Many of our patients take several prescription and over-the-counter medications. This situation often causes a challenge for us, Chinese medicine (CM) practitioners. In 2017, 38% of Swiss people (over 15 years old) took medication every week. According to Frontiers in Pharmacology, this number increases annually. In Australia, an estimated nine million people (35% of the population) take a prescribed medication daily, eight million of whom even take two or more pharmaceuticals.

As a Reminder, Here are Some Basic Pharmacology Terms

Pharmacokinetics studies the effects of drugs in the body, from absorption to distribution, and the impact on metabolism to excretion. Pharmacodynamics deals with the effects of medicines—specifically, details on the mechanism of action, drug concentration, and doses. Pharmacological interactions describe how the drug achieves the therapeutic goal and the receptors affected by these actions. Pharmaceuticals are manufactured under controlled, low-germ or sterile conditions.

According to Health.gov.au, medicines are:

Substances that help our bodies – physically or mentally – to prevent, treat or cure diseases.

The term “medicine” is different to what we refer to as:

• Drugs, which is a broader term that includes medicines, alcohol, tobacco and illicit substances
• Medical devices encompass a wide range of products, including medical gloves, bandages, syringes, blood pressure monitors, prostheses, and stoma appliances.

As CM practitioners in Western countries, we primarily prescribe our patients pills, capsules, tablets, liquids, tinctures, granules, raw herbs, or creams. Prescribing suppositories or injecting herbs or saline solution directly into the acupuncture points is less common. Thus, we can assume that most of our prescriptions are taken orally. From my experience in practice, most patients take pharmaceuticals in this way, too.

The Paradigm of Chinese Herbal Medicine

Although most patients take medicine the same way (orally), they are prescribed using different medicine systems. We recall that the first compilation of herbs was created during the Eastern Han Dynasty, around 100 AD. It was known as the Shen Nong Ben Cao Jing. A total of 365 herbs were identified and classified. The first category contained the “top” 120 herbs (e.g., Ren Shen and Huang Qi), which could be taken daily. The following class (also 120 substances) was that of the “middle” herbs (e.g., Dang Gui and Bai Shao), which should be taken to prevent disease, and the remaining 125 “lower” herbs (e.g., Fu Zi and Ban Xia) were considered a means of treating illness. Because of their toxicity, these substances should only be taken briefly.

Example – Chang Pu (The first remedy of the upper category)

• Rhizomes of Acorus gramineus
• Acrid flavour, warm, non-toxic
• Treats wind-, cold/ and damp-related bi impediment and counterflow cough with the ascent of qi; opens the apertures of the heart; supplements the five zang organs; unclogs the Nine Orifices; brightens the ears and eyes; and makes the sound of the voice come forth.
• Consumed over time, it lightens the body, staves off forgetfulness and confusion, and extends the years.
• Grows in ponds and marshes.

(Shen Nong Ben Cao Jing The Divine Farmer’s Classic of Materia Medica translated by Sabine Wilms, Ph.D.)

In Shen Nong Ben Cao Jing, herbs are listed with their thermal energetics and five flavours. This book continues to inspire me personally to this day. How come? Because it connects me to the origins of our medicine. Unfortunately, the other side of the coin is that our medicine speaks a language and has a philosophy that seems complex or abstract to those who do not regularly use it. To this day, the “compilation” of Materia Medica is maintained in China to support research in CM.

In contrast to the categorisation and description of herbs, formulas combine these individual substances. Typically, formulas are divided by pattern (of the disease). Classic formulas are popular because they have been used for several centuries and promise a synergistic effect, particularly in reducing toxicity. But formulas balance many individual factors, and we cannot tell which ones.

But just because “our” herbs are products of nature does not mean that they cannot be poisonous or interact with one another. Certain herbs are incompatible; some have antagonistic effects, while others inhibit each other, which can also amplify their impact. Chinese drug therapy is complex in prescribing formulas and individual substances and requires much knowledge and experience.

The Apparent Differences Between Pharmaceuticals and Herbs

Pharmaceuticals are manufactured synthetically, while medicinal plants are considered natural products in CM. The quality of the substances depends on numerous factors (soil, region, weather, harvesting methods, etc.), and consequently, the composition of these plants’ “chemical compounds” also varies. As stated and discussed above, as CM practitioners, we are not interested in the individual components, but rather in the overall effect of a formula on the disease pattern we diagnose. Often, the formulas we prescribe are intended to relieve multiple symptoms of a pattern. We may add individual herbs to a formula (such as for constipation or dizziness). Still, we always aim to support the organism holistically and create a “harmony” that the patient experiences as well-being.

One reason our patients take a lot of medication is that conventional medicine prescribes its “remedies” so that each one treats an isolated symptom. Although drugs are “tested” for over 15 years before they are used on people, nothing says anything about the extent of their effect. An excellent example of this is Viagra, which was initially designed for use in cardiovascular problems and is now sold for erectile dysfunction.

I wanted to reiterate that CM and conventional medicine employ fundamentally different treatment methods. This is another factor that complicates the estimation or avoidance of interactions between Chinese herbs and pharmaceuticals.

How can we ensure the safety of Chinese drug therapy for our patients?

That is the question we aim to answer in this brief article. We know that the interaction between herbs and pharmaceuticals is a crucial and complex issue, as both systems of medicine are utilised by patients worldwide. Interactions can occur between herbs and medications, as well as between individual pharmaceuticals and between individual herbs. Unfortunately, such interactions between different patient medicine components are complicated to predict.

1. Pharmacokinetic and pharmacodynamic interactions: Chinese herbs can affect the absorption, distribution, metabolism, and excretion of pharmaceuticals, potentially altering their efficacy and safety. It may also be that the mechanism of action can lead to a strengthened or weakened result.
2. Enzyme induction and enzyme inhibition: Chinese herbs can induce or inhibit enzymes in the body, resulting in altered drug levels in the blood and thus causing suboptimal effects or side effects.
3. Herb-Drug Interactions: Herbs with blood-thinning properties may interact with anticoagulant medications, leading to a higher risk of bleeding.
4. Interactions between herbs and supplements: Due to limited research, it is challenging to predict whether and how these substances will interact.

As you can easily see, this is a complex matter because existing databases only contain individual substances. To the best of my knowledge, there is no central location where Chinese formulas are compared to dietary supplements or pharmaceuticals. I asked a few universities and received the following sources:

• You can find a database here where you can query individual medicines.

Western Sydney University (NICM) initiated a project (database) a few years ago, but it was unable to continue due to a lack of funds. However, I was informed that this project will be reopened over the next year.

I have a rule of thumb in my practice:

• If the patient is taking multiple pharmaceuticals, I will not prescribe herbs. I believe there are not enough reliable sources to estimate possible interactions. The patient can at least benefit from acupuncture and our advice on potential lifestyle changes.
• If the patient takes many nutritional supplements (mainly if another complementary medicine practitioner prescribed them), I will not prescribe herbs and “only” offer acupuncture.
• If the patient is motivated to stop taking one or more pharmaceuticals, I will only agree if the treating doctor is informed and can carry out regular blood tests. I typically set a timeframe of three to six months for such undertakings.
• If the patient takes three or four common medications, I will prescribe herbs after working with the person on a detailed plan for when they are taking the herbs. All Chinese medicines must be taken at least two hours before or after the pharmaceuticals. Additionally, the patient must continue to undergo regular blood tests.

Unfortunately, there are no precise instructions on the use of Chinese herbs in combination with pharmaceuticals. But we must protect our patients from harm, and although I don’t like to admit it when in doubt, I am very cautious about prescribing herbs because too many factors could cause injury.

References

http://www.itmonline.org/safety.htm

Sperber, G. (2007). Integrated pharmacology: combining modern pharmacology with Chinese medicine. Blue Poppy Enterprises, Inc.