Modern day practitioners are using other forms of dispensing herbs from the traditional method of decoction.
There are patents, ready made pills and concentrated powders and more recently these quick method compression like machines that even put your decoction in a vacuum sealed bag for you.
I am interested in discussing if they all work equally?
An interesting comment on the cervical mucous thread about using a large dosage of herbs (200 grams raw used in decoction)
Mathematically it seems that concentrated herbs cannot provide an equivalent daily dosage of each herb in a formula once you have more than 10 herbs in a formula or you require an equivalent to 200 grams of raw herbs per day.
For example, if you tell you patient to take 5 grams of powder concentrate twice a day and you are using KPC or Sun Tan (5:1 ratio) then they are getting an equivalent to 50 grams of raw herbs a day (homeopathic dosage). But yet many are claiming great success using these concentrated powders. I know Jane Lyttelton and Randine Lewis both use the 5:1 ratio concentrated herbs. We at Acubalance have been using the 10:1 ratio herbs. In theory these should not be so helpful. i am curious to know of those of you using powder concentrate, are you getting good results and how fast. I would love to hear about conditions relating dermatology, endometriosis and other complicated diseases that usually require large formulas ( 15 plus herbs). And yes, I am still thinking the herbal formula is based on the pattern diagnosis and not the name of the disease.
I think this is important to know. The implications are significant in the form of cost and risk to our patients.
I have seen very good results treating painful menses with a Kidney yang vacuity cold and Blood stasis using concentrated herbs. They will get some benefit in the first few cycles but i usually need 4-6 months to reach a "cure" or significant improvement. But I use powders that come in individual packages at a rtio of 10:1. So theoretically my patients are getting a daily dose of each herb (10 grams) and if i wanted say 40 grams of Huang Qi I just give then 4 packages of Huang Qi. i use to use KPC and switched because I was concerned that they would not be getting the correct dosage of each herb.
So those of you using these powders... tell me if they work. Or do I really need to look into decoction.
Lorne
Wanting to Grow*Share*Connect with like minded TCMers
Chinese herbal extract powders were pioneered in Taiwan where the standard concentration ratio is 5:1. In Taiwan, the standard daily dose of such extracts is 18 grams. Eighteen grams is the limit because that is all Taiwanese health insurance will pay. However, according to Eric Brand, many Taiwanese practitioners lament the fact that they cannot prescribe more than 18 grams per day. They believe that 18 grams per day is too little for many cases. At 5:1, 18 grams equal 90 grams in decoction. Therefore, having higher concentration ratios is a good thing. Blue Poppy Herbs sells Zuo Gui Yin, Liu Wei Di Huang Wan, and Zhi Bai Di Huang Wan all in 10:1 concentration ratio. Now give 18 grams per day and your patient is getting the equivalent of 180 grams per day in decoction.
I understand this on a mathematical level. i am curious what kind of therapeutic effect practitioners are having with pills and powders. To take the other side, I have been told that some companies guarantee their bio availability. use the correct formula for the pattern and it has the desired effect EVEN THOUGH they may be only getting the equivalent of 90 grams of raw herbs.
I wonder if there is anyone who uses both decotion and powders. Do they see the same results. Are there certain patterns or conditions you find that need decoction? What responds well to powders.
i ask this because mathematically it seems off that so may practitioners claim success treating with powder herbs even though the patient may be getting an equivalent of 50 grams of raw herbs?????
Also, thanks for letting me know about Blue Poppy herbs being 10:1 ratio. I have used phoenix Rising (PMS headaches) , Added flavors & Boost the Center (Flooding and leaking) and Cold Quell (gan mao) with great success when the pattern fits. And I usually prescribe them at 12 pills a day (6X2) so equivalent of 120 grams of raw.
Lorne
Wanting to Grow*Share*Connect with like minded TCMers
Lorne,
I have used both extract powders and decoctions, sometimes in the same patient at different times, and, definitely, my experience is that correct dose for the case is hugely important. However, to address your question of why so many people seem to be getting good results with lower doses, I would say several things:
1. Since most practitioners are also simultaneously doing acupuncture, it's impossible to say what is getting what effect. I only prescribe herbs; so I definitely do know what works and what does not for my patients. I expect to see some results within one week at least when using higher doses than most other (non-Asian) practitioners I know.
2. The post about not seeing increases in vaginal mucus in anything less than three months of continuous treatment itself suggests that the meds being used are too low in potency. In China, doctors do not have the leisure to expect results only after three months.
3. Since there are few controlled studies in N. America on the efficacy and outcomes of CM, it is hard to say exactly how successful people really are. To do that, one would need stated, objective, quantifiable outcomes, the kinds of outcomes used in CM studies in China. My experience after 30 years in this field is that people are generally less successful than they say they are in public. All too often, one or two cases are used to make general statements of success. I see this all the time on the CHA website. Don't forget that everyone gets 40% placebo effect. Add to that another 30% amelioration rate (not cure rate) and one is at 70%, and one can maintain a successful practice for years and years with only a 70-80% amelioration rate.
My point here is that, although your questions are valid ones, no one in N. America can actually answer those questions because of a lack of adequate outcomes parameters and controls for weeding out extraneous factors. Because our patient populations are so small statistically, because of our intent to treat, because of our patients' self-selection, and because of our using a combination of modalities to treat, I do not believe that any N. American answers to these sorts of questions can carry much real weight.
That being said, at least one Chinese study has shown that powdered extracts and decoctions are equally effective when prescribed at equivalent doses. Check out the free articles section or the herbal newsletters section at www.bluepoppy.com if you need the documentation for that study. That study has also been cited by John Chen at Evergreen Herb Co.
Hi Bob,
I always appreciate how you can clearly and simply get your thought across, regardless of the complexity. You have allowed to take one of my many thoughts and issues off my mind. It would be interesting if there could be other studies like the one you mention on www.bluepoppy.com comparing powders to raw. We were debating switching on herbal supplier. After our discussion it makes sense to remain with them since all our herbs are individually packages at 10:1 ratio. (Some more and some less) So although we cannot easily create a king and assistant herbs like with decoction, we are assured the patient is getting a daily dose of at least 10g of each herb per day.
next issue ( I said I had lots in mind)
is there any evidence to show that companies like yourself and E fong (we use them0 are getting 10:1 and in some cases like Shu Di (15:1). How can we support these claims. What kind of test can be done. What about the bio availability?
Again thank you for explanation above. i look forward to your 3 day intensive seminar on Obstetrics in November 2007.
Lorne
Wanting to Grow*Share*Connect with like minded TCMers
"Is there any evidence to show that companies like yourself and E fong (we use them0 are getting 10:1 and in some cases like Shu Di (15:1). How can we support these claims. What kind of test can be done．"
There is no way to analyze a finished product to determine the extract ratio. You have to depend on trusting the math, chemistry, and production line of the factory. In their certificate of analysis, they state the concentration ratio. Were that not to be the truth, legally, that would be fraud and potentially actionable. That's why we went to China last summer -- to visit our factory, watch what and how they were doing things, meet the people doing things, and building mutual trust and relationship (guan xi). However, we have gotten quotes from a half dozen different Chinese companies and no one has ever suggested that there is any problem with meeting the higher concentration ratios we required. So there's no problem with the technology.
What you can test for after the fact are heavy metals, pesticides, microorganisms, and, if one so desired, specific chemical constituents (for instance, what you believe to be the so-called active ingredients).
"What about the bioavailability?"
I don't any company that routinely tests for this. Certainly one could test for this if one wanted to. However, each time you add a test, you add a cost to the bottom line. I find it hard to think that one powdered extract would be significantly more or less bioavailable.
Bob, I like your article on this topic. I am posting it here as well since it fits in with our discussion. Thanks for putting these free article on the bluepoppy site.
Bioavailability, Patient Preference & Placebo Effect Vis á Vis Various Forms of Chinese Ready-made Medicines
by Bob Flaws , L.Ac., FNAAOM (USA), FRCHM (UK)
Keywords: Chinese medicine, Chinese herbal medicine, bioavailability, patient preference, placebo effect
When treating patients with internally administered Chinese medicinals, most practitioners place primary importance on the correct selection of a formula in terms of the patient's disease diagnosis and Chinese medical pattern discrimination, and, of course, that is where the emphasis should be. However, almost as important are the issues of bioavailability, patient preference, and placebo effect, all of which significantly affect therapeutic outcomes. Ready-made Chinese medicines for oral administration mainly come in two forms: 1) pressed tablets (and caplets) and powder-filled capsules, and there are real differences in bioavailability, patient preference, and placebo effect between these two methods of administration. In my opinion, professional practitioners of Chinese medicine should take these differences into account when deciding which ready-made Chinese medicines to prescribe and dispense. Such a decision may very well make the difference between clinical success and failure.
Bioavailability
In pharmacology, bioavailability describes the fraction of an administered dose of medication that reaches the systemic circulation, and it is one of the principal pharmacokinetic properties of any and all medicinals, including Chinese "herbs." By definition, when a medication is administered intravenously, its bioavailability is 100%. However, when a medication is administered via other routes (such as by mouth), its bioavailability decreases (due to incomplete absorption and first-pass metabolism). Bioavailability is one of the essential tools in pharmacokinetics and should be considered when calculating dosages for non-intravenous routes of administration,1 and per os or oral administration is such a non-intravenous route. Various physiological factors reduce the extravascular availability of medicinals prior to their entry into the systemic circulation. Such factors may include, but are not limited to:
1. Poor absorption from the gastrointestinal tract
2. Degradation or metabolism of the medicinal prior to absorption
3. Hepatic first-pass effect
Each of these factors may vary from patient to patient and, indeed, in the same patient over time. For instance, whether a drug is taken with or without food will affect absorption. Other drugs taken concurrently may also alter absorption and first-pass metabolism, while intestinal motility alters the dissolution of the drug and may affect the degree of chemical degradation of the drug by intestinal microflora. Further, disease states affecting liver metabolism or gastrointestinal function will also have an effect.2
However, the bioavailability of medicinals which are swallowed and absorbed through the gastrointestinal tract is also markedly affected by the form of medication. According to Laurel Kallenbach in the August 1999 edition of Vegetarian Times, "In some cases, as little as 15 percent to 20 percent of a supplement will be delivered to your cells."3 In such cases, the other, nonabsorbed nutrients or medications simply go to make up very expensive urine. Tablets (including caplets) are formed by applying tons of direct pressure to a powder at high temperatures. Besides pressing the ingredients together into a hard mass, this can cause a decomposition of active ingredients. In addition, many "inactive" ingredients, primarily sugars, starches, and bonding agents (glue), are added to the formulas in order to hold all the substances in a tablet. Some tablets also have chemical coatings that are added to make them easier to swallow and mask the taste of powders. The end result of all this is that tablets (and caplets) will often pass through the entire digestive system undissolved or only partially dissolved without absorption. In a capsule form, free-flowing powdered ingredients become available for absorption in a matter of a few minutes after swallowing. Research (as well as common sense) suggests that oral administration of medicinals in gelatin capsules results in better bioavailability of those medicinals than when administered in the form of pressed tablets. For instance, a study published in British Journal of Dermatology (1985, Vol. 112, p. 469) showed that bioavailability of the drug 5-methoxypsoralen (a constituent of many Chinese herbs) was significantly greater (P < 0.01) after administration in capsule form over tablets.4 Similarly, according to research carried out by the Sichuan Pudu Pharmaceutical Company, glimepiride capsules (a hypoglycemic drug) possess better bioavailability and patient compliance compared to glimeride tablets.5 For more than 20 years, Jack Challem has served as a nutrition reporter for numerous consumer health magazines, including Let's Live, Natural Health, Prime Health & Fitness, and Health Naturally (Canada). According to Challem in an article titled, "Why you don't absorb the nutrients you should—and what you can do about it," tablets take much longer to break down and, instead, wind up passing through one's system either partially or wholly unused. Based on this, it is Challem's advice that "Whenever possible..., opt for capsules" when buying nutritional and herbal supplements.6
Patient preference
Like bioavailability, patient preference in terms of dosage forms may also affect therapeutic outcomes. If a patient does not like the form of administration of a particular medicine, they are less likely to take that medicine as prescribed by their health care provider. In other words, preference directly affects compliance or adherence. Obviously, if patients do not take their medicine as prescribed, they are also not likely to get the intended therapeutic effect, and, when it comes to capsules versus pills, a number of studies have shown that capsules are what patients prefer. For instance, according to a study carried out in 1982 by the Burke Marketing Research Institute on the patient acceptance of solid oral dosage forms, 96% of the 1,000 patients queried had very definite ideas on what is most acceptable to swallow. In this study, the majority of patients, i.e., 54%, expressed preference for a drug in capsule dosage form. Only 29% of those asked opted for coated tablets, while only 13% favored standard (uncoated) tablets. In another study conducted in 1990 which involved 7,000 patients in five European countries, gelatin capsules were the most strongly associated form of oral medication with perceptions of "effectiveness" and "easiness to swallow."7 In 1997, Povlin Research queried 700 nutritional supplement users about their preference in solid oral dosage forms. Four hundred of these were herbal users and 300 were vitamin users. According to this study, the majority of herbal users, 74%, expressed preference for two-piece capsules, while vitamin users preferred the two-piece capsule over a tablet by a 2-to-1 margin. In this case, ease-of swallowing was the dominant reason (66%) for preferring capsules over tablets.8
Placebo effect
The placebo effect (Latin placebo, "I shall please") was first mentioned in 1955 by Henry K. Beecher, M.D. It is also known as non-specific effects and the subject-expectancy effect.9 It is the phenomenon that a patient's symptoms can be alleviated by an otherwise ineffective treatment since the individual (and/or their care-giver) expects or believes that it will work. A person's beliefs and hopes about a treatment, combined with their suggestibility, may have a significant biochemical effect. Sensory experience and thoughts can affect neurochemistry. The body's neurochemical system affects and is affected by other biochemical systems, including the hormonal and immune systems. Thus, it is consistent with current knowledge that a person's hopeful attitude and beliefs may be very important to their physical well-being and recovery from injury or illness.10 In an article titled, "The Healing Power of Placebos," Tamar Nordenberg states that, "For a given medical condition, it's not unusual for one-third of patients to feel better in response to treatment with placebo."11 According to research carried out at the UCLA Neuropsychiatric Institute, between 30-60% of patients with illnesses ranging from arthritis to depression report a substantial improvement in their symptoms after receiving a placebo.12 Further, "There is a placebo factor in every therapeutic maneuver"13 or act. In terms of what this means in clinical practice, an independent study carried out by Dr. M. Z. Hussain published in British Journal of Psychiatry (1972, Vol. 120, p. 507-509) found that capsules, in comparison to other oral dosage forms, are consumed more regularly and that more patients requested continuation of treatment with capsules, indicating their belief of the positive impact of the capsule dosage form. Because this study found that the actual physical form of the medication could act as an important additive ancillary factor in the placebo response, most clinical trials of psychiatric-directed medicines are required to use the capsule dosage form.14
Conclusion
Based on the foregoing, I highly recommend professional practitioners to consider that different dosage forms of orally administered Chinese ready-made medicine may well achieve different therapeutic outcomes regardless of their other differences, such as ingredients and their proportions or their extract ratios or potencies. As practitioners, we need to remember that the healing encounter is a multifactorial transactional experience and that far more is involved beyond simply getting the formula or its ingredients right for any given patient. If we keep in mind and, more importantly, act on such factors as bioavailability, patient preference, and placebo effect, we will bring more of these factors to bear in that encounter with the intention of achieving better outcomes for all involved.
Copyright © Blue Poppy Press, 2006. All rights reserved.
Endnotes:
1. http://en.wikipedia.org/wiki/Bioavailability
2. Ibid.
3. http://findarticles.com/p/articles/mi_m0820/is_1999_August/ai_55266467
4. http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2133.1985.tb02322.x#search=%22capsules%20%2B%20bioavailability%22
5. http://www.pudu.com/doce/cpjs.shtml
6. Ibid.
7. http://findarticles.com/p/articles/mi_m0820/is_1999_August/ai_55266467
8. http://answers.google.com/answers/threadview?id=536724
9. http://en.wikipedia.org/wiki/Placebo_effect
10. http://skepdic.com/placebo.html
11. http://www.fda.gov/fdac/features/2000/100_heal.html
12. http://www.placebo.ucla.edu/
13. http://home.comcast.net/~bkrentzman/meds/placebo.html
14. http://www.capsugel.com/services/rx_dpstdy.php
Has anyone ever heard of what type of gelatin is beeing used to create these caps ?
Is it possible to create chinese medicinal gelatin caps ? (ie - Lu Jiao Jiao, Gui Ban Jiao, E Jiao, ...)
Would the dosage be high enough just in the gelatin capsule alone (with other ingredients inside the capsule) to have a therapeutic effect ?
maybe I'm just starting to over think this discussion now !!
Ryan
Promoting a Greater Level of Health
I know Blue Poppy Herbs are made out of beef that has been certified free of BSE (mad cow disease). You can get a certificate of analysis on our capsules by contacting our business manager, Bruce Staff. We had to fill out all the paperwork for our capsules for Health Canada. So I know we hyave this info.
Joined: 2007-05-08