Gallbladder-Cardiac Syndrome - Blue Poppy Press

The Issue of Dose in the Use of Chinese Ready-made Medicines

Bob Flaws, Lic. Ac., Dipl. Ac. & C.H., FNAAOM (USA), FRCHM (UK)

Keywords: Chinese medicine, Chinese herbal medicine, ready-made medicines, dose, dosing guidelines

If you’re like me, you get at least one spam per day offering Western prescription drugs either at a discount or without a doctor’s prescription. If you’ve ever looked at any of these offers, you know that any given Western prescription medicine and even many OTC medicines typically come in a variety of dosages. For example, the antidepressant amitriptyline (Elavil) comes in 10, 25, 50, 75, 100, and 150mg tablets. The anti-anxiety medicine alprozolam (Xanax) comes in 0.25, 0.5, 1, and 2mg tablets. The beta-blocker atenolol (Tenormin) comes in 25, 50, and 100mg tablets, and levothyroxine (L-Thyroxine) comes in 0.0125, 0.025, 0.037, 0.05, 0.075, 0.088, 0.1, 0.112, 0.125, 0.15, 0.175, 0.2, and 0.3mg tablets. This variety of dosages for the same medicine underscores a fact that any Western MD knows: different patients may need different dosages of the same medicine. Unfortunately, this fact is either not dealt with at all or glossed over in acupuncture and Oriental medical schools in the West when it comes to the prescription of ready-made (a.k.a. patent) medicines.

In China, ready-made medicines are rarely prescribed by professional Chinese medical practitioners. They are primarily meant for A) over-the-counter use by laypersons and B) the treatment of chronic conditions or the consolidation of therapeutic results after more active remedial therapy. Therefore, the stated dosages on their packaging tend to be low to prevent accidental overdose by the untrained. The problem is that, here in the West, many professional practitioners do prescribe these kinds of ready-made Chinese medicines for the remedial treatment of active disease. However, in my experience, all too many of us simply recommend the dosage written on the label. After all, those are the directions, aren’t they?

The answer to that question is both yes and no. Yes if the person is buying the medicine OTC on their own volition. No if we are prescribing the medicine professionally to one of our patients. In that case, as a prescribing physician (no matter what our legal title), it is our responsibility to determine exactly what dosage is the best for each individual patient. Just as one dose of Western pharmaceuticals does not fit all, so also a single dose of Chinese medicinals does not fit everyone. In fact, the determination of correct dose is one of the things our patients are paying us for whether they know it or not. So, what are some of the criteria necessary for determining the correct dose of a Chinese ready-made medicine?

There are five things to keep in mind when trying to determine the correct dose for a given patient: 1) age, 2) weight, 3) disease severity, 4) disease diagnosis, and 5) medicinal strength. For instance, babies and young children should be given smaller doses than adults due, in part, to their immature metabolisms and medicinal sensitivity. However, the elderly (i.e., those over 60) should also receive half doses due to the decline in function of the digestive system as well as the liver and kidneys. Because the elderly do not metabolize medicines as quickly as younger adults do, medicines stay in their systems longer. The second thing to take into account is a patient’s weight or body mass. The larger the patient’s body, the more medicine they typically will require to catalyze changes in that mass of cells. That means a patient who weighs 300 pounds will require significantly more medicine than a patient who weighs 150. Tables presenting standard guidelines of dosing according to age and weight are given in Blue Poppy Herbs’ Product Manual. The third factor is disease severity. In Chinese medicine, the more severe or acute a disease is, the higher the doses we usually administer. That is because we are trying to achieve results as quickly as possible in order to minimize pain and suffering as well as the possibility of irreversible damage. The fourth factor is the disease diagnosis. The disease diagnosis tells us the natural history of the condition, for instance, whether it is self-limiting, relapsing-remittent, chronic, progressive, disabling, fatal, etc. In acute diseases of expected short duration, we typically prescribe high doses to knock the disease out as quickly as possible, while, in chronic, lingering, slowly progressive diseases, we typically prescribe lower doses in a more user-friendly form of administration so that we can assure good patient adherence over a long period of time. For example, in a relapsing-remittent disease such as MS, we may prescribe high dose decoctions during relapses and low dose ready-made medicines during remittent stages.

The fifth factor in determining dosage is somewhat more difficult to deal with at the moment due to many companies not transparently telling practitioners how to assess the strength of their medicines. Without knowing how strong a medicine is, how can we determine what it’s dose should be? Perhaps, since practitioners have not asked for this information, these companies have not figured there is a need for this information. However, if we ever intend to earn the status, respect, and earnings of Western MDs, we must eventually practice medicine, albeit Chinese medicine, at the same professional level, and that means prescribing the individualized dosages of medicines to individual patients. Therefore, one of the first questions when considering prescribing a Chinese ready-made medicine to a patient is, "How strong is that medicine?"

Since most Chinese ready-made medicines are made from extracts, one way of answering that question is to know the concentration ratio used in making that medicine. If a medicine is a 5:1 extract, that means that five pounds of bulk herbs were used to make one pound of finished medicine. If it is a 7:1 extract, it means that seven pounds of bulk herbs were used to make one pound of finished medicine, and, if it is a 12:1 extract, it means that 12 pounds of bulk herbs were used to make one pound of finished medicine. The assumption here is that the higher the concentration ratio, the more potent the medicine is. However, that still does not tell us everything we need to know. In standard professional Chinese medicine, the average daily dose of a single medicinal is nine grams (9g). If there are 10 ingredients in a formula, that means a dose of 90 grams per day made into decoction. If we want our patient to receive the equivalent of not less than 90 grams of Chinese medicinals per day for the remedial treatment of active disease, then we would need to prescribe 18 grams per day of a 5:1 extract, 12.6 grams per day of a 7:1 extract, nine grams per day of a 10:1 extract, and only six grams per day of a 15:1 extract. In real life, if a patient is also receiving acupuncture, they might not need the equivalent of 90 grams per day since, unlike in China, they are being treated by more than one modality. So maybe you could cut the dose down to 60 or even 45g per day. In that case, it would only take nine grams per day of a 5:1 extract, 4.5 grams per day of a 10:1 extract, and three grams per day of a 15:1 extract.

Since, typically, unwanted side effects are directly proportional to increased dose, in general as prescribing physicians, we want the lowest dose which will achieve the intended therapeutic effects within the desired time-frame. This also means starting patients with chronic diseases with low doses and then raising those doses, increment by increment, until one achieves the intended therapeutic effect with either no or the least adverse reactions. Further, when patients are taking Chinese ready-made medicines long-term for chronic diseases, they should be allowed breaks or rests every so often so that they do not become habituated to the medicine. For instance, every 6-8 weeks, they may be given five days off to allow their metabolism to re-set itself.

In closing, if you’re not getting the results you expect from Chinese ready-made medicines, A) raise the dose and B) consider using a higher concentration extract. Blue Poppy Herbs are the highest extracts in the business. All our medicine are 8:1 to 15:1 extracts.