Autoimmune Diseases and the Potential Role of Chinese Herbal Medicine

Autoimmune Diseasesand the potential role of Chinese Herbal Medicine

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

BACKGROUND TO THE DISEASE CATEGORYAutoimmune diseases are chronic disorders that have been difficult, and often impossible, to cure.

There can be remission of symptomsspontaneously or as the result of applied therapiesbut the

potential for return of the disease remains in almost all cases. The characteristic of these diseases is

immune system targeting of body components, so that these components are damaged, either

temporarily or permanently, or their activities are altered. The autoimmune diseases almost always

have a significant genetic component; in addition many of the diseases in this category appear to have

a viral or other infectious agent as a trigger for onset of the autoimmune status. There may be a

variety of other factors that are important to finally set off a pattern of symptomatic disease so that its

first manifestation may be after age 20 (there are also late-onset autoimmune diseases). In fact, if the

disease appears much earlier than that (i.e., prior to the teen years), it is usually a very aggressive form

with a strong genetic component.

There are dozens of diseases that are classified as involving autoimmune responses or suspected

of having an autoimmune basis. In many of the diseases, there is a significant difference in incidence

among men and women; overall, women are about 3 times as likely as men to suffer from autoimmune

disorders (however, in some disorders, such as MS, men appear to have a more severe disease

pattern). If the initial symptoms are mild or if the disease progresses slowly or develops its symptoms

in an unusual pattern, diagnosis is difficult. Some patients relay experiences of pursuing medical

diagnosis and treatment for a decade before getting a definitive disease name. A greater number of

tests that can suggest or confirm presence of an autoimmune disease have become available so that it

is now easier to make a diagnosis than ever before, but some disorders suspected of being autoimmune

diseases still lack reliable tests, especially for their early stages.

The incidence of autoimmune diseases in the U.S. has been estimated to be just over 3%, with a

current affected population of about 10 million people. Societies representing people suffering from

autoimmune diseases consistently over-report the incidence rates, using the upper limits from the

highest estimate ranges; thus, the incidence rates given in these circumstancesoften relayed by the

news mediamust be interpreted cautiously. Some of the common autoimmune disorders are

outlined below.

Connective Tissue DiseasesThe most prevalent autoimmune disorders are connective tissue diseases, accounting for nearly half of

all the cases; rheumatoid arthritis is the dominant one. The main connective tissue diseases are:

RHEUMATOID ARTHRITISThis is a systemic disorder in which immune cells attack and inflame the membrane around joints (it

also can affect the heart, lungs, and eyes, though rarely). The incidence in women is far higher than

men for younger individuals, but the difference is less with disease onset after age 50. Symptoms:

Autoimmune Diseases and the potential role of Chinese Herbal Medicine http://www.itmonline.org/arts/autoimmune.html

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Inflamed and/or deformed joints, loss of strength, swelling, pain.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)SLE can affect virtually any organ system, producing inflammation. It is up to 9 times more common

in women than men and occurs in black women 3 times as often as white women. Symptoms: 90% of

patients experience joint inflammation similar to rheumatoid arthritis. Fifty percent develop a classic

butterfly rash on the nose and cheeks. Raynaud's phenomenon (extreme sensitivity to cold in the

hands and feet) appears in about 20 percent of people with SLE. Other symptoms include fever,

weight loss, hair loss, mouth/nose sores, malaise, fatigue, and brain disorders. Exposure to UV light

can promote the disease process.

SYSTEMIC SCLEROSIS (SCLERODERMA)Scleroderma results from attack of immune cells that produce scar tissue in the skin, internal organs,

and small blood vessels. It affects women three times more often than men overall, but increases to a

rate 15 times greater for women during childbearing years, and appears to be more common among

black women. Symptoms: In most patients, the first symptoms are Raynauds phenomenon and

swelling and puffiness of the fingers or hands. Skin thickening follows a few months later. Other

symptoms include skin ulcers on the fingers, joint stiffness in the hands, pain, sore throat, and

diarrhea.

SJGREN'S SYNDROMESjgren's syndrome is a chronic, slowly progressing inability to secrete saliva and tears, and is usually

a late-onset disease. It can occur alone or with rheumatoid arthritis, scleroderma, or SLE. About 90%

of cases occur in women, most often at or around the menopausal years. Symptoms: Dryness of the

eyes and mouth, swollen neck glands, difficulty swallowing or talking, unusual tastes or smells, thirst,

tongue ulcers, and severe dental caries (which occur because of the lack of saliva).

The other autoimmune diseases fall into several groupings, among the most common are these:

Neuromuscular DiseasesThe neuromuscular diseases are mainly those involving immune attack affecting the nerves, which has

the result of impairing muscle responses. The primary response is usually muscular paralysis, but

there can also be tremor and/or tonic spasm where nerve transmission is partially blocked.

MULTIPLE SCLEROSIS (MS)A disease of the central nervous system that usually first appears between the ages of 20 and 30, and

affects women twice as often as men. MS is the leading cause of disability among young adults, and it

causes irreversible scarring of the myelin sheath to varying extents. The primary form is

remitting/relapsing, but there is also a progressive form, which worsens regularly. Symptoms:

Numbness, weakness, tingling or paralysis in one or more limbs, impaired vision and eye pain, tremor,

lack of coordination or unsteady gait, and loss of control of urination.

MYASTHENIA GRAVISThis is characterized by gradual muscle weakness, often appearing first in the face, particularly at the

eyes and then affecting the mouth and throat. Symptoms: Drooping eyelids, double vision, and

difficulty breathing, talking, chewing, and swallowing.

Endocrine Diseases


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The endocrine diseases involve attack of the immune system against one of the glands, sometimes

with rapidly progressing destruction (as in diabetes or Addisons disease). However, in Graves

disease, antibodies attach to a hormone stimulating receptor on thyroid cells and dont destroy the cells

but rather stimulate their production of thyroid hormone.

HASHIMOTO'S THYROIDITISThis is a type of autoimmune disease in which the immune system destroys the thyroid gland. It is

primarily a disease suffered by women (50 times more often than men). Symptoms: Low levels of

thyroid hormone cause mental and physical slowing, greater sensitivity to cold, weight gain,

coarsening of the skin, and goiter (a swelling of the neck due to an enlarged thyroid gland).

GRAVES' DISEASEGraves' disease is one of the most common autoimmune diseases, affecting about 1% of people in the

U.S, frequently appearing during childhood, and affecting women 7 times as often as men. Patients

with Graves' disease produce an excessive amount of thyroid hormone. Symptoms: Weight loss due to

increased energy expenditure; increased appetite, heart rate, and blood pressure; tremors, nervousness

and sweating; frequent bowel movements.

INSULIN-DEPENDENT (TYPE 1) DIABETESType 1 diabetes is caused by autoimmune attack against the pancreatic islet cells that produce insulin,

resulting in very low levels of insulin production, usually too little to survive without providing

exogenous sources (insulin shots). The disease usually occurs in children and young adults

(differentiated from Type 2 diabetes that does not originate from autoimmune processes, and most

often affects those who are obese), and affects boys and girls at about the same rate, a slightly higher

incidence in boys. Symptoms: Increased thirst, increased urination, weight loss, fatigue, nausea,

frequent infections.

Other Autoimmune DiseasesSome of the more common disorders that dont fit the above categories are mentioned here. These

occur in roughly equal rates for men and women.

INFLAMMATORY BOWEL DISEASEInflammatory bowel disease refers primarily to two autoimmune disorders of the small intestine

Crohn's disease and ulcerative colitis. Symptoms of Crohn's disease: Persistent diarrhea,

abdominal pain, and general fatigue. Symptoms of ulcerative colitis: Bloody diarrhea, pain, urgent

bowel movements, joint pains, and skin lesions. In both diseases, there is a risk of significant weight

loss and malnutrition.

HEMATOLOGIC AUTOIMMUNE DISEASESBlood cells can be affected by autoimmune disorder. In autoimmune hemolytic anemia, red blood

cells are prematurely destroyed by antibodies; in thrombocytopenic purpura (usually described as

ITP), the immune system attacks the platelets, and in autoimmune neutropenia (destroying a group of

white blood cells, neutrophils). These diseases often occur in children and are believed to be triggered

by a viral infection in many instances.

UNDERSTANDING THE DISEASESMany times, autoimmune disorders are mistakenly described as excessive responses of the immune


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system or deranged responses of the immune system (the immune system has broken down). In

fact, this depiction is misleading. A portion of the immune system has been targeted to attack specific

parts of the body, in the same manner that it would target a pathogen; it may be functioning normally

and without disorder, other than the target, which was established by genetics and certain events.

Thus, even if the immune system is in all other ways normal, this response gives rise to the disease

symptoms. What is of particular interest is the fact that for several of the autoimmune diseases the

activity of the immune system may come and go, so that there are periods of remission and periods

of exacerbation. For these diseases, if a method for maintaining remission can be found, then even

though the underlying condition isnt completely eliminated, it is not producing new symptoms or

progressing. And, a discovery for significantly prolonging remission may result in developing

strategies for addressing other, more consistently active autoimmune diseases.

The medical method of treating many of these diseases that has been available for about a century

is with potent anti-inflammatory and immune-inhibiting drugs. The therapy usually provides a very

quick beneficial result (noted within hours of the first dose) but then there is the conundrum that most

of these drugs are not well suited to long-term therapy, so there has been a difficult risk-benefit

balancing to help keep people symptom free to the extent possible without them suffering too many

side-effects or adverse events. Overall, the results have been remarkably good, but far from

satisfactory.

An example of the unusual steps that may have to be taken to maintain results is in Graves

disease, which involves an antibody-induced stimulation of the thyroid gland rather than

inflammation. Absent a good method to inhibit the immune systems role in overproduction of thyroid

hormone, a treatment commonly used is to eliminate the thyroid tissue by administering radioactive

iodine and then provide an exogenous source of thyroid hormone for life. This method saves lives

and helps people lead a life free of the serious Graves disease symptoms, but one would prefer to

eventually resolve the antibody problem instead and preserve the thyroid gland.

Modern research has aimed at two ways of addressing the basic problem: one is trying to

interrupt the specific immune attack (rather than using broad immune suppression) by determining

which substances can interact with the involved portion of the immune system; the other is to find

ways to modulate the immune response so that there is less likely to be an attack against the body (but

still leaving the immune system fully capable of fending off infections or inhibiting other pathological

processes). Other approaches to treatment will develop with genetic engineering, use of stem cells,

and upcoming techniques yet to be evaluated.

An example of the immunological approach is use of IVIG (intravenous immunoglobulin) for

ITP. This treatment is based on extraction of human blood plasma, which is rich in immunoglobulins

that interfere with the destruction of platelets by the autoimmune process. The treatment is fast acting,

but does not cure the disease, and little is known about its mechanism. IVIG is currently very

expensive and reserved for emergency cases, though its use is becoming more prevalent with

favorable experience. The standard therapy is to use prednisone, which is inexpensive, also has quick

response, but can not be maintained long term (spleen removal also helps reduce the severity of the

disease, but rarely halts its progression for long). Another example is an experimental approach to

treating MS in early stages of investigation. In this disease, T-cells are involved in the attack against

the myelin sheath of the nerves of the central nervous system. The T-cells appear to be controlled by


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exposure to large amounts of the myelin proteins they normally would attack, so by intravenous

administration of these proteins, the MS attacks might be impaired. Currently, MS patients take drugs

that are derivatives of interferon which modifies the immune response in a manner not fully

understood, but results in reduced frequency of exacerbations for the remitting/relapsing type of MS.

If there is success in the endeavors to interrupt the autoimmune attacks, patients my not need to

turn to Chinese medicine as a potential method of alleviating autoimmune responses. However,

medical research is several years away from finding reliable treatments, and even where some success

has been attained, there are limitations. Thus, patients with these diseases will for many years be

seeking help through adjunctive methods, such as traditional Chinese medicine.

CHINESE MEDICINE AND AUTOIMMUNE DISEASESThe long tradition of Chinese medicine that has led up to its modern practice did not have a concept

that clearly correlates with what we know today as autoimmunity. Possibly the closest concept was

related to the idea of trapping a pathogenic force inside the body (for example, by closing the pores

rather than dispelling pathogens through sweating), or by providing conditions that would invite such

a pathogen to remain in the body (e.g., interior nourishment and dampness, but weak defense), so that

a disease would continue far longer than it should. Xu Dachun (1) described a condition where the

bodys own qi merges with that of the pathogen; he used the analogy of oil poured into flour: the

ingredients can not be separated. In such situations, the bodys normalizing efforts may end up

participating in the problem, and this reminds us of the case where the immune system is participating

in an attack against the body itself. He also mentions a situation where a disease appears to have been

cured, but then suddenly it seems to come back and may even end in death; he likens the situation to a

fight between two tigers, where one wins (that is, the body wins; the pathogen is defeated), but in

doing so, it has exhausted all his strength and eventually succumbs as well. This can remind us of a

remitting and relapsing autoimmune disease. Although there are some intriguing parallels with

autoimmunity in these kinds of stories, the fact is that the ancient Chinese depictions are too general

for us to use in any practical way.

Generally, the traditional Chinese medical ideas became fixed upon the concept of external

pathogens (which can be climactic influences, such as cold and wind) entering the body; they might

then be successfully expelled. With autoimmunity, one part of the body (an invisible immune system

component) is attacking another part (such as connective tissue), and there may be no foreign disease

component involved at the time (even if one served as a trigger years earlier) and nothing to expel.

Thus, the analogies remain limited.

Most times, the description of diseases in the pre-20th century literature of China gives us

insufficient information to associate them with specific modern diseases. That is because the literature

would often leave out key elements we need to make the correlation, such as how long the disease has

lasted and how it has varied over time (months). More typically the descriptions in the Chinese texts

involve the immediate situation: the symptoms as presented and how the disease has changed over just

a few days. Then, it is impossible to know if this was a case of exacerbation of an autoimmune

disease, or if it was an infectious disease, or some other condition. Still, we are able to turn to the

centuries of Chinese medical experience for insights into at least one of the autoimmune diseases:

rheumatoid arthritis. It seems evident from the Chinese literature that this disease existed in the past;

we have the traditional descriptions which show a distinct overlapin terms of symptoms and disease


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progressionwith the modern depiction.

The textual evidence points to rheumatoid arthritis among other painful disorders of the joints,

muscles, tendons, ligaments, blood vessels, and other tissues: the bi syndromes. In the Neijing

Suwen, it is indicated that the pathological entities of wind, cold, and wetness could lead to such a

bi syndrome, at least one of which had characteristics of rheumatoid arthritis. It was said in that

ancient record that when the wind component dominated, the symptoms would migrate; when cold

dominated, the condition would be especially painful; when dampness dominated, the site of the

affliction would become fixed (today, Chinese literature often attributes this localization to blood

stasis and/or phlegm accumulation).

During the 20th century, Chinese doctors began routinely incorporating modern medical

diagnostics into the field of traditional medicine. Immunology didnt develop significantly anywhere

in the world before the 20th century, and it came to China somewhat late, but was immediately applied

to discussion of traditional disease categories and to the use of herbs or their active components for

treatment of the disorders. Chinese publications in the late 1970s and into the 1980s showed

awareness of immune system components in the autoimmune diseases, but there was lack of clarity as

to what role they might play. Then, during the 1990s, as Western literature was more readily accessed,

Chinese studies began to concentrate on specific immune system components and the role of

mediators of immune responses, which brings us to the current situation.

TRADITIONAL APPROACHES INTO THE MODERN TIMEThe development of traditional Chinese medicine over the centuries led to a focus on treating patients

individually according to the signs and symptoms (syndrome) rather than according to a disease

name. The exception to the general principle is that certain herbs or acupuncture points might be

deemed especially good for a disease type, such as bi syndrome, and included for that reason

primarily. As Chinese medicine was modernized during the 20th century, great emphasis was still

placed on this approach of differential diagnosis. Reports of diagnostics and treatments based on

this method shed only limited light on the basis for Chinese herb treatment of autoimmune diseases,

because of the great variability in treatment from patient to patient and even from visit to visit of the

same patient, and also because of the lack of specific diagnosis. Thus, for example, a report on

treating rheumatoid arthritis might involve patients with several different diseases that could have

been distinguished by modern means, because the focus of attention was on the Chinese medicine

syndromes. Also, the claims of resulting improvements as the result of treatment were not reliable due

to a number of political, social, and educational factors prevalent during this period.

An example of a report from this field may suffice to reveal the difficulties. In the 1983 Journal

of the American College of Traditional Chinese Medicine (2), a lengthy article by Lin Jiehou on

rheumatoid arthritisas treated by one of Chinas leading physicians Wang Weilanwas presented.

Wang Weilan is to this day a medical doctor at the Beijing Municipal TCM Hospital. This is how the

disease was described:

Rheumatoid arthritis is a generalized chronic disorder. It usually has a prolonged

course with complicated manifestations. The existence of hot, cold, excess, deficiency

and the persistence of the bi entity eventually involve the yin, yang, qi, blood, and the five

solid organs [zang]. In the struggle between the evil and normal qi of both the hot and


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cold types of rheumatoid arthritis, the flourishing of either of the evils will generate a state

of deficiency. The pertinent tonification of the deficiency, supporting the normal qi, and

the dissipating of the evil are critical in a proper treatment. Clinically, it is recognized that

there is qi deficiency, blood deficiency, and deficiency of the organs. For qi deficiency,

herbs for tonifying qi are used; for blood deficiency, herbs for tonifying blood are used;

for yin deficiency, the principle used is to moisten the yin; for yang deficiency the

principle used is to tonify the yang.....From the wholistic point of view, although

rheumatoid arthritis usually manifests as a local lesion, the disease process is intimately

related to the entire integrated defense mechanism of the body, which is explained by the

following: The normal qi must be deficient before the evil can take the opportunity to

invade....The internal existence of normal qi will prevent the interference by the evil.

Therefore, the deficiency of the normal qi is the basis of the internal factor and leads to the

looseness of the cutaneous tissue [body surface] and the lowering of the bodys resistance.

If the external factor is the contraction of cold in the winter, then the cold evil can take the

opportunity to enter the weak and deficient body and to directly strike at the ligaments and

the bones, thus causing: internal damage to the blood and the meridians, qi stagnation,

blood stasis and ecchymosis, and limitation of movements. The prolongation of the

disease course will cause the cold evil to transform into heat and form toxins; thus, there

will be the appearance of both cold and hot, and the existence of both deficiency and

excess symptoms which creates a very complicated situation.

This description fits the generally recognized theories of traditional Chinese medicine. While the

authors is admitting to a complicated situation, one can see in the analysis reference to virtually

every category of pathology: wind, cold, heat, damp, blood stasis, normal and evil qi, blood, yin/yang,

five internal organs, deficiency, excess, toxins, etc. This seeming state of disarray or lack of focus in

the description of the disease, its pathology, and its treatment, reflects two important features of

traditional Chinese medicine:

1. The tradition developed in the absence of modern analysis of disease. Attempting to apply the

traditional concepts to a modern disease category (such as rheumatoid arthritis) is very difficult

because the origins and nature of the descriptions are so different. There are claims often made by

Western practitioners of Chinese medicine that they are able to target the underlying problem to

resolve the disease (while modern medicine can only suppress symptoms), because they identify

the syndrome and target it. In fact, it is a complicated matter to pin down a specific pattern, as

displayed in the above description, and many times practitioners rely instead on selecting from a

small number of set formulas for the disease; perhaps one for people sensitive to cold, another for

those with joints that feel hot, one for upper body manifestation, and another for the lower body.

However, such selection is really aimed at the branch of the disease, rather than the root.

2. While Traditional Chinese medicine presents therapeutic methods that correspond directly to the

diagnostic categories (hence; the comments by the above quoted author: for qi deficiency, tonify qi;

for blood deficiency, tonify blood, etc.), there had been no specific claims for success in the past.

Instead, Chinese authors would usually simply state that for a certain syndrome one should apply a

certain corresponding remedy. Thus, it is possible that these treatments might be given with only

moderate or temporary improvements. Then, as medical doctors and researchers began treating

patients in the modern setting, they found that the responses were not as clear cut as hoped, so that


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they would express the fact that the situation was complicated.

The above explanation must be taken in context: rheumatoid arthritis (as is the case with most

autoimmune diseases) is not easily understood by modern medicine and although initial treatments are

usually simple, over time, the situation becomes quite complex. On the other hand, broad categories,

such as qi, blood, yin, and yang and their corresponding tonics is far less precise that the modern

medical knowledge of the disease and the treatment options.

Medical journals presenting clinical reports in China began appearing from all the major

hospitals, medical colleges, and research institutes (which were often grouped into giant complexes).

For rheumatoid arthritis, many of the reports described new agents, such as the active components

of Tripterygium wilfordii (leigongteng), which is a toxic plant (though it can be used without apparent

adverse effects by many patients). It has potent immunosuppressive activity from it glycosides similar

to that attained with steroids, but without the usual steroid side-effects. Other isolated active

ingredients, such as the alkaloids of Sinomenium, were indicated as helpful, but these alkaloids could

cause serious side-effects in a significant portion of the treated patients. There were also numerous

reports of using ordinary decoctions.

As an example, Li Jun, at the Ministry of Health in Gansu, reported on treatment of 46 cases of

rheumatoid arthritis with a decoction (3). The formula he used was comprised mainly of herbs that

vitalize blood (such as achyranthes, cyathula, persica, cnidium, tang-kuei, carthamus), but it was

modified according to differential diagnosis for each patient. He claimed that 12 patients were cured,

25 markedly improved, and 7 improved. This appears a remarkable result; according to modern

medical analysis, this disease is almost never cured, yet here more than one in four patients was said to

be cured; in addition, more than half the remaining patients were markedly improved (this category

was explained: signs and symptoms basically disappeared). One would think that with such results,

this formulation would be studied further and developed into a modern drug or health product or a

routine therapy at one or several of the hospitals, especially since none of the ingredients reported to

be used were toxic in normal dosage. However, this report was never followed up, and though many

other doctors in China have reported using blood-vitalizing herbs, their formulas were apparently

based on their own ideas, rather than pursuing what Li Jun had accomplished in Gansu. Why?

There are two primary answers to this:

1. The results reported in many such publications were, in fact, unreliable and other researchers in

China were aware of this. Under the conditions that prevailed at the time of Li Juns work (in the

1980s, published in 1988), clinical reports were often exaggerated. Therefore, no follow-up was

called for.

2. A highly competitive situation existed (and still exists) in this field; each doctor has his favored

recipes and is interested in working with his own formulation(s) and reporting their success, rather

than following-up a prior study with a formula of someone elses design.

This is an unsatisfactory situation that is only gradually improving. The lack of adequate

progress is easily noted in the English language publications from China, such as the Journal of

Traditional Chinese Medicine and the Chinese Journal of Integrative Medicine. In relation to the first

point, it has been noted that virtually all TCM clinic reports issued in Chinese journals provide


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positive results, often extremely positive; negative results are rare, and usually involve only a

control substance, which might be a commercial product that the researcher is pointing to as inferior

to his test formulation. In relation to the second point, frequently researchers provide very limited

information about the formula, hiding ingredients, not disclosing proportions, and giving incomplete

details of dosing, thus protecting their personal recipes, but also preventing others from pursuing the

apparently promising research further.

Today, the study techniques are getting better, and therapies thought to be of benefit are more

often being subjected to pharmacological analysis to verify activity and determine a mechanism of

action. As an example, in a report in the 2000 issue of Journal of Traditional Chinese Medicine (4),

the authors presented six data tables showing characteristics of the patients, comparison of overall

therapeutic results, analysis of the symptom and sign changes, and the changes in laboratory measures

of the patients blood, such as immunoglobulins, rheumatoid factor, sedimentation rate, T-cell subsets,

and changes in hemoglobin and red blood cells. There were two treatment groups, with some details

given about the herbs used (one for yang deficiency; one for yin deficiency), and a control group using

an established herbal formula on the market.

In that report, as with other studies, there is a remarkable result claimed: of 87 cases treated with

the research formulations, 9 were said to be clinically cured, and 58 showed that the treatment was

markedly effective. Only 13 cases were said to show the treatment ineffective. Yet, up to this time

(six years later), further research on these particular formulas has not been presented. The authors,

led by Zhou Xueping and Zhou Zhengying at Nanjing University of TCM, ventured an explanation of

the disease:

Rheumatoid arthritis is a chronic obstinate disease that involves multiple joints all over

the body. Because of its diversity in classification and therapeutic principles in TCM,

there has been confusion whether it is a deficiency or excess in nature. We hold that

deficiency of the liver- and kidney-yin, stagnancy of qi due to accumulation of pathogenic

cold in channels and collaterals, and phlegm stagnation combined with blood stasis are the

main pathogenesis, of intermediate and late rheumatoid arthritis. The cardinal viscera

being deficient is the kidney, the syndrome belongs to the category of deficiency in origin

and excess in superficiality, or deficiency intermingled with excess, which also has the

differences of cold and heat, yin and yang in nature. If one suffers from insufficiency of

the yang-qi and invasion of pathogenic cold and dampness from the outside for a long

time, manifestations of yang insufficiency, cold in the interior, stagnation of phlegm, and

blood stasis would occur. If one has yin deficiency, the pathogenic wind, dampness, and

heat would take advantage of the yin deficiency and invade into the body. In this case,

treatment with drugs too warm and too dry in nature, the stagnating cold would transform

to heat, resulting in damp-heat syndrome, a pathogenic factor causing too much

consumption of yin and blood. Therefore, tonifying kidney, resolving phlegm, and

removing blood stasis are the primary principles in the treatment....

There is a slightly more focused presentation than in the earlier analysis quoted, but this is partly

because the authors have decided here to focus on more advanced cases, thus eliminating some of the

variables associated with also considering more recent disease onset. While these explanations are

instructive in revealing the way these physicians thought, they are far from definitive. Descriptions


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like these are so broad and lacking in evidence to support them, that it is difficult to apply practically.

The same lead authors presented another paper in the same journal in 2004 (5), reporting on

another formulation, claimed to be derived from one of the formulas used in the prior report, but

containing almost no overlapping ingredients other than rehmannia and wasps nest. This was given

to patients with rheumatoid arthritis of the yin deficiency type with heat in the collaterals. As with

the above paper, they claimed a similar level of effectiveness with 9.5% cured, 38.1% markedly

effective and only 9.5% ineffective, with better results than a control group treated with Tripterygium.

They explained:

In rheumatoid arthritis (RA), though arthralgia due to cold is commonly seen

clinically, arthralgia due to heat is also frequently seen. RA of the type of yin-deficiency

and heat in the collaterals is caused by the following factors: weak body constitution,

deficiency of yin and blood, invasion of exogenous heat, improper use of drugs, and so

on. If yin is deficient, the evils of wind, dampness, and heat would invade through the

weak points, and then channels and collaterals would become obstructed. If yang is in

excess there would be excessive heat in the body. After invading into the body, the evils

of wind, cold, and dampness will produce heat with the help of the excess of yang. When

these evils remain in the body, their stagnation would cause damp-heat. Furthermore, if

the drugs too warm and dry in nature or hormones are taken for a long term, yin and blood

might be consumed. This disease manifests as excessive in superficiality at the beginning,

but there is deficiency in origin at the same time. Deficiency of the kidney is the root

cause of the occurrence of RA of the type of yin deficiency and heat in the collaterals,

which is the pathogenic basis for long-term arthralgia....

In the formulation revealed by the authors, raw rehmannia and loranthus were included to nourish

the kidney yin; the main focus was on treating inflammation with sinomenium, silkworm, wasps nest,

and other herbs that have such a reputation; the selected ingredients do not necessarily treat heat or yin

deficiency. The basic theory presented by the authors is that the weak body allows for invasion of

exogenous factors, which, in this case, produce a heat syndrome. There is a surprising lack of

commentary about the unusually good results in this and the other reports, other than the apparent

superiority to the control treatments. In this case, because Trypterigium is so potent, a further analysis

and discussion would seem essential.

While Chinese medical reports indicate the presence of clear-cut syndromes in the patients, there

are difficulties in lack of consistency in diagnostics among Western practitioners. Studies have shown

that if the same patients are presented to different experienced practitioners of traditional Chinese

medicine, the diagnosis will often not be in agreement among them. This was confirmed recently in

the analysis of patients with rheumatoid arthritis (6). Three American practitioners of Chinese

medicine who each had at least 5 years experience were presented with 40 rheumatoid arthritis

patients. The average agreement rate for the individual patient diagnostic category among the

practitioners was just 31.7%. However, when they prescribed textbook remedies (standard formulas,

such as Duhuo Jixue Tang), they had a high level of agreement in their recommendations, about 91.2%

of the time. This evaluation demonstrates, as described earlier, that there are a few basic formulas

that practitioners will rely upon, and they are usually applied without much reliance on refined


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diagnostics, but instead turning to certain obvious and general conditions.

Despite the difficulties with the Chinese literature, we may be able to distill some valuable

lessons from the intensive work done in China. It is a matter of sorting through the various concepts

and reports to follow the theories and practices. I have chosen to focus on rheumatoid arthritis for the

analysis given above because of its higher frequency of occurrence than other autoimmune disorders

and the fact that it has a long history of analysis and treatment in China. The results that could be

obtained by examining the Chinese literature for numerous autoimmune disorders would be beyond

what can be presented here. Some analysis of the literature on rheumatoid arthritis and other

autoimmune diseases have been set forth in other ITM publications, which are available on the ITM

web site (www.itmonline.org); these include: ulcerative colitis, Raynauds syndrome, scleroderma,

lupus, multiple sclerosis, and ITP.

UNDERLYING DISORDERAutoimmune disorders, because of their chronic nature are understood to be based on an underlying

deficiency syndrome, as was explained by Lin Jiehou and Zhou Xueping. In brief, it is the deficiency

that permits the pathology to manifest. If the vessels were full of qi and blood, and the organs

working properly and full of their essences, the person would be healthy, or might, at the worst, suffer

minor and short term diseases. Instead, the deficiency condition allows external pathogenic influences

to enter, and permits the disease to progress, transform, and become serious because of inadequate

resistance to this process by the normalizing qi. Genetic factors involved in diseases are often

associated with the Chinese concept of essence deficiency (specifically, a kidney deficiency); diseases

that progress with aging are also attributed to deficiencies of kidney and liver and involve the

essence deficiency (jingxu). The potential role of viruses or other infectious agents in triggering the

disease process (as indicated by some modern investigations) corresponds, in part, to the failure to

repel the external pathogen.

As underlying contributors to disease, one would expect the deficiencies to be evident prior to the

initiation of the autoimmune disease. On the other hand, there might be little chance to observe this

because the deficiencies might involve only those aspects of qi, blood, and essence that regulate

resistance to certain disease conditions, so that more obvious signs of deficiency, such as pallor,

fatigue, imbalances of heat and cold, etc., might not be especially pronounced for such individuals.

Still, one would expect that by undertaking a careful diagnosis prior to the onset of the autoimmune

symptoms, some deficiencies would be observed. Otherwise, the TCM theory would have to be

relinquished.

In order to more firmly establish the presence of such underlying deficiencies, it would be

necessary to obtain medical histories (including information oriented to reveal the standard signs

recognized by TCM practitioners) from persons who were recently diagnosed with an autoimmune

disease. That way, they might be able to reliably recall preceding conditions, particularly those in

months before the first clear evidence of the disease. Such an investigation has not yet been done.

Most attention is naturally focused upon treatment of persons who are seeking relief from an existing

disease, one which may have been present for some time already since early symptoms are often easily

controlled by modern drugs while Chinese herbal medicine is sought out if the disease is inadequately

controlled by that means or if the drugs are not well tolerated.


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According to common TCM approaches to disease treatment, tonification of the deficiencies

would be a part of the therapy throughout treatment, since the effect of other therapeutic approaches

would be boosted by the presence of adequate qi, blood, and essence. For example, to vitalize

circulation of blood, the qi must be adequate, according to the Chinese theory. Tonification would be

especially important during any phases of remission where there would not be an immediate

requirement to intensively alleviate inflammation, pain, and other acute symptoms, while it would

usually be a secondary part of the treatment if the acute syndrome is present.

BRANCHESEach autoimmune disorder manifests differently, and often one disease appears entirely unrelated to

another, despite a common basis in immune attack. For example, early onset diabetes (type I) results

in hunger, weight loss, excessive urination, fatigue, and other symptoms, while connective tissue

diseases may result in pain, stiffness, swelling, and redness; ITP results in spontaneous bleeding (or

risk of it), and Sjogrens disease results in dryness. Put simply, the symptoms of the autoimmune

diseaseand the TCM analysis of themwill depend on which cells in the body are the subject of

attack by the immune system.

Nonetheless, there are some secondary patterns that are relatively consistent. First, any of the

diseases that reach an advanced stage appear to manifest at least two imbalances defined in TCM.

One is the deficiency of kidney that may be at the root of the disease but may also come about from

the damage caused by the disease process or even by the drugs previously used to control the disease.

This deficiency may manifest as cold or hot symptoms (depending on whether yin or yang is most

severely affected), weakness of limbs, fatigue, changes in bowel and urination patterns, dryness or

excess moisture. The other is development of blood stasis (which is considered a type of excess

pattern). Blood stasis can occur directly as part of the local disease manifestation (for example: the

autoimmune attack causes inflammation, which damages the capillary beds in the affected area) or as a

later effect (for example, high blood sugar in diabetes over time causes circulatory disorders, with

damage to both the capillary beds and the larger vessels).

In the case of advanced rheumatoid arthritis described by Zhou, it was suggested that in addition

to kidney deficiency and blood stasis, phlegm accumulation was involved. Even so, in the treatments

used for those arthritis cases, each formula had only one herb specific for resolving phlegm

accumulation (sinapis in one formula and arisaema in the other).

Certainly, in each disease, one has to consider that there will be additional factors, aside from

kidney damage and blood stasis, though the kidney imbalance may explain many of those additional

factors (e.g., kidney cold leads to accumulation of phlegm in the channels). Treating the kidney

system successfully may help resolve these other secondary disorders. The presence of obvious hot or

cold symptoms is a major reason for modifying formulas; it is common to use cinnamon, aconite, and

other warming herbs that benefit the kidney yang for cold disorders, and to use raw rehmannia and

moutan along with other herbs to clear heat in the blood, for the hot disorders.

MODERN ANALYSISMany herbs and isolated active components of herbs, when evaluated in model systems (such as cell

cultures or laboratory animals), are shown to have anti-inflammatory activities or immune-regulating

functions. Unfortunately, it is often difficult to project from the laboratory studies to the effects that


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might be attained in the complex autoimmune diseases as they manifest in humans. Still, it may be

worth mentioning here an example where the results are intriguing. Some Chinese herbs that are

frequently used in treatment of autoimmune diseases have been analyzed for active component groups,

which are then tested to demonstrate a possible mechanism of action in autoimmune disorders.

Testing in models of arthritic inflammation is relatively easy and it is in demand because of the high

frequency of the disease. We can begin the examination with the central herb for kidney tonification,

a common ingredient in formulas for chronic diseases, particularly autoimmune disorders, and used in

formulas for cold and for hot syndromes: rehmannia.

Rehmannia used in most kidney tonic formulas, such as Rehmannia Six Formula

(Liuwei Dihuang Wan) and Rehmannia Eight Formula (Bawei Dihuang Wan), has as

primary active components a class of chemical substances called iridoid glycosides.

Iridoids, a type of monoterpene, have the basic structure shown here; which often has

a glucose molecule attached, making it a glucoside (general term: glycoside). Iridoid glycosides are

among the main active components for two ingredients of these formulas: rehmannia (dihuang) and

cornus (shanzhuyu). And, for those formulas containing the yang tonic cistanche (roucongrong), there

are additional iridioids that it provides.

Iridoid glycosides are also found as major components of some of the heat-clearing herbs, such as

gardenia, scrophularia, picrorhiza, plantago seed, and chin-chiu (qinjiao) that are sometimes included

in treatment of autoimmune disorders. For example, in a report on lupus therapy by integrated

traditional and modern medicine (7), patients received Lingdan Pian, which included at least three

herbs with iridoid glycosides: chin-chiu (qinjiao), rehmannia, and scrophularia; the formula also

contains ching-hao, moutan, turtle shell, buffalo horn, licorice, and other herbs. In a treatment for ITP

(8), the main ingredients of a formula included at least two herbs with iridoid glycosides: gardenia and

raw rehmannia; the formula also contains red peony, moutan, tang-kuei, and astragalus. In the

treatment of rheumatoid arthritis of the yin deficiency type described in the first report by Zhou, the

formula included the iridoid-containing herbs rehmannia and chin-chiu; other formula ingredients

were ho-shou-wu, campsis, and earthworm.

Recent studies revealed that geniposide, and other iridoids from gardenia fruits (see sample

structure illustrations above, the glucose molecule is at the bottom right of each structure), showed

pharmacological action consistent with suppressing immune inflammatory processes. For example,

the compounds produced significant inhibition of IL-2 secretion, thus reducing antibody-stimulated

activation of human peripheral blood T cells (9). In another study (10), it was shown that geniposide

could lower serum IL-1 and TNF- levels in rheumatoid arthritis rats, which was suggested to be

related to its clinical effects of inhibiting development of rheumatoid arthritis. In another study,

extract of chin-chiu (Gentiana macrophylla) was used in animal models of inflammation (11). It was


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noted in the abstract that:

The anti-inflammatory activity observed in Gentiana macrophylla is comparable to that

observed in prednisone. These observations suggest that Gentiana macrophylla displays

considerable potency in anti-inflammatory action and could be used as an

anti-inflammatory agent in the control of inflammation of rheumatoid arthritis.

Chin-chiu extract tablets were used in previous Chinese clinical work in the treatment of lupus

(SLE). It was claimed to be especially effective for nephropathy, arthralgia, and erythema, and

contributed to improvement in blood parameters indicating immune status (12).

This kind of workwith clinical evaluations, chemical analysis, and pharmacological

investigationsmay help elucidate the role of traditional medicine in autoimmune diseases and point

to efficacious treatments relying on selected herbs or their active components. Such efforts would not

necessarily overshadow the potential benefits of using additional herbs to treat constitutional or

other aspects of a disease, but would aid in the process of selection from the huge number of herbs that

are currently in use. The applicatiion of herbs and their active components for autoimmune diseases

would rarely be cause for concern when combining this type of therapy with modern drugs. Very few

cases of interactions that would be detrimental have been observed with use of herbs and drugs, and

those few cases are mainly restricted to certain drugs (e.g., Warfarin) and certain herbs (e.g., St. Johns

Wort) that are not routinely used in these cases (13). Thus, there is a good possibility for utilizing

Chinese medicine for patients with autoimmune diseases relying on both traditional concepts and

modern developments.

REFERENCESUnschuld PU, Forgotten Traditions of Ancient Chinese Medicine, 1990 Paradigm Publications,

Brookline, MA.

Lin Jiehou, Bi-entity (arthritis): Clinical experience of master-physician Wang Weilan, Journal of the

American College of Traditional Chinese Medicine 1983; (3): 328.

Li Jun, Treatment of 46 cases of rheumatoid arthritis with modified Shentong Zhuyu Tang, Beijing

Journal of Traditional Chinese Medicine 1988; (6): 3536.

Zhou Xueping, et.al., Intermediate and late rheumatoid arthritis treated by tonifying the kidney,

resolving phlegm, and removing blood stasis, Journal of Traditional Chinese Medicine 2000;

20(2): 8791.

Zhou Xueping, et. al., Clinical study of Qingluo Tongbi Granules in treating 63 patients with

rheumatoid arthritis of the type of yin deficiency and heat in collaterals, Journal of Traditional

Chinese Medicine 2004; 8387.

Zhang GG, et. al., Variability in the traditional Chinese medicine (TCM) diagnoses and herbal

prescriptions provided by three TCM practitioners for 40 patients with rheumatoid arthritis,

Journal of Alternative and Complementary Medicine 2005; 11(3): 415421

Zhong Jiaxi, et. al., 25 cases of systemic lupus erythematosus treated by integrated traditional Chinese

medicine and Western medicine, Chinese Journal of Integrated Traditional Chinese Medicine and

Western Medicine 1999; 19(1): 47-48.


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Fruehauf H, The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 ITM,

Portland, OR.

Chang WL, et. al., Immunosuppressive iridoids from the fruits of Gardenia jasminoides, Journal of

Natural Products 2005; 68(11): 16831685.

Zhu J, et. al., Effect of geniposide on serum IL-1beta and TNF-alpha of rheumatoid arthritis rats,

Chinese Journal of Traditional Herbal Drugs 2005; 30(9): 708711.

Yu F, et. al., Inhibitory effects of Gentiana macrophylla extract on rheumatoid arthritis of rats, Journal

of Ethnopharmacology 2004; 95(1): 7781.

Yuan ZZ and Feng JC, Observation on the treatment of systemic lupus erythematosus with a Gentiana

macrophylla complex tablet and a minimal dose of prednisone, Chinese Journal of Integrated

Chinese and Western Medicine 1989; 9(3): 156157.

Dharmananda S, Checking for possible herb-drug interactions, START Manuscripts 2003, Portland,

OR.

September 2006


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Autoimmune Diseases and the Potential Role of Chinese Herbal Medicine