29 herbs are described in some detail below, with the herbs presented from most frequently mentioned (21 times for tang-kuei and siler) to least frequently mentioned (4 times for coix, persica, scute, and phellodendron). In both Tables, the common name and pinyin name for the herb is given in the first column, followed by the botanical name and the plant family (in parentheses) in the second column. Traditional actions are from Oriental Materia Medica (11) and only include those that are related in some way to treatment of arthralgia.

Table 2: Standard Herbs. The following herbs are routinely used in arthritis treatments and are not specific for a location or type of arthritis. In some cases, more than one variety of an herb can be used. For example, with cinnamon, the twig is most often utilized, but cinnamon bark, considered more warming, is included in some formulas; white atractylodes, which serves as a qi tonic, is more often used than red atractylodes (for clearing dampness), but sometimes both are included in the formulation; white peony, the blood-tonifying herb, is more often used than red peony, which may be substituted when a stronger blood-vitalizing action is desired.

Table 3: Adjunctive Herbs. The herbs in this section are used for particular types of arthralgia or particular constitutional conditions of the patient. The herbs may be selected to address the dominance of one of the three factors contributing to bi syndromes: wind (e.g., use ma-huang or angelica); damp (e.g., use tu-huo, hoelen, clematis, stephania, or coix); or cold (use aconite or asarum). Further, the herbs may be selected for deficiency syndromes: for weakness add astragalus; for kidney/liver deficiency add rehmannia, eucommia, and achyranthes; for blood-stasis syndrome add persica and carthamus; for stiffness add chin-chiu and chaenomeles; for underlying heat syndrome, add scute and phellodendron.

CHARACTERISTICS OF THE COMMONLY USED HERBS

There are at least three important characteristics of the herbs listed in Tables 2 and 3 in relation to treatment of arthritis: the common nature and taste of most of the herbs; the fact that several of the listed herbs are components of widely used traditional tonic formulas; and the reliance on herbs from a particular plant family with a similar group of active constituents.

As to the nature and taste of the herbs, nearly all are warming, or at least neutral (exceptions: peony, stephania, coix, scute, and phellodendron are cold-natured), and most are spicy (exceptions: licorice, peony, achyranthes, hoelen, rehmannia, eucommia, stephania, astragalus, chaenomeles, coix, persica, scute, and phellodendron). Even among the herbs that stand as exceptions to this rule, only very few of these are used frequently in the formulas that were analyzed, namely: licorice, peony, and achyranthes, all of which serve the role as tonics. The warm quality dispels cold, and the spicy quality dispels wind; the warm-spicy action disperses dampness accumulation and resolves stagnation at the surface (i.e., limbs, skin, flesh; not internal organs).

As to the correspondence of several key herbs to traditional base formulas, the following two formulas contribute several of the herbs that are used with high frequency:

1. Tang-kuei Four Combination (Si Wu Tang), which contains tang-kuei, peony, cnidium, and rehmannia; Tang-kuei Four Combination nourishes and vitalizes blood circulation; and
2. Four Major Herbs Combination (Si Junzi Tang), which contains ginseng, atractylodes, licorice, and hoelen. Four Major Herb Combination invigorates the stomach/spleen functions, tonifies qi, and promotes moisture circulation.

Deficiency of qi and blood flowing through the meridians makes the body susceptible to external pathological factors, such as wind, cold, and dampness. Qi deficiency further makes the body susceptible to developing internal chilliness or moisture accumulation that will merge with external cold and damp factors to worsen arthralgia. Blood deficiency will allow the development of internal wind secondary to liver dryness, which will merge with external wind to worsen arthralgia. The herbs in these two formulas are not specific for arthralgia, but, instead, are aimed at treating internal deficiencies that contribute to susceptibility to this and other diseases and that allow further progression of the diseases rather than spontaneous remission.

The plant family that dominates this group of herbs is the Umbelliferae, sometimes known as the "celery family" because it includes this well-known plant. The herbs in this family mentioned in Tables 2 and 3 are: tang-kuei (see Figure 1), siler (see Figure 2), chiang-huo, cnidium, tu-huo, and angelica. In all cases, the root material is used. The roots are fragrant, and there is a certain similarity in their odor that is attributable to the common active constituents. By contrast, the three Ranunculaceae herbs (peony, aconite, and clematis), the two Rosaceae herbs (chaenomeles and persica), and the two Leguminoseae herbs have only remotely related substances within each family group that contribute to their actions in the arthritis formulas (i.e., it is a coincidence that they fall into the same plant family).

The common active constituents of interest belong to the chemical category of benzopyrone derivatives, mainly the coumarins (e.g., osthenol) and the furanocoumarins (e.g., bergapten). These compounds have been claimed to reduce protein-rich edematous swellings (see: Chinese herbs for lymphedema) and they have some antiinflammatory actions that have been revealed in laboratory animal experiments. Of the formulas listed in Table 1, all but one formula contains at least one of the Umbelliferae herbs (Da Qinjiao Tang contains all six of them); the exception is Stephania and Astragalus Combination, an ancient formula for leg edema that has been adopted to treat arthralgia of the knee.

REPRESENTATIVE FORMULAS

There are five formulas presented in Table 1 (the first five listed) that are comprised almost entirely of the commonly used herbs for treatment of arthralgia and might be considered representative formulas:

1. Sanbi Tang (Chin-chiu and Tu-huo Combination)
2. Shujing Huoxue Tang (Clematis and Stephania Combination)
3. Duhuo Jisheng Tang (Tu-huo and Loranthus Combination)
4. Da Qinjiao Tang (Major Chin-chiu Combination)
5. Da Fangfeng Tang (Major Siler Combination)

Each of these formulas contains at least 14 ingredients from Tables 2 and 3, but few additional ingredients not listed in the Tables. All of these formulas contain Tang-kuei Four Combination (Siwu Tang: tang-kuei, peony, cnidium, and rehmannia) plus siler and licorice. Of these, Sanbi Tang and Duhuo Jisheng Tang are the most commonly referenced formulas in the modern literature devoted to traditional herb formulas for treatment of arthritis.

RESEARCH EFFORTS

The most recent Chinese medical literature on rheumatoid arthritis treatments, including English language publications as found in the Journal of Traditional Chinese Medicine and the Journal of Integrated Western and Traditional Medicine, reveal that there is much experimentation still going on with herbal recipes for rheumatoid arthritis. The new formulas may treat heat syndrome, blood stasis, phlegm accumulation, or other disorders that were not the principal targets (wind, cold, damp) of the more traditional approaches. In addition, they may utilize ingredients that are toxic and cannot be used in Western practice, such as the immune-inhibitor tripterygium or the powerful muscle stimulant strychnos. Such ingredients may have a more profound effect than the commonly used and gentle components of the formulas described above. Since Western patients are usually seeking treatments to substitute for the modern drugs that cause unacceptable side effects, the herbal prescriptions used must be essentially non-toxic.

Due to concerns about the quality of design, conduct, and reporting of clinical trials for Chinese herbs, rather than reviewing the broad range of reports that can be found by searching the literature, an example will be provided here to illustrate the claimed results and the duration of therapy that was indicated as sufficient to yield those results. The study was selected for its large number of patients enrolled.

The tableted formula Fengshi Hantong Pian (Rheumatism Cold Pain Tablets) was given to 310 patients suffering joint pain (12). The prescription included tang-kuei, chiang-huo, cinnamon, red peony, aconite, astragalus, clematis, coix, scute, sinemonium, deer antler, lycium, and corydalis. According to the report, after a course of treatment lasting ten days, marked pain relief was experienced by about 70% of the patients, with pain being the main arthritic symptom of concern. A 30 day course of this therapy produced normalization of ESR (erythrocyte sedimentation rate) and RF (rheumatoid factor) values in about half of the patients that were followed up (31 of 61 had normal ESR; 24 of 38 had RF turn from positive to negative).

This report, and information garnered from other Chinese studies, suggest that alleviation of pain may be expected during the first week of treatment, blood chemistry changes may be expected as early as the first month of treatment, and remission may occur from one month to several months after treatment begins in some patients. Since rheumatoid arthritis can have periods of spontaneous remission, the possibility that the herbs bring on an earlier or more complete remission can only be determined by very careful testing with large treatment and control groups.

Unlike steroid drugs that powerfully inhibit the immunological component of the disease and can produce results within 24 hours, the herbal compounds may need to first reach a certain blood concentration that requires two or three days of regularly consuming the herbs, and then there may be another few days in which the changes in metabolism and immune function eventually result in a reduction of the inflammatory process. Still, if given in adequate dosage and if the formula ingredients are suited to the individual, some improvements (most alleviation of severe pain) could be reasonably expected in the first 3-7 days. Patients should not need to pursue the therapy for several weeks to determine if it has any influence on their condition. Other effects may take longer. For example, with benzopyrones in the treatment of protein-rich edemas, it has been indicated that a treatment time of several months is required to markedly reduce the swelling. Typically, Chinese herbal therapies for chronic diseases, such as rheumatoid arthritis, are given for several weeks or several months to attain substantial improvements. This duration of time is consistent with traditional Chinese theories of treatment of deficiency syndromes that underlie the disorder: it simply takes time to overcome the visceral weaknesses so that pathologic factors can be expelled.

MECHANISM OF ACTION

Chinese researchers have attempted to elucidate how the herbs used in traditional arthritis formulas alleviate the symptoms-from the modern viewpoint-by carrying out numerous studies of the blood constituents of patients. According to studies that have been carried out recently (13, 14, 15), the mechanism of action that may be dominant in the situations with good therapeutic results is a reduction in the levels of pro-inflammatory cytokines, such as interleukin-1 (IL-1). The effect is then to alter the levels of T-cells and the production of activated antibodies and other components. In addition, or as a result, the properties of the blood and its circulation also change, with lowered sedimentation rate and improved circulation to the extremities. The herbs may also act on the prostaglandin synthesis and degradation pathways, yielding a lower level of pro-inflammatory prostaglandins.

REFERENCES

1. Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations, 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA.

2. Hsu HY, Neuralgia, rheumatism, and gout and their Chinese herb treatment, Bulletin of the Oriental Healing Arts Institute, 1979; 4(4): 16-27.
3. Vangermeersch C, and Sun Pei-lin, Bi-Syndromes, 1994 SATAS, Belgium.
4. Guillaume G and Chieu M, Rheumatology in Chinese Medicine, 1996 Eastland Press, Seattle, WA.
5. Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 1, 1993 Heilongjiang Education Press, Harbin.
6. Bensky D and Barolet R, Chinese Herbal Medicine: Formulas and Strategies, 1990 rev. ed., Eastland Press, Seattle, WA.
7. Fratkin J, Chinese Herbal Patent Formulas: A Practical Guide, 1986 Shya Publications, Santa Fe, NM.
8. Chun-Han Zhu, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA.
9. Chen Keji (editor), Chinese Patent Medicines, 1997 Hunan Science and Technology Press, Hunan, China.
10. Tsung PK and Hsu HY, Arthritis and Chinese Herbal Medicine, 1987 Oriental Healing Arts Institute, Long Beach, CA.
11. Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.
12. Wang Zhaoming, et al., A report on 310 cases of articular rheumatism treated with Fengshi Hantong Pian, Chinese Journal of Integrated Traditional and Western Medicine 1985; 5(5): 284-285.
13. Zhou Xueping, et al., Clinical and experimental study on treatment of mid-late stage rheumatoid arthritis with Shuguan Granules, Chinese Journal of Integrated Traditional and Western Medicine 1999; 5(3): 165-170.
14. Xu Desheng, et al., Clinical and experimental study on RA Mixture in treatment of rheumatoid arthritis, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(3): 178-183.
15. Li Shangzhu, et al., Changes in blood flow in the extremities in patients with rheumatoid arthritis and treatment with integrated traditional and western medicine, Chinese Journal of Integrated Traditional and Western Medicine 1996; 2(2): 115-116.

August 2000

Figure 1. Angelica sinensis; tang-kuei.

 

Figure 2. Ledeborella divaricata; siler.