Consultant’s Corner: Determining the Right Dosage for Your Patient

Although Chinese medicine is an herb-based tradition and is regulated in the United States as “food supplements”, as practitioners we know that it is nonetheless still medicine. In China most prepared Chinese herbal formulas, even common ones such as Liu Wei Di Huang Wan, are still considered prescription medicines. However, unlike pharmaceuticals, there is a much greater variance in how herbal formulas work on our patients. Even with standard dosages printed on their labels, it doesn’t mean that as practitioners we shouldn’t increase or decrease the dosage if we feel it is best for a given patient. As practitioners, we can diagnose and assess each patient to determine the best therapeutic dosage. To that end, here is information you may find useful.

What does the standard dosage really mean?
Most of our Plum Flower® teapill formulas have a standard daily dosage of 24 pills a day, and most tablet formulas around 12-16 tablets a day. While this may seem like an enormous dosage to American patients, it is in fact fairly conservative, roughly the equivalent to 9g-12g of raw powder per day, that assumes an adult patient under common clinical conditions. It can be helpful to remind patients that Chinese herbal formulas are made from decocted herbal teas – containing for the most part twigs, leaves, roots, and some shells and minerals. They are not isolated chemical compounds like pharmaceutical drugs that Americans are used to taking in just a few pills per day.

Origin of the standard dosage
The standard adult dosage for most of our teapills and tablets was originally established by the Lanzhou Foci Pharmaceutical Co. Ltd., which was the first factory in China to use modern technology to manufacture extracted, concentrated teapills in 1929. As their products were classical formulas, they calculated the dosage based on the raw herb prescriptions in classical texts, and on the extraction yield from their own manufacturing.

Although a 9g-12g daily dosage for an herbal formula may seem low, the use of advanced extraction technologies including closed-system, dynamic extraction vessels with volatile oils preservation, thermal insulation, temperature and pressure gradients, percolation, vacuum condensation and high-quality herbs significantly increases the therapeutic value of the teapills compared with a typical home decoction. Whereas decocting herbs at home is relatively easy, it can be an inefficient or ineffectual method of obtaining all of the essential components in the herbs. For example, as the decoction is brought to a boil and then simmered, much of the aromatic portion of the herbal ingredients is lost in the steam. Some of the herbs may be overcooked and loose potency, and others may not be cooked long enough to extract all essential components. Some herbs, such as Ren shen/Panax ginseng root, require both ethanol and water processing to fully extract all their essential components, which is almost never done by patients when decocting a formula at home.

Standard Dosages vs. Clinical Dosages
Consideration of the whole clinical picture (including the patient’s age, weight, diet, lifestyle, health history, concurrent treatments and medications) by the prescribing practitioner is required to make a clinical dosing recommendation. We do include thoughts on determining a therapeutic dosage on each of our formulas product details page on our website. For example (please login to view), see the “TCM Info” tab for our An Mian Pian: https://www.mayway.com/an-mien-tablets.html

Many acute issues may require a higher dosage. The dosage may also be modified based upon the nature and severity of the disorder. A larger dosage of 50-100% higher than the standard dosage may be used in severe cases or in the initial phases of treatment, then reduced as the treatment takes effect. Long-term tonification with mild formulas can often be effectively achieved with relatively lower dosages for all types of patients.

Low Dosages
Sensitive patients may need only a small fraction of the standard dose to achieve a therapeutic level. Some patients are more sensitive than others and may need lower doses due to age, strength, and some for no apparent reason at all. Other conditions such as food sensitivities and autoimmune diseases may also contribute to sensitivity to herbs. The rise in food sensitivities and allergies in patients in the United States and Europe has been steadily growing, which many practitioners believe can affect how these patients respond to herbs. For example, a 2008 study by the Centers for Disease Control and Prevention showed that there was an 18% increase in food allergies between 1997 and 2007.[1] "For reasons that we don't understand, the prevalence of food allergies has doubled in the last 15 years," noted Wesley Burks, chief of allergy and immunology at Duke University Medical Center in an article with the Washington Post in 2007.[2] Some patients without any known allergies or food sensitivities may still have a strong reaction to their environment for no apparent reason, including responding more strongly than most to air quality, smells, chemicals, food and herbs. These patients tend to know that they are sensitive to drugs and supplements, but that is not a hard and fast rule. These patients may need only a small fraction of the recommended standard dose to achieve a therapeutic level.

High Dosages
Many practitioners believe that the standard dosages are somewhat inadequate for most American patients. While the average adult weight in China still hovers around 125 lbs, most American adults are slightly to significantly heavier, and thus may potentially require a larger daily dose to get the same effect. In robust or heavier patients, 50-100% of the standard dosage may be required to achieve a therapeutic dose. With many patients this higher dosage is only needed short -term, and then can be reduced to a maintenance dose as the treatment takes effect. However, when treating acute, severe or recalcitrant issues, a much larger dosage for any sized patient may be necessary to achieve a therapeutic effect and be used for several weeks or even months.

In China, it has been found that some patients require larger doses not due to illness severity or weight, but because they have developed a resistance to the effects of herbs from long term use. In other cases, higher doses were found to be required because of the poor quality of herbs being used.

Prescribing Multiple Formulas
Patent medicines are increasingly being given in combination. This strategy is becoming popular because it can produce a greater therapeutic effect. It also gives practitioners some of the benefits of modifying formulas inherent in custom herbal prescriptions by allowing them to address multiple aspects of a Chinese medical diagnosis similarly to how they would with an herbal decoction. When given in appropriate combination and at an adequate dosage, high quality patent medicines can be very effective, even for acute or severe conditions.

When practitioners prescribe two (or more) formulas to more completely address the patient’s TCM diagnosis, then moderating the dosages of each also offers a way to target the chief complaint and secondary complaints in tandem. A practitioner may decide that a patient needs to have a small dose of one formula with a large dose of another, or may even decide that the patient needs to take the standard dose of two or more formulas. The proportions are dictated by the constitutional patterns, symptom presentation and treatment goals.

Assessing Effectiveness
One of the challenges both students and practitioners face is to know how long to administer a remedy before assessing its effects. Over the years, we have found that there is a tendency with practitioners and patients alike to expect results too quickly. Because many of the conditions and patterns we treat in Chinese medicine practices are chronic and often multidimensional it usually takes some time for results to be clearly felt. Of course each individual and each presentation is unique so there is not one standard for assessing results, but if the diagnosis is correct and there are no adverse effects occurring it is good to give a remedy 4-6 weeks before determining if it is working or not. Some chronic problems can take many months to rectify so it important to have some patience and perseverance.

Your patient should be experiencing some signs along the way that things are heading in the right direction. General health signs and symptoms of improved Qi should begin to appear. Areas that this can be seen are in energy levels, mood, sleep, digestion, Shen, and even improved circulation, or skin and hair quality. When these aspects of your patient’s health are improving it is likely you are on the right path. Conversely, when these indicators are adversely impacted, it is wise to reassess the clinical picture right away, including diagnosis, treatment strategy, dosage, as well as patient compliance, concurrent illness or infection, concurrent use of drugs or pharmaceuticals, diet, lifestyle and life cycle events.

Additionally, the initial TCM diagnosis for chronic and multidimensional conditions is often more of a working hypothesis than a hard and fast diagnosis. Therefore, it is often necessary to watch the patient’s response closely over the first few weeks of a long-term treatment plan and adjust the dosage as well as the combination of formulas as we see the patient’s response to the herbal treatment.

Signs Dosage is Too High
Typical symptoms that can occur that indicate that the dosage is too large include nausea, loose stool, digestive discomfort, headache and general malaise. When any of these occur, it is best to lower the dosage or stop the formulas and reassess.

Further Notes on Administration
In general, we suggest taking Chinese herbal formulas on a relatively empty stomach, either a half-hour before, or one hour after eating. This allows for the herbs to benefit from the digestive enzymes in the stomach around mealtimes without directly competing with food in the stomach, better facilitating the absorption of the herbs. According to traditional Chinese medicine, they are most effective when swallowed with warm water.

Certain foods can actually decrease the absorption of herbs. For example, grapefruit is known to hinder the absorption of fats, which may decrease the absorption of fatty-based components in herbs, including many important active ingredients. Additionally, the tannins in tea, fiber supplements, and activated charcoal can hinder the absorption of herbs. For this reason, some practitioners feel that for a stronger effect, the herbs should be taken in between meals (at least two hours after eating) to ensure that the stomach is completely empty so that the herbs do not get mixed with any food and compete for absorption.

Conversely, if your patient experiences any abdominal discomfort, you may need to administer the herbs with meals, or else slowly build up to the standard dosage to ensure that they do not experience any digestive difficulties. Those with sensitive stomachs or difficulty digesting herbs can also try to take the herbs with an herbal tea such as ginger or mint, or with Curing Pills to facilitate digestion.

It is also generally recommended that herbs or any other dietary supplements be taken two hours apart from pharmaceutical medications. Although there is limited information available on potential herb-drug interactions, and almost none have proven definitive by clinical research available in English thus far, it is still safest to avoid taking herbs and medications at the same time.

Finally, timing can have a big effect on your treatment. Qi and Yang tonics are best administered in the morning because they can result in such increased energy that the patient may have difficultly sleeping if taken too late in the day. Sleeping and Shen calming herbs should be administered towards the end of the day for best effect, and many practitioners advise taking one dosage after dinner and another just before bed. For acute problems, it is best to have smaller more frequent dosages throughout the day (such as Gan Mao Ling, which works best for most patients if given at 3-4 tablets every 2-3 hours).

However, taking the full daily dosage is of paramount importance to achieving good results even if they work best when taken throughout the day. Therefore, if patients have difficulty taking the herbs three times a day, they can be allowed to take the daily dosage in two lots, and if it is the only way that will work for them, they can even take the full daily dosage all at once.

References:

• Maclean, The Clinical Manual of Chinese Herbal Patent Medicines, Pangolin Press, Sydney 2000.
• Taylor, Chinese Patent Medicines; A Beginner’s Guide, Global Eye International Press, Santa Cruz, CA 1998.
• Flaws, 160 Essential Chinese Herbal Patent Medicines, Blue Poppy Press,
• Fratkin, Essential Chinese Formulas, Shya Publications, Boulder, CO 2014.

1 Food Allergy Among U.S. Children: Trends in Prevalence and Hospitalizations, Centers for Disease Control & Prevention Report, NCHS Data Brief No. 10, from October 2008. Online at: https://www.cdc.gov/nchs/products/databriefs/db10.htm

2 When Food is a Danger, by Sally Squires, Health and Nutrition Columnist, Washington Post, published Tuesday July 10, 2007. Online at: http://www.washingtonpost.com/wp-dyn/content/article/2007/07/09/AR2007070901328.html

About the Author

Laura Stropes, L.Ac. is a licensed practitioner of acupuncture and traditional Chinese medicine with a great love of Chinese herbology. She has been in practice since 1998. She has a passion for helping people on their path to achieve balance and wellness. She is a Fellow of the Acupuncture & TCM Board of Reproductive Medicine (ABORM), and specializes in women's health, in helping women, men, and couples optimize fertility, and supporting healthy pregnancies. She also has a strong focus on treating problems that negatively impact everyday health and well-being (sleep, digestion, stress level, pain). Laura worked at Mayway from 1999-2019 as an herbal consultant and project manager. Laura’s projects included the initial Mayway website in 2004 and website redesign in 2012, the Herb ID Kit recreation in 2009, and she coauthored the book “A Practitioner’s Formula Guide: Plum Flower & Minshan Formulas” - Wrinkle, Stropes & Potts, published in 2008. She also worked on product research and development, writing articles, and consulting services for other acupuncturists, chiropractors, veterinarians and medical doctors in choosing suitable TCM herbal treatments for their patients. Laura can be reached at: laura@laurastropes.com.