Consultant's Corner: Notes on Herb Administration

As the senior herbal consultant at Mayway, I receive a lot of feedback from practitioners about what works (and what doesn’t) when administering herbs to their patients. I’m frequently asked for advice on the best time to take herbs, and while often there is no universal answer to that question, here are a few notes on interactions with food, dosage intervals and special circumstances, each of which can influence the effectiveness and safety of herbal treatments.

Herbs and Mealtimes

•Close to Mealtimes - in general, we suggest administering herbal formulas on a relatively empty stomach, but close enough to a meal to take advantage of the body’s readiness for digestion. Either a half-hour before, or one hour after eating seems to work best. This allows the herbs to benefit from the increased digestive enzymes in the stomach around mealtimes without directly competing with food in the stomach, and will facilitate the absorption of the herbs.

•Between Meals - however, in some cases food can actually decrease the absorption of herbs. For example, grapefruit is known to hinder the absorption of fats, which would decrease the absorption of fat-based components in herbs, including many important active ingredients. For this reason, some practitioners feel that for a stronger effect, herbs should be administered in between meals to ensure that the stomach is completely empty so that the formulas are not mixed with any food.

•With Meals - conversely, if the patient experiences any abdominal discomfort, he or she might need to take Consultant’s Corner the herbs with meals. Patients with sensitive stomachs or difficulty digesting herbs can also be advised to take the herbs with an herbal digestive tea such as ginger (when warming is needed) or mint (when cooling is needed), or with Curing Pills or Xiang Sha Liu Jun Zi Wan to facilitate digestion. Some patients may need to slowly build up to a regular dosage without experiencing digestive difficulties, such as bloating, gas, and frequent or loose stools. In some cases, if the digestive symptoms don’t resolve, the formula may need to be reevaluated or discontinued.

Notes on Specific Herbal Strategies

•Insomnia or Night Sweating Formulas : these formulas are most effective for chronic sleep problems or night sweats if taken regularly for several weeks. Optimally a small or moderate dose is administered after dinner, and a larger dose administered before bed. Another small to moderate dose can be put on the nightstand and taken if the patient wakes during the night. However, formulas for insomnia may still be effective for occasional bouts of sleeplessness if a large dose is taken right before bed.

•Purgative Formulas : these formulas are often taken before bed so that a bowel movement is induced in the morning. Formulas that contain Da Huang/Rheum palmatum root & rhizome may initially cause mild abdominal cramping and/ or diarrhea in sensitive patients, and may be habituated to. After a few months of treatment, it is recommended that patients should be moved to an appropriate constitutional formula, or encouraged to progressively and slowly lower their dosage of a Da Huang containing formula until bowel movements seem negatively impacted, then add in a pill or two per day until a smooth bowel movement is achieved with the lowest number of daily pills.

•Skin Formulas : during the course of treatment for any skin disorder, it is advisable to have the patient avoid substances that promote heat, toxins and damp-heat such as spicy, greasy foods, shellfish, peanuts, coffee, alcohol and smoking.

•Tonic Formulas : to increase the effectiveness of long-term tonic formulas, many practitioners recommend that the patient take a week’s break from a tonic formula for every three months of treatment. This is done to prevent the body from building up a tolerance that could potentially decrease the formula’s effectiveness. Tonic formulas are generally prescribed to be taken three times a day, but for patients who are sensitive to tonics (usually Qi tonics) or those who already suffer from insomnia, it is recommended that they take their whole day’s dose by noon or early afternoon.

•Wei Qi Tonic Formulas : these formulas are taken for several months to strengthen the Wei Qi, or in the cold and flu season in between recurrent colds and flu. If the patient catches a cold or flu the Wei Qi tonic should be discontinued and replaced with an appropriate formula to releases wind-cold or wind- heat. Once the acute condition is resolved the Wei Qi may be tonified again.

•Wind-Cold Releasing Formulas : these formulas may be taken with hot soup, hot ginger tea, or rice and ginger congee to encourage sweating. It may also be beneficial to have the patient follow administration of herbs with a hot bath or getting in bed under heavy blankets.

•Wind-Heat Releasing Formulas : these formulas may be taken with hot soup, hot mint or green tea, or rice congee to encourage sweating. It may also be beneficial to follow administration of herbs with a hot bath or getting in bed under heavy blankets.

•Blood-Moving Formulas : these formulas were traditionally administered with a small amount of alcohol, or half alcohol/half water to increase their effectiveness. Alcohol increases their ability to invigorate the Blood, and helps them work more quickly to stop pain. Prolonged use or overuse of strong Blood-moving formulas may break the Blood excessively, resulting in a slight deficiency of Qi and Blood over time. On the other hand, Blood stagnation can be a stubborn diagnosis that requires long-term treatment for months or even years. For this reason, with long-term Blood invigorating strategies, many practitioners will prescribe a Qi and Blood tonic for a couple of weeks in rotation for every 3-6 months that a patient is on a strong Blood-moving formula. Therefore, with a long-term Blood-invigorating strategy, we recommend monitoring the patient for signs of Qi and Blood deficiency, including bruising or increased tendency to bleeding.

Blood-moving formulas that are used to treat gynecological disorders may result in heavier and possibly more painful menses for a cycle or two as the Blood stasis is moved out, which is considered a normal response. However, for patients with hemorrhagic conditions or for women who bleed excessively during menstruation, we recommend extreme caution when using strong Blood- moving formulas.

Finally, although mild to moderate Blood-moving formulas may be used when absolutely necessary during pregnancy, very strong Blood-moving formulas or Blood- breaking formulas are contraindicated because they are traditionally considered destabilizing to the pregnancy.

Side Effects

While we can never rule out a patient’s new symptoms being related to herbal treatment, there is often no way of knowing whether it does in fact come from taking a given Chinese herbal formula. To be safe, we always recommend that the practitioner ask their patient to discontinue the formula(s) they are on, to check whether the symptoms will quickly disappear. If the symptoms are minor, and go away that day or the next, it is possible that the formula may be related to the issue. If the symptoms are observed to be in direct connection with the administration of the herbs, then the formula should be discontinued and the treatment strategy reevaluated. If new minor symptoms do not resolve with the discontinuation of the herbs, they may be unrelated to the herbs and be a sign of a new complaint, which should be reevaluated. However, if the symptoms are severe, we recommend that the practitioner refer the patient to seek western medical attention.

Practitioners are strongly encouraged to contact us if their patients develop any side-effects, so that we can watch for any negative trends(1). Under our GMP protocols we are required to accept Adverse Event Reports (AERs) and submit Serious Adverse Event Reports (SAER) to the FDA.

Taking Herbs and Pharmaceutical Drugs,

We recommend that practitioners carefully evaluate the prescription drugs that a patient is on to determine whether Chinese herbal treatment is still indicated. Patients who are taking multiple drugs, often prescribed by several different physicians who may or may not be in communication with each other, and may or may not evaluate all of the drugs the patient is taking, may not be good candidates for herbal treatments.

While concurrent use of herbs and pharmaceuticals is commonplace, a significant body of evidence has grown over time that indicates that herbs and drugs can and do interact. In some cases, herbs or even foods may decrease a drug’s effectiveness. For example, even simple dietary fiber can affect the absorption of some drugs; soluble fibers such as psyllium seed husk can slow down the absorption of the painkiller acetaminophen and insoluble fibers such as those found in seeds and nuts can have a similar effect on the major heart medication digoxin. Some drugs and herbs act synergistically, potentiating the pharmaceutical effect. (Ex: Blood invigorating herbs and anti-coagulants) And some drugs and herbs have the same mechanism of action, which might in some cases increase the likelihood of unwanted side effects. For example, when diuretic drugs and diuretic herbs are administered together, they could potentially cause excessive urination and become too dehydrating.

While the body of research into herb-drug interactions is steadily growing, we still have very little specific information about Chinese formula or single herb-drug interactions or contraindications, let alone interactions with multiple pharmaceuticals. We encourage practitioners to consult books, go online to PubMed and other reputable resources, take CEU courses, etc. to broaden their knowledge about herb-drug interactions. If you do decide to give herbal formulas to a patient on pharmaceutical drugs, as a simple precautionary measure we always recommend taking the herbs and drugs two hours apart, to minimize interactions. Here are a few books we recommend for a fuller discussion of herb-drug interactions:

• Herb, Nutrient, and Drug Interactions: Clinical Implications and Therapeutic Strategies, 1 e by Mitchell Bebel Stargrove ND LAc (Author), Jonathan Treasure MA MNIMH RH (AHG) MCPP (Author), Dwight L. McKee MD (Author), published by Mosby 2007.
• A-Z Guide to Drug-Herb-Vitamin Interactions Revised and Expanded 2nd Edition: Improve Your Health and Avoid Side Effects When Using Common Medications and Natural Supplements Together, 2 Rev Exp Edition, by Alan R. Gaby (Editor), Inc. Healthnotes (Editor)
• The Essential Herb-Drug-Vitamin Interaction Guide: The Safe Way to Use Medications and Supplements Together, Apr 17, 2007, by George T. Grossberg M.D. (Author), Barry Fox (Author)

We always encourage practitioners to contact us at: consult@mayaway.com with any questions you might have. We answer many questions relating to formulas we carry for a given TCM diagnosis, raw herb vs. extract powder formulas, quality assurance, and more.

What is an Adverse Event Report?
Federal law requires us to record information from anyone who reports a negative reaction or adverse event that they associate with the use of any of our products. It does not however require practitioners to help us complete it. We record all of the information that is asked for on the QA 4001 AER form, which includes a number of questions, not only about the use of our product that is associated with the attributed adverse event, but also about the health, lifestyle, and other personal matters related to the individual who is the subject of the adverse event.

By federal law the reporter is not under any requirement to answer any of the questions we need to ask, we will simply record “declined to answer” for any question to which the reporter chooses not to answer . Similarly, for any question to which they are not able to respond, we will record that the reporter stated that the “answer was not known”.

What is done with an Adverse Event Report?
After the form is completed, the quality assurance department at Mayway will look it over to determine what if any next steps should be taken. We will then keep the document on file for 6 years. We can assure you that this information will be kept confidential, and is only viewed by Mayway staff and by any federal employees who may ask to view our adverse event reports.

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.