Veterinary acupuncture and Chinese herbs: Clinical applications and contraindications (Proceedings)

Traditional Chinese Medicine (TCM), also known as Traditional Oriental Medicine (TOM) has been utilized over several thousands of years in people and animals. The first veterinary acupuncture text, Bole's Canon of Veterinary Acupuncture, was written by Sun Yang, aka Bole Zhenjing, a Chinese veterinarian that lived from 659-621 B.C.

TCM is a complete system of medicine that is used to diagnose, prevent and treat disease. TCM takes the entire physical body into consideration, as well as the balance between the body and the mind, emotions and spirit. Disease is therefore considered a manifestation of imbalance. It is important to note that TCM treats patterns of disharmonies, rather than specific diseases. A Western medical diagnosis is not necessarily required for successful treatment with TCM, however a standard Western minimum database ( imaging, other diagnostic tests) is often recommended to help uncover hidden or buried issues and to further direct treatment.

There are five branches to TCM: 1) acupuncture, 2) Chinese herbal medicine, 3) Chinese food therapy, 4) Tui-na [Chinese medical massage]; and 5) Qi Gong or Tai Chi.

When two or more treatment modalities are utilized concurrently, the effect is more synergistic than additive and response to treatment is vastly improved. Since we cannot teach our animal patients how to do the prescribed breathing patterns and movements that are specific to Qi Gong or Tai Chi exercises, regular daily exercise is substituted for our animal patients.

In Western medicine, a disease or condition is typically treated with the same medication(s) in all patients even though some variations in physical symptoms may exist. Although there are recognized disease syndromes in TCM such as Bi syndrome (equivalent to arthritis or DJD) and Lin syndrome (urinary incontinence, stranguria, dysuria, pollakiuria), there are multiple patterns associated with each syndrome which require a different treatment. A saying in TCM is "yi bing tong zhi" (different diseases, one treatment) and "tong bing yi zhi" (one disease, many treatments). For example, patients with a TCM Kidney deficiency may be treated with herbal formulas for Kidney Qi Deficiency (e.g., Suo Quan Wan), Kidney Yang deficiency (e.g., Zhen Wu Tang), Kidney Yin Deficiency (e.g., Zhi Bai Di Huang), Kidney Qi and Yin Deficiency (e.g., Rehmannia 11) or Kidney Jing Deficiency (e.g., Epimedium Powder). Thus two animals with the same Western disease (e.g. hyperadrenocorticism, diabetes mellitus, colitis, renal failure, epilepsy) often have completely different TCM treatment regimens.

TCM treatment protocols are designed for an individual based on the pattern(s) of imbalance or disharmony(ies) they are exhibiting at that time; these patterns and disharmonies can and will change with treatment and time. Routine rechecks with adjustments in therapies are therefore critical to the successful practice of TCM. Treatment protocols are designed based on the chronicity (acute, sub-acute, chronic), severity and nature of disease. These protocols may vary in frequency of treatment and interval between sessions. Some disharmonies may be cured with a single acupuncture treatment alone while chronic issues may require periodic treatments during the life of a pet, for example 2-4 acupuncture treatments and herbal re-evaluations per year.

Clinical Applications of acupuncture and Herbs

• Anhydrosis

• Behavior: Thunderstorm phobia, stereotypical behavior, aggression, anxiety (note: TCM treatment for behavior issues is not intended to be used as sole treatment for most behavior problems.)

• Cardiovascular: Congestive heart failure, hypertension

• Dermatology: Dermatitis, demodicosis, seborrhea, acral lick dermatitis, otitis externa, pyoderma, pododermatitis

• Endocrine: Diabetes, hyperadrenocorticism, hypo or hyperthyroidism

• Fever of unknown etiology (may only be temporary alleviation of symptoms in some cases)

• Gastrointestinal: Gingivitis, IBD, diarrhea, vomiting, pancreatitis, megacolon, constipation/obstipation, colitis, gastric ulcers

• Hematological disorders: Anemia, leukopenia, thrombocytopenia, pancytopenia

• Hepatic disorders: Hepatitis, cholangiohepatitis, hepatic lipidosis

• Immune-mediated diseases: Discoid lupus erythematosus, systemic lupus erythematosus, immune-mediated polyarthritis, immune-mediated hemolytic anemia, immune-mediated thrombocytopenia, Evan's Syndrome, pemphigus foliaceus

• Musculoskeletal: Spondylosis, hip dysplasia, degenerative joint disease, post-operative rehabilitation, hindend weakness, muscle atrophy, laminitis, navicular disease

• Neoplasia

• Neurologic: IVDD, FCE, degenerative myelopathy (potentially slow progression of disease), seizures, vestibular disease, traumatic nerve disease, Sweeny, laryngeal hemiplegia

• Orthopedic: partial cranial cruciate ligament rupture, osteochondrosis dissecans, cervical instability, fracture (aid in healing and pain management), luxating patellas

• Pain Management: Generalized, idiopathic, secondary to trauma, improper or over-training, post-operative, colic

• Pulmonary/peripheral edema, ascites

• Renal/Urological: ARF, CRF, UTI, bladder and kidney stones, crystalluria, urinary incontinence

• Reproduction: dystocia, pseudocyesis, infertility, anestrus, "bitchy mare" syndrome

• Respiratory: Bronchitis, sinusitis, feline asthma, pneumonia, URI, recurrent airway obstruction (RAO; previously known as chronic obstructive pulmonary disease or COPD, or heaves)

Acupuncture Contraindications and Cautions

Western medicine is the modality of choice for initial treatment in some issues, followed up with TCM. Examples include, but are not limited to, most acute severe conditions such as severe trauma, fractures, pneumothorax, FUS, or surgical cases such as GDV, pyometra, orthopedic deformities (e.g., radius curvus), complete CCL rupture, or cancers that can be cured with complete surgical excision. Such cases often benefit from follow-up treatment with TCM to calm the patient, speed the healing process, pain management, or treat the disease/disharmony after the initial crisis. It is often the integration of TCM and Western medicine that yields the best results.

While acupuncture is typically considered to be a safe and minimally invasive modality, there are some conditions that merit caution or where acupuncture may be contraindicated. For example, in pregnant animals, it is contraindicated to use acupuncture points around the abdomen and lumbosacral areas. Proper training in veterinary acupuncture will ensure that the patient is treated with minimal risk of adverse reaction.

Herbal Applications

There are over 7000 species of medicinal plants in China and ten or less species are considered toxic. While there is always the potential for herbs or any substance taken orally (food, drugs, nutraceuticals, etc.) to cause an adverse reaction or negative side effect, most herbs have a high safety margin and low incidence of negative side effects. Chinese herbal medications are usually combinations of 1-20 different plant products (herbs), living or dead tissue (e.g., insects, reptiles, venom, shell, mammalian products) or minerals. The proper combing of herbs reduces noxious impact hence these formulas can often be used for relatively long periods of time with minimal to no adverse side effects when used correctly (i.e., correct diagnosis and treatment) and within the recommended dosage range. It is important to recognize, however, that Chinese herbal medication should only be administered by a medical practitioner that has been trained in TCM or TOM.

Herbal Contraindications

Herb-Drug Interactions

Most herbs are safe when used individually or in combination with other herbs, however certain combinations do have adverse reactions. There are classical listings of such herbs that are hundreds of years old. To date, these same interactions have not been proved to be necessarily true in our animal species.

There are few formal studies published in English that document the safety and efficacy of combining herbs with Western pharmaceuticals. The highest risk of herb-drug interactions occurs between drugs and herbs that have the following effects:

• Sympathomimetics: Herbs with sympathomimetic effects may interfere with anti-hypertensive and anti-seizure drugs. Use such herbs with caution in patients predisposed to hypertension, seizures, diabetes, thyroid conditions, other regulatory imbalances. E.g., Ephedra Ma Huan

• Anticoagulant/Antiplatelet: Herbs with blood activating and blood stasis removing properties may interfere with anticoagulant or anti-platelet drugs (aspirin, heparin, warfarin). Concurrent usage may lead to prolonged or excessive bleeding. E.g., Radix Salviae Miltiorrizae Dan Shen, Radix Angelicae Sinensis Dang Gui.

• Antidiabetic (insulin, Glipizide): Possible additive or synergistic effects of herbs may cause excessive decrease in blood glucose levels.E.g., Atractylodes Cang Zhu with Dioscorea Shan Yao

• Diuretics: Concurrent use of herbs and drugs with diuretic properties may have additive or synergistic effects making blood pressure regulation more difficult and predisposing the patient to hypotension. Dosage of herbals and drugs must be adjusted carefully. E.g., Poria Fu Ling, Polyporus Zhu Ling,

• Chemotherapy: Herbs have powerful antioxidant properties which Western practitioners postulate may interfere with the mechanisms of some chemotherapeutic agents. There is no current research to date to support or contradict the use of Chinese herbals in conjunction with chemotherapy. To avoid potential drug-herb interaction, stop herbal administration 3 days before and after chemotherapy

Some considerations while taking Western drugs and herbs concurrently are absorption, metabolism and elimination.

• Absorption: May be adversely affected if herbals administered with drugs that promote binding in the GI tract (e.g., sucralfate) or change gastric pH (e.g., H2-receptor antagonists, gastric acid proton pump inhibitors, antacids). Separate administration of drug from these classes and herbals by 2 hours. Drugs that affect GI motility (e.g. metoclopramide, cisapride, neostigmine) may make a higher dosage of herbals required for effective treatment.

• Metabolism: As most drugs and herbs are metabolized into inactive derivatives in the liver, the slower the hepatic metabolic rate of a substance, the longer it stays active in the body and vice versa. In general, drugs that induce hepatic metabolism (e.g, phenobarbital, rifampin) take several weeks to affect liver metabolism. Herbs given concurrently may be deactivated more rapidly, so a higher dosage of herbals may be indicated. Conversely, drugs that inhibit liver metabolism (e.g., cimetidine, erythromycin, fluconazole, itraconazole, ketoconazole, etc.) have an immediate effect and a decreased rate of hepatic metabolism may be seen within several days. Hence herbals are metabolized slower creating the risk of accumulation of herbal components in the body and lengthened time of action. Dosage of herbals may need to be reduced accordingly.

• Elimination: Impaired renal function will decrease the rate of elimination and lead to the accumulation of active substances in the body. Dosage of herbals should be reduced in patients with renal dysfunction/failure or that are currently receiving drugs such as amphotericin B, methotrexate, and gentamicin.

• Pregnancy: Herbs with potent effects to regulate Qi, move Blood or drain downwards have the potential to cause abortion or birth defects. Herbals with these characteristics should be used with caution in pregnant patients. There are just a few herbs in Chinese herbal medicine that have a narrow window of toxicity. Such herbs (e.g. Aconite, Fu Zi extremely acrid and hot) should be used with caution.

• Geriatric/very weak or debilitated: Potent herbs should be used with caution if at all. Partial dosage is often required with such herbals.

• Liver failure/impairment: see Metabolism above.

• Kidney dysfunction/failure: see Elimination above.

• Surgery: Herbs with blood invigorating properties should NOT be used prior to surgery to prevent prolonged bleeding.