AN ANALYSIS OF CHINESE HERB
PRESCRIPTIONS FOR RHEUMATOID ARTHRITIS
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:
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.
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:
Formula selection was based on two main factors:
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.
|Formula Name: Pinyin, |
Common Name, References
|Ingredients: Most Frequently Used Herbs/Additional Herbs||Source Text (with Author, Date), and Comments|
Chin-chiu and Tu-huo Comb.
|tang-kuei, siler, licorice, cinnamon, cnidium, peony, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, eucommia, ginseng, astragalus, asarum; plus dipsacus||Furen Liangfang (Chen Ziming 1237 A.D.). This formula nourishes qi and blood and addresses the three bi factors: wind, damp, and cold.|
|Shujing Houxue Tang|
Clematis and Stephania Comb.
|tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, achyranthes, chin-chiu, hoelen, ginger, rehmannia, angelica, clematis, stephania, persica; plus citrus||Wanbing Huichun (Gong Tingxian 1587 A.D.). This formula is widely used in Japan and Taiwan for lower limb arthralgia, and for lumbago and sciatica; it clears the meridians and vitalizes blood.|
|Duhuo Jisheng Tang|
Tu-huo and Loranthus Comb.
|tang-kuei, siler, licorice, cinnamon, cnidium, peony, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, ginseng, eucommia, asarum; plus loranthus||Qianjin Yaofang (Sun Simiao 652 A.D.). This is perhaps the best known and most widely used formula for arthralgia; also sold as a patent remedy; it tonifies liver/kidney.|
|Da Qinjiao Tang|
Major Chin-chiu Combination
|tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, chin-chiu, tu-huo, hoelen, rehmannia, angelica, asarum, scute; plus gypsum||Suwen Bingji Yiqi Baomingji (Zhang Yuansu 1186 A.D.). This formula is usually considered when there is muscle contraction and stiffness accompanying joint pain.|
|Da Fangfeng Tang|
Major Siler Combination
|tang-kuei, siler, licorice, chiang-huo, atractylodes, cnidium, peony, achyranthes, ginger, rehmannia, aconite, eucommia, ginseng, astragalus; plus jujube||Hejiju Fang (Imperial Medical Dept. 1085 A.D.). This formula was designed for pain and weakness in the legs due to downward flow of cold fluid; knee swelling may occur in such cases.|
|Shujing Lian San|
Clematis and Carthamus Formula
|siler, licorice, chiang-huo, atractylodes, cnidium, achyranthes, chin-chiu, tu-huo, hoelen, rehmannia, aconite, angelica, stephania, clematis, citrus, carthamus, persica, scute, phellodendron, others||Wangbing Huichun (Gong Tingxian 1587 A.D.). This formula is mostly used in Japan, where it is given to patients with recalcitrant arthritis producing severe pain.|
|Jianbu Huqian Wan|
(3, 4, 6)
|tang-kuei, siler, chiang-huo, atractylodes, peony, achyranthes, tu-huo, hoelen, rehmannia, aconite, ginseng, eucommia, astragalus, chaenomeles, coix, phellodendron; plus lycium, others||Shoushi Baoyuan (Gong Tingxian 1615 A.D.). This formula is designed for cases of kidney/liver deficiency resulting in weakness, stiffness, and pain in the lower body. The formula has been made into a patent medicine as well.|
|Shufeng Houxue Tang|
Stephania and Carthamus Comb.
|tang-kuei, cinnamon, chiang-huo, atractylodes, cnidium, hoelen, ginger, angelica, clematis, stephania, carthamus, phellodendron; plus arisaema||Shenshi Zunsheng Shu (Shen Jinao 1773 A.D.). This formula is used in cases of excess syndrome, with red, swollen joints.|
|Shangzhong Xiatong Yongtong Feng|
Cinnamon and Angelica Formula
|cinnamon, chiang-huo, atractylodes, cnidium, chin-chiu, angelica, clematis, stephania, persica, carthamus, phellodendron; plus arisaema, shen-chu||Xifang Jijie (Wang An 1682 A.D.). This formula is used to treat arthralgia that is due to an excess syndrome; therefore, it lacks most of the tonic herbs used in other formulas.|
|Fangfeng Tang |
|tang-kuei, siler, licorice, cinnamon, chiang-huo, chin-chiu, hoelen, ginger, ma-huang, scute; plus pueraria, apricot seed, jujube||Xuanming Lunfang (Liu Wansu 1172 A.D.). This formula is given to patients with wind-type arthritis, where the symptoms may vary considerably in intensity and site.|
Astragalus and Aconite Formula
|tang-kuei, siler, cinnamon, atractylodes, cnidium, peony, hoelen, rehmannia, aconite, astragalus||Yijianfang (Wang Shuo, Song Dynasty). This formula is designed to treat weakness and stiffness; it has a warming quality to treat cold-sensitive arthralgia.|
|Guizhi Shaoyao Zhimu Tang|
Cinnamon and Anemarrhena Comb.
|siler, licorice, cinnamon, atractylodes, peony, ginger; aconite, ma-huang; plus anemarrhena||Jingui Yaolue (Zhang Zhongjing 220 A.D.). This formula is used for treating those with swollen, stiff joints, especially if warm to the touch.|
|tang-kuei, siler, licorice, cinnamon, chiang-huo, atractylodes, cnidium, tu-huo, ginger; ma-huang, aconite (wutou), coix||Mingyi Zhizhang (Huang Fuzhong 1502 A.D.). This formula is aimed at treating cold-dominated arthralgia.|
|tang-kuei, licorice, cinnamon, atractylodes, peony, ginger, ma-huang, coix||Mingyi Zhizhang (Huang Fuzhong 1502 A.D.). This formula is used for patients with moisture dominant rheumatic disorder; it is widely used in Japan.|
|Shufeng Liushi Yin|
Clematis and Chin-chiu Comb.
|siler, peony, achyranthes, chin-chiu, hoelen, angelica, clematis, stephania; plus capillaris, moutan||STNA. This formula is mostly used in Japan, where it is given to patients with moisture accumulation as the dominant disorder; the syndrome may cause numbness.|
|Danggui Niantong Tang|
Tang-kuei and Anemarrhena Comb.
|tang-kuei, siler, licorice, chiang-huo, atractylodes, ginseng, scute; plus cimicifuga, polyporus, alisma, capillaris, pueraria, sophora, anemarrhena||Lanshi Micang (Li Gao 1276 A.D.). This formula was designed to treat dampness accumulation in the lower body, causing swelling and pain.|
|Shentong Zhuyu Tang|
Cnidium and Chiang-huo Comb
|tang-kuei, licorice, chiang-huo, cnidium, achyranthes, chin-chiu. persica, carthamus; plus myrrh, pteropus, earthworm, cyperus||Yilin Gaicuo (Wang Qingren 1830 A.D.). This formula is designed to treat a blood stasis syndrome, which is generally associated with fixed location of stabbing pain.|
|tang-kuei, licorice, cinnamon, peony; ma-huang, atractylodes, asarum, carthamus, chaenomeles; plus typhonium, strychnos, frankincense, myrrh||STNA. This formula is used for cold type arthralgia, marked by worsening with exposure to cold.|
|cinnamon, chiang-huo, atractylodes, achyranthes, chin-chiu, aconite, clematis, chaenomeles; plus piper, pangolin, drynaria, sinomenium||STNA. This formula is used for cold-damp arthralgia with symptoms of joint swelling and stiffness.|
|tang-kuei, siler, cinnamon, peony, ma-huang, aconite, angelica; plus zaocys, typhonium, schizonepeta||STNA. This formula is used for wind-dominant arthralgia, with the location of pain changing.|
Chiang-huo and Turmeric Comb.
|tang-kuei, siler, licorice, chiang-huo, peony, ginger, astragalus; plus turmeric||Yixue Xinwu (Cheng Guopeng 1732 A.D.). This formula is often selected for pain in the neck, shoulder, and upper back.|
|Qianghuo Shengshi Tang|
Chiang-huo and Tu-huo Comb.
|siler, licorice, chiang-huo, cnidium, tu-huo; plus kao-pen, vitex||Nei Wai Shangbian Huolun (Li Gao 1247 A.D.). This formula is especially used when the patient reports a sensation of heaviness.|
|Fangji Huangqi Tang|
Stephania and Astragalus Comb.
|licorice, atractylodes, ginger, stephania, astragalus; plus jujube||Jingui Yaolue (Zhang Zhongjing 220 A.D.). This formula treats dampness accumulation in patients with a weak constitution; used especially for knee arthralgia.|
|Siwu Qinjiu Tang|
Chin-chiu Four Combination
|tang-kuei, cinnamon, cnidium, peony, chin-chiu, rehmannia, carthamus; plus morus twig||STNA. This formula is used for vitalizing blood circulation, a therapy applied in cases of fixed location stabbing pain.|
|Qing Huang San|
Schizonepeta and Ma-huang Formula
|tang-kuei, siler, licorice, cinnamon, chiang-huo, atractylodes, cnidium, peony, tu-hou, ma-huang; plus schizonepeta, pueraria, cimicifuga||STNA. This formula is given in cases of moisture accumulation and for pain in the upper body and arms.|
|tang-kuei, cnidium, achyranthes, angelica, aconite, ginseng, clematis, chaenomeles; plus cibotium, millettia||This is a patent medicine that is indicated primarily for numbness and pain in the lower body.|
|Baixianbi Jianbu Wan|
|tang-kuei, siler, chiang-huo, atractylodes, peony, achyranthes, rehmannia, eucommia, ginseng, astragalus, phellodendron; plus lycium, sinomenium, cuscuta, dioscorea, psoralea, others||This formula is used in Japan, where it is known as Kenpo-gan, for general rheumatoid arthritis treatment.|
|cinnamon, atractylodes, achyranthes, chin-chiu, tu-huo, ginger, ma-huang, stephania, coix; plus erythrina||This is a patent medicine aimed at treating dampness-dominant arthralgia, which usually affects the legs.|
|siler, cinnamon, licorice, achyranthes, tu-huo, ma-huang, eucommia; plus scorpion, strychnos||This is a patent medicine indicated for arthralgia associated with stiffness and numbness of the limbs.|
|Duzhong Fengshi Wan|
|tang-kuei, siler, cinnamon, cnidium, achyranthes, chin-chiu, tu-huo, hoelen, eucommia, ginseng (codonopsis), asarum; plus loranthus||This is a patent medicine mainly used for pain in the lower body.|
|Zhuifeng Huoxue Pian|
|siler, cinnamon, licorice, chiang-huo, achyranthes, tu-huo, ma-huang, eucommia; plus frankincense, myrrh, homalonema, chaenomeles, illicium, pyritum||This patent medicine is indicated for weakness, coldness, and pain in the legs and lower back. It is a blood vitalizing formula, used in treating sharp pain.|
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.
|Herb Name: Common/Pinyin||Botanical Source/Family||Traditional Actions/Uses||Comments|
|Angelica sinensis (Umbelliferae)||supplements and moves blood||By nourishing blood and moving blood, tang-kuei prevents external factors of wind, cold, and damp from entering the vessels and causing disease.|
|Ledeborella divaricata = Siler divaricata|
|dispels wind, resolves surface, removes dampness||Siler is important because it not only dispels wind and damp, but it also tonifies the spleen to aid in circulation of dampness.|
|Glycyrrhiza uralensis (Leguminaceae)||supplements spleen, replenishes qi, harmonizes all drugs||Licorice is included in the formulas mainly to support the tonic action of other herbs and to harmonize the various herbal components; additionally, it has powerful antiinflammatory actions that have been demonstrated in laboratory experiments.|
|Cinnamonum cassia (Lauraceae)||resolves surface, warms and promotes the flow of channels, removes obstruction of qi||Cinnamon twig is traditionally used in formulas to resolve the surface and normalize circulation; cinnamon bark may be used in cold-dominant arthralgia syndromes.|
|Notopterygium forbesii or Angelica pubescens|
|dispels wind, resolves surface, expels wind-damp, controls pain||Chiang-huo is highly aromatic and is thought to quickly break through blockages in the surface.|
|Atractylodes macrocephala [baizhu] and Atractylodes lancea [cangzhu]|
|baizhu: supplements spleen, tonifies qi, directs dampness; cangzhu: dries dampness, strengthens spleen, removes wind-dampness||Atractylodes is mainly used to tonify the stomach/spleen system in order to properly distribute moisture and generate healthy qi; red atractylodes is sometimes selected for dampness-dominated arthralgia when the fluid retention is obvious.|
|Ligusticum walichii or Cnidium officinale|
|invigorates blood circulation, promotes the flow of qi, dispels wind, controls pain||Cnidium has a sedative action in laboratory experiments.|
|Paeonia lactiflora (Ranunculaceae)||baishao: supplements blood, controls pain; chishao: invigorates blood circulation, disperses stagnancy||Peony is used along with tang-kuei to nourish blood and along with cinnamon to regulate the surface; red peony is selected for blood-stasis type arthralgia, usually in the advanced stages.|
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.
|Herb Name: Common/Pinyin||Botanical Source/Family||Traditional Actions/Uses||Comments|
|Achyranthes niuxi/chuanniuxi||Achyranthes bidentia [niuxi] and Cyathula capitata [chuanniuxi]|
|niuxi: removes stagnant blood, disperses swelling, supplements kidneys and liver; chuanniuxi: removes wind, promotes water metabolism, invigorates blood||Achyranthes is mainly utilized as a blood tonic for cases of liver/kidney deficiency; for this purpose it is usually combined with rehmannia and/or eucommia. Cyathula is used in cases of blood-stasis type arthralgia.|
|Chin-chiu qinjiao/longdancao||Gentiana macrophylla [qinjiao]; Gentiana scabra [longdancao]|
|qinjiao: removes wind and dampness; longdancao: expels dampness-heat||Chin-chiu is usually selected in cases of deficiency-type arthralgia, added to formulas comprised of many tonic herbs. It is especially selected when there is stiffness; gentiana is used instead when there is an excess-type arthralgia, with stagnation being the dominant condition.|
|Tu-huo duhuo||Angelica pubescens or A. laxiflora|
|removes wind-dampness, promotes circulation of meridians, expels dampness||This herb is closely related to chiang-huo and sometimes interchangeable. Tu-huo is preferred for dampness-dominated arthralgia, while chiang-huo is preferred for wind-dominated arthralgia; they are often combined together in formulas.|
|Hoelen fuling||Poria cocos = Pachyma hoelen|
|promotes diuresis, eliminates dampness, strengthens spleen||Hoelen is preferred for dampness dominated arthralgia, where it is often combined with either atractylodes or stephania or both.|
|Ginger shengjiang/ganjiang||Zingiber officinale|
|shengjiang: resolves surface, warms stomach and spleen; ganjiang: warms middle warmer, reinvigorates yang||Fresh ginger (shengjiang) is usually used in arthralgia formulas to resolve the surface and benefit the spleen; dry ginger may be substituted in cold-dominated arthralgia. Laboratory studies reveal an antiinflammatory action.|
|Ma-huang mahuang||Ephedra sinensis|
|resolves surface, regulates water metabolism||Ma-huang is especially used for the early stage of arthralgia where there are intense but short-duration inflammatory reactions and where the site of inflammation varies.|
|Rehmannia dihuang||Rehmannia glutinosa|
|shoudi: nourishes blood, supplements liver and kidneys||Cooked rehmannia (shoudi) is usually used in arthritis formulas, as a tonic, almost always with tang-kuei, to nourish the liver.|
|Aconite fuzi/caowu||Aconitum charmichaeli|
|restores yang, warms spleen and kidneys, dispels cold, controls pain||Aconite is used in cold-dominated arthralgia; it has marked analgesic action when used in higher doses (or if unprocessed roots are used), but toxicity concerns lead to limiting the dosage and using it to restore yang.|
|Angelica baizhi||Angelica dahurica|
|removes wind, dissolves surface, controls pain, dries dampness||Angelica is primarily used in formulas for early stage arthritis, where the site of inflammation varies, and in arthralgia affecting the upper body.|
|Eucommia duzhong||Eucommia ulmoides|
|supplements liver and kidneys||Eucommia is mostly used for arthralgia affecting the lower body.|
|Ginseng renshen||Panax ginseng|
|replenishes and supplements qi, expels evil qi||Ginseng is used to tonify the spleen and improve the qi and blood conditions. In patent medicines, it is substituted by Codonopsis pilosula (Campanulaceae)|
|Clematis weilingxian||Clematis chinensis|
|removes wind-dampness, promotes meridian flow, controls pain||Clematis is mainly used in cases of dampness-dominated arthralgia, which usually affects the legs, especially the knees.|
|Stephania fangji||Stephania tetrandra [hanfangji] (Menispermaceae) or Aristolochia fangji [guangfangji] (Aristolochiaceae)||promotes diuresis, disperses swelling, expels wind, relieves pain||Stephania is mainly used in cases of dampness-dominated arthralgia, usually in combination with hoelen. Recently, Aristolochia plants have been removed from the herb trade due to rare but serious kidney toxicity problems.|
|Astragalus haungqi||Astragalus membranaceous|
|supplements qi, increases yang, delivers water||Astragalus is mainly included in formulas for weakened patients. It is used along with ginseng, atractylodes, and other tonic herbs.|
|Asarum xixin||Asarum heterotropoides; Asarum sieboldii|
|dispels cold and wind||Asarum is mainly used in formulas for cold-dominated arthralgia; it is often combined with aconite for that purpose.|
|Chaenomeles mugua||Chaenomeles lagenaria|
|relaxes muscles and meridians, harmonizes the stomach, removes dampness||Chaenomeles is usually used in dampness-dominated arthralgia and especially when there is stiffness of the limbs.|
|Coix yiyiren||Coix lacryma-jobi|
|relieves water retention, dispels dampness, strengthens the spleen, soothes numbness||Coix is usually used for dampness-dominated arthralgia and for accompanying numbness.|
|Persica taoren||Prunus persica |
|stagnated blood accumulated in the meridians||Persica is used for blood-stasis syndrome, which contributes to fixed stabbing pain; it is often combined with carthamus for this purpose.|
|Scute huangqin||Scutellaria baicalensis |
|dries moisture||Scute is used in cases where there is some internal heat or localized heat; the herb is selected because it also dries dampness.|
|Phellodendron huangbai||Phellodendron amurense|
|dries dampness||Phellodendron is used in cases where there is some internal heat, especially in cases of kidney deficiency syndrome. For this purpose, it is combined with rehmannia.|
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:
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.
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:
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.
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.
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.
Hsu HY and Hsu CS, Commonly Used Chinese Herb Formulas with Illustrations, 1980 rev. ed., Oriental Healing Arts Institute, Long Beach, CA.