Herbal Treatment in Special Populations

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Herbal Treatment in Special Populations

By Chava Quist, MSTOM

Recently, I heard a colleague lament, “how come my patients take anything without question from their MD, but when I prescribe herbs suddenly they become a researcher?” It was a funny moment, albeit a common one. As Chinese medicine (CM) has gained more mainstream press, research, celebrity and professional athlete followers, this attention has garnered more interest into the nuts and bolts of our profession.

Herbal medicine sometimes brings up two very opposite notions: thinking that herbs, being a natural substance, can do no harm, or looking at them with great suspicion and wondering “what exactly is in there”. In truth, both ends of the spectrum are making some incorrect assumptions. These sentiments are as prevalent in our colleagues as our patients. As a public face of CM, it is important for practitioners to be well informed and comfortable in speaking about their practice of herbs. Creating an open exchange with your herb vendor and being willing to put in a small amount of additional time in patient education and research will go far.

In my daily conversations with practitioners, I frequently respond to questions regarding prescribing herbs to patients with unusual considerations. Commonly, these involve patients with allergies or religious/dietary restrictions. Herbs are overwhelmingly safe for most populations, and thankfully easily edited to accommodate direct contraindications.

Allergies

Your allergic patients will likely be some of the most vigilant in confirming ingredients of any formula or product you prescribe, with good reason. Allergic response can run the gamut from mild digestive upset, skin reactions, headaches, or joint pain, and difficult-to-classify symptoms such as fatigue or mental dullness to more urgent presentations such as difficult respiration and life-threatening anaphylaxis. Even with serious allergies, practitioners should not be fearful of using herbs in these cases, but simply aware that it may involve more research in preparation.

Question your patient on all known allergies and what the allergic reaction is. It is important to differentiate between diagnosed and self-reported allergies. The incidence of self-reported allergies has risen over the past decade, even while the incidence of doctor-diagnosed allergies has not grown at nearly the same rate (1). Practitioners should not be dismissive of self-reported allergies, however, as a complete history in this area will yield valuable information and inform your treatment plan.

Patients with multiple allergies or systemic inflammatory conditions often seem to report difficulty in taking herbs even when not exposed to known triggers. This can be due to cross-reactivity from herbs that are botanically related or close enough to the trigger item. With a history of severe allergic reactions, it is worthwhile to research the botanical taxonomy of ingredients in a potential formula. Another reason for this intolerance I see more often in clinic is due to the form of herbal prescription. Individuals with an active inflammatory cascade can have difficulty digesting things like granule extracts that are 25-50% starches. Adding digestion supportive herbs such as Shan Zha (Fructus Crataegi) is an easy approach, easing the use of granule herbs in such patients if they are closed to taking raw herbs.

In addition to spending a little extra time on patient preparation and your own research, it is necessary to have a transparent relationship with the vendor from whom you obtain herbs and supplement products.  Vendors should be expected to provide any necessary ingredient or manufacture information needed and, if they fill custom formula orders, to have operating procedures in place to deal with allergens. Protecting against cross-contamination, especially with granule extracts, requires constant vigilance and strong quality control. Food-grade disposable containers and tools should be used in the filling of all herbal formulas, and separate surfaces maintained for the processing of orders that need to be protected from certain allergens.

One benefit that third-party dispensaries provide is allergen alerts. Most dispensaries will provide an option within their ordering system to flag common allergens for your patient. Allergen alert information can also be found on product labelling, but it is not ubiquitous across brands, so when in doubt, ask. These automatic safeguards can be a lifesaver, as we are all prone to lose contact with some of our rote memorization from school or come across an herb that we never knew could be a trigger.

If filling herbal prescriptions in your own office, it is recommended to establish a Standard Operating Procedure (SOP) for your fulfillment process.  You can get a good start by referencing the procedures that have been established by your school. Write down all the steps to fill a formula in a checklist. Use this checklist every time you fill a prescription.

By doing this, it forces you to fill your prescriptions according to established standards each and every time. It also gives a good basis for training any staff that you may hire for various office duties. Your SOP should include all aspects of filling a prescription, of which order confirmation and using clearly delineated work areas have the most impact on managing allergens.  Having a second person around to double-check your work may be a luxury that you do not have, but it is the single most important thing one can do to avoid mistakes.  A receptionist or assistant, when properly trained and armed with a checklist, can serve as that second person to perform the order confirmation.

Include an allergen check to your list. This would involve checking your patient file for any reported allergies that you have flagged and comparing it with the herbs you’ve chosen. A handy cheat sheet of herbs and formulas that contain common allergens hanging in your dispensary area would make this process very quick.

Wheat and Gluten

Wheat derivative and gluten-containing herbs are a hot topic, as CM maintains grains as supportive of digestion and Western thinking continues to vilify their use. Diagnosed allergy to celiac sprue is important to differentiate from patient-reported intolerance to grains and gluten along with the nature and level of reaction. While certain herbs are wheat varieties, gluten can also come from wheat-frying (fu chao) Pao Zhi methods and those herbs processed with barley malt or rice wine.

Ironically, patients with wheat or gluten allergy can often present with digestive symptoms that would normally call for a triggering herb, such as Shen Qu (Massa Medicata Fermentata). Research is inconclusive regarding the maximum amount of gluten ingestion (10-100g per day in one study) permissible in individuals with celiac sprue without provoking reaction, but the incidence of an individual threshold is recognized (2). Patients with mild to moderate gluten reaction and those voluntarily abstaining can often tolerate small doses of gluten-containing herbs and benefit from their therapeutic actions (3).

Common Wheat-Derivative or Gluten-Containing Herbs

Cang Zhu (Fu Chao) (Wheat-fried Rhizoma Atractylodis)- commonly wheat-fried in patent formulas

Fu Xiao Mai (Fructus Tritici Levis)

Huai Xiao Mai (Ripe Fructus Tritici Levis)

Mai Ya (Fructus Hordei Germinatus)

Shan Yao (Fu Chao) (Wheat-fried Rhizoma Dioscoreae)- commonly wheat-fried in patent formulas

Shen Qu (Massa Medicata Fermentata)

Yi Tang (Maltosum)

Xiang Fu (Fu Chao) (Wheat-fried Rhizoma Cyperi)- commonly wheat-fried in patent formulas

Shellfish

Shellfish is another common allergy with a wide spectrum of reactionary responses and some room for consideration of the individual. A common misunderstanding is that shellfish allergy is due to a reaction to iodine, but research does not bear this out (4). Shellfish allergy is a reaction to the animal protein (4)(5), so people with this allergy should not have reactions to iodine or radio-contrast materials (4)(5).

The question then arises: are shellfish-derivative herbs, which are largely shells, safe for allergic people? The dietary supplement glucosamine, which is derived from the shells of shrimp and crab, is well-tolerated by many with this allergy, as it does not intentionally contain the animal flesh and thus the protein (5)(6)(7). Certainly, people with severe anaphylactic response cannot take glucosamine or shell-based herbs, as this segment of the population may be sensitive enough to react to even inhaling the vapors of cooking shellfish. Those with mild to moderate shellfish reaction, however, tolerate shellfish-derivative herbs (and supplements like glucosamine) well (6) (7).

Common Shellfish Derivative Herbs

Ge Qiao (Concha Meretricis/Cyclinae)

Hai Piao Xiao (Endoconcha Sepiae)

Mu Li (Concha Ostreae)

Shi Jue Ming (Concha Haliotidis)

Wa Leng Zi (Concha Arcae)

Zhen Zhu (Margarita)

Zhen Zhu Mu (Concha Margaritaferae Usta)

Tree Nuts and Seeds

Allergies to tree nuts and seeds appear nearly ubiquitous nowadays, and we often hear of life-threatening reactions, especially in children, in response to very minor exposures. When dealing with nut allergy patients, it is important to research herb ingredients for cross-reactivity. While few herbs used in practice are the same food source allergen trigger ingredients, herbs in the same botanical family as the primary trigger should be avoided.

Topical herbal products should also be investigated. Identify any nut derivative in oil based formulations. It is generally good practice to avoid using known allergens topically in a patient who has shown a reaction to it when taken internally.

Common Herbs that are Tree Nuts or Seeds

Bai Guo (Semen Ginkgo)

He Tao Ren (Semen Juglandis)

Hei Zhi Ma (Semen Sesame Nigrum)

Li Zhi He (Semen Litchi)

Shen Qu (Massa Medicata Fermentata)

Tao Ren (Semen Persicae)

Xing Ren (Semen Armeniacae)

Yu Li Ren (Semen Pruni)

Soy

Soy often crops up in surprising places in herb processing methods, especially animal-derivative gelatin herbs. Massage oil blends and supplements in liquid gel caps should be considered possible sources of soy.

Common Soy Containing Herbs

Dan Dou Chi (Semen Sojae Preparatum)

E Jiao (Colla Corii Asini)

Lu Jiao Jiao (Cornu Cervi Pantotrichum)

Gui Ban Jiao (Plastrum Testudinis Gelatine)

Latex

Neither internal nor topical herbal products containing Du Zhong (Cortex Eucommiae) should be used in patients with latex allergy, or their use closely monitored. Herbal patches often use a latex containing adhesive base. Such patches should be avoided in these individuals.

Religious Dietary Laws

Patients who follow certain religious dietary laws may have many questions regarding both ingredients as well as manufacturing processes before taking herbs. Some individuals will consult their clergy or other religious advisor for approval before embarking on a course of herbs. Practitioners should be open to having a conversation with a patient’s religious advisor as part of this decision-making process. While particular herb ingredients may be very easy to substitute or avoid, you may need to consult with your herb vendor for detailed information on manufacturing.

On the other end of the spectrum, you may engage with religious patients who see herbs as medicine and thus are open to consuming ingredients they normally would not eat. Defining patient goals in keeping true to their religious practice will guide you best here.

Islamic dietary laws restrict the consumption of meat to certain animals that have undergone specific slaughter methods. The consumption of pork and alcohol are prohibited. All plant foods are permitted. There is some consideration for sources of alcohol that are not at a level that can cause inebriation, such as found in items like vanilla extract used in baking, or in mouthwash. While this exception is detailed in classic texts, it may not be followed by more observant Muslims (8). Thus wine-fried (jiu chao) herbs should be avoided, as well as those that have alcohol as part of their standard processing.

Another potential source of alcohol is herbal tinctures. Most herbal tinctures on the market are based on alcohol. Even tinctures that are vegetable glycerin-based can be “fixed” with alcohol. Islamic law categorizes alcohol not only in its capacity to inebriate but also its source. Alcohol derived from grapes or dates is prohibited. Popular flower extracts on the market are commonly based in grape brandy and would likely be refused by your Muslim patients. The types of alcohols found in topical products like cosmetics and aftershaves are largely acceptable. This permission could extend to alcohol-based herbal liniments, but it may require verifying the source of alcohol for your patient.

Another important variable to consider with patients who abstain from eating pork is encapsulated products. Gelatin capsules are most commonly made from pigs. When reading a product label, assume that a listing of “gelatin capsule” is animal-sourced. Vegetarian capsules will be marked as such or listed as “vegetable capsule.” Vegetable capsules are made from tree cellulose, gluten-free, and hypoallergenic. If using an outside dispensary to process your custom formula orders, inquire about what capsules they use. Products containing collagen or insect-derivative herbs should also be avoided as they are animal products.

Common Grain Alcohol Processed Herbs

E Jiao (Colla Corii Asini)

Lu Jiao Jiao (Cornu Cervi Pantotrichum)

Shu Di Huang (Radix Rehmanniae Preparata)

Huang Jing (Rhizoma Polygonati)

Chuan Xiong (Chuanxiong rhizoma)

Gui Ban Jiao (Plastrum Testudinis gelatin)

Rou Cong Rong (Herba Cistanches)

Patients who follow Jewish dietary laws have considerations of ingredients as well as supervision of manufacturing, and the environment, vessels, and staff involved. The laws of kashrut require particular slaughtering methods for livestock as well as only permitting certain animals, certain cuts, and prohibit pork. Consumption of shellfish and insects is also prohibited, as is mixing meat and milk. This separation extends not only to maintaining different sets of pots, plates, and utensils for each, but also defined working surfaces in the kitchen. For this reason, it is unlikely an observant Jew will accept cooking raw herbs in their kosher kitchen.

While plant-based foods are universally permitted, kosher consumers know that modern manufacturing processes may hide non-kosher ingredients, and thus they depend a good deal on product labeling. Packaged foods and supplements must contain a kosher certification symbol on the labeling to show that their manufacture was overseen by a rabbi specializing in the dietary laws. Chinese herbal product lines with kosher certification are almost non-existent, but it does not make using herbs prohibitive.

Kosher patients are often open to taking granule or patent herbal products with plant-only ingredients. A good number of my patients are observant Jews belonging to various Hasidic sects, and I cannot recall any of them or their rabbinical advisors refusing granules or teapills and even vacuum-packed herbs. For these products, the patient or religious advisor will want to know about manufacturing practices. It is important to note that most manufacture of such products is subcontracted to pharmaceutical factories and thus is produced with good quality control as well as thorough washing of machinery in between runs to prevent cross-contamination in regards to allergens. The details of the machinery cleansing will be important to your patient or their advisor in determining whether a product is permissible under Jewish law. Confirm these details with your herb vendor.

As with Muslim and other pork avoiding patients, it is necessary to source vegetable cellulose capsules. Herbs processed with alcohol are not an issue however. Jewish law around wine is very complex and extensive, but this refers only to grape wine. Alcohol used in CM herbology is rice wine or barley malt.

During the annual Passover holiday, Jewish dietary laws change for eight days. During this period, leavened foods and those with the capacity to rise or ferment are avoided. This means abstaining from wheat, barley, oats, spelt, and rye, along with foods that are considered related like corn and legumes.

This impacts the use of granule and teapills formulas. Incipients in granule extract herbs are widely used in pharmaceutical production and are hypoallergenic. The most common incipients are dextrin, maltodextrin, and corn starch, all derived from corn, prohibited during Passover. Teapills and press tablets often include trace amounts of corn starch as a binder. The inclusion of these is prevalent in pharmaceutical medications as well. Many people will seek a dispensation from their rabbi to continue taking a needed medication that contains prohibited agents during Passover. It is individual though whether a patient will include your herbal formula under the umbrella of medication or if they will want to discontinue it during this period.

Another surprising herb contraindication during Passover is Wang Bu Liu Xing (Semen Vaccariae). This herb, popularly used for medicated ear seeds, is regarded as a relative of the main prohibited grains. During Passover, the prohibited foods are not only prohibited for consumption, but also any benefit derive from their use or even sight, so for this reason your kosher patients may question the use of ear seeds during Passover.

Other faiths such as Seventh Day Adventist, certain Buddhist sects, and Jainism may require adherents to follow a vegetarian or vegan diet. This is covered in the next section.

Common Grain Derivative Herbs

Bai Jie Zi (Semen Sinapsis)

Hei Zhi Ma (Semen Sesame Nigrum)

Yu Mi Xu (Stigma Maydis)

Mi Cu (Rice Vinegar)

Wang Bu Liu Xing (Semen Vaccariae)

Gu Ya (Fructus Oryzae Germinatus)

Geng Mi (Semen Oryzae)

Su Ya (Fructus Setariae Germinatus)

Yi Yi Ren (Semen Coicis)

Nuo Mi (Semen Oryzae Glutinosae)

Vegans & Vegetarians

Abstaining from eating meat or utilizing any animal derivative products can be an expression of health practice, of ethical or moral concern, or of religious observance. As with patients who have other concerns in relation to herbs, it is important to discuss the motivations and parameters of the dietary practices of your vegetarian and vegan patients. Practice will range across a large spectrum and you will likely see patients who consider herbs medicine and will bend their dietary practices for such as well as those who are much more restricted.

It is important to discuss dietary practices in detail and define what the patient considers animal derivative. Avoidance of animal gelatin capsules and shellfish-derivative herbs is a consideration with this group. The question of honey-fried (Mi Zhi) herbs or insects will be individual.

The question of what is an animal seems to have an obvious answer, but if you consider that some people who will not eat meat do not have concern for insects, then the big picture shifts. If your patient does consider insects animals, then what about herbs that are a result of animal work, like Feng Mi (Apis Mel), or of lifecycle, like Chan Tui (Periostracum Cicadae)? Another herb that might require some consideration is Dong Chong Xia Cao (Cordyceps), a fungus that does not exist without the death of an insect. With the current price hovering at around $35k USD/lb, it is no surprise that the vast majority of Dong Chong Xia Cao (Cordyceps) on the market is the more accessible lab-cultivated (jun fen) variety. How far removed from the original animal death does your patient start to consider this herb only a fungus?

Topical liniments and “hit medicine” formulas commonly utilize animal-derivative herbs for their abilities to address move stagnation from the channels and support the blood. There are some moxa oil extract products on the market that contain added gelatin to enhance their action. If you come across such a listing, use the same approach as with capsules: if it does not say vegetarian or vegetable assume it is animal-based.

Common Animal Derivative Herbs

Bai Hua She (Akistodron/Bungarus)

Bie Jia (Carapax Trionycis)

Can Sha (Faeces Bombycis)

Chan Tui (Periostracum Cicadae)

Dan Nan Xing (Arisaemae cum Bile)

Di Long (Pheretima)

Dong Chong Xia Cao (Cordyceps)

Dong Chong Xia Cao (Jun Fen) (Lab cultivated Cordyceps)

E Jiao (Colla Corii Asini)

Feng Mi (Apis Mel)

Ge Jie (Gecko)

Gui Ban (Plastrum Testudinis)

Gui Ban Jiao (Glue of Plastrum Testudinis)

Ji Nei Jin (Endothelium Corneum Gigeriae Galli)

Jiang Can (Bombyx Batryticatus)

Long Chi (Dens Draconis)

Long Gu (Fossilia Ossis Mastodi)

Lu Jiao Jiao (Glue of Colla Cervi Cornus)

Lu Jiao Shuang (Cervi Cornu Degelatinatum)

Lu Rong (Cornu Cervi Pantotrichum)

Quan Xie (Scorpio)

Sang Piao Xiao (Ootheca Mantidis)

Shui Zhi (Hirudo)

Tu Bie Chong (Eupolyphaga/Steleophaga)

Wu Gong (Scolopendra)

Wu Ling Zhi (Faeces Trogopterori)

Wu Shao She (Zaocys)

Zi He Chi (Placenta Hominis)- the modern source for this herb is sheep placenta

Defining your patients’ needs and goals in terms of their lifestyle choices, dietary restrictions, or religious practice will support your formulation of a treatment plan and options for herbs. Practitioners should be open to providing herb information to a patients’ religious advisor when asked, as most of these conversations will help define a permissible treatment approach and make the patient feel comfortable in their healthcare choices. Asking for specific information from your herb vendor in regards to manufacture, testing, and allergen management can go a long way in starting the conversation with a patient about using herbs, as well answer any of the practitioner’s concerns. This medicine that we’ve been given is powerful and education in these areas can help its practice be more universal.

Chava Quist, MSTOM, a 2014 graduate from PCOM-NY, is the Chief Operating Officer of Kamwo Meridian Herbs, one of the oldest and largest Chinese Herb Dispensaries on the east coast, where she has been working since she was a student at PCOM and now manages a staff of dozens of Chinese medicine practitioners and sales and administrative personnel. She is a licensed acupuncturist and massage therapist in the state of New York. Chava oversees relations with herb suppliers, the FDA, and other regulatory agencies, educational institutions, members of the public, as well as hundreds of Chinese medicine practitioners nationally and internationally.

References
 

1.Prevalence of self-reported food allergy in U.S. adults:2001, 2006, and 2010

Linda Verrill, Ph.D., Richard Bruns, Ph.D., and Stefano Luccioli, M.D., U.S. Food and Drug Administration

(Allergy Asthma Proc 36:458–467, 2015)

2. Collin P, Thorell L, Kaukinen K, Maki M. The safe threshold for gluten contamination in gluten-free products. Can trace amounts be accepted in the treatment of coeliac disease? (Aliment Pharmacol Ther 2004; 19: 1277-83.)

3. Dharmananda, S., Ph.D. (n.d.). Gluten in Chinese Herbs: Addressing the Concerns of Those with Celiac Sprue. Retrieved from http://www.itmonline.org/arts/gluten.htm

4. E, S., & M, W. (2010). The relationship of radiocontrast, iodine, and seafood allergies: a medical myth exposed. Journal of Emergency Medicine,39(5), 701-7. doi:10.1016/j.jemermed.2009.10.014

5. Glucosamine safety- Mayo Clinic. (n.d.). Retrieved November, 2017, from http://www.mayoclinic.org/drugs-supplements/glucosamine/safety/hrb-20059572

6. Matheu, et al. Immediate-hypersensitivity reaction to glucosamine sulfate. Allergy 1999; 54(6):643.

7. Clin Exp Allergy. 2006 Nov;36(11):1457-61.Do shrimp-allergic individuals tolerate shrimp-derived glucosamine? Villacis J, Rice TR, Bucci LR, El-Dahr JM, Wild L, Demerell D, Soteres D, Lehrer SB.

8. The Issue of Alcohol in Cosmetic products and Medicine. (2014, May). Retrieved December, 2016, from http://www.ummahnews.co.uk/article.php?id=86

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