RE: Granules dosage

[Guest guest]

Eric,

 

 

 

I wanted to say one more thing about dosage of granulars, because every

couple of months the same thing comes up, 12-18 grams in Taiwan! For

example, in September Eric Brand wrote:

 

 

 

" Is giving someone 9-12 grams of powdered herbs per day ethical when the

standard of care is at least

12-18 grams of approx. 5:1 extract per day? Can we advertise this as Chinese

medicine even though we are giving a fraction of the medicine

that is used in Chinese " medicine " ? "

 

 

 

My answer is, I see no ethical issues nor have any problem calling " 6 grams

of granulars a day " Chinese medicine. I am curious what other's dosage

ranges are. I personally start at about 10g / day. My other colleagues start

at around 6g a day. The real question is what range gets results for our

population set. If one blindly gives 18 grams a day without really asking

these questions (and looking at the variables I mentioned in the previous

email) and just does it because " this is how they do it in China / Taiwan "

then this is not thinking critically, and somewhat irresponsible. For most

patients that I see the " Standard of care " is where things break down. BTW-

these comments are not directed at Eric or anyone else, because I know

personally that Eric has thought much about this topic and his above

statement is just to provoke thought. I have just used it as a springboard.

 

 

 

Since there is such a huge difference in treating in the States versus Asia,

one could ask why I keep going back there to study? I think that I do not go

to Asia to learn how to treat, but more importantly learn how to think. I

think one learns how to treat from one's own patients. They are our

teachers. What do others think?

 

 

 

-

 

 

 

_____

 

 

On Behalf Of Eric Brand

 

 

No one is being dogmatic or failing to think critically. There are

many things that work and many different ways to prescribe and dose.

All types of new acupuncture techniques with no historical basis have

been shown to work, and many many applications of Chinese herbs have

been shown to be effective in doses far lower than their textbook

Chinese doses- just look at a major European work like the ESCOP

Monographs by Theime. The current state of knowledge isn't the apex

of all that is possible or effective, and there are many things that

work.

 

Dose is variable and needs to be determined flexibly based on the

individual. Certainly there is no reason to use two aspirin tabs

without first seeing whether one will do the trick, but everyone

should know that the standard dose range is 1-2 (or more) tabs. If

you want to split one tab into 9 pieces it may well work for your

patients (and they probably won't get many adverse effects!), but

don't criticize the PDR for providing the standard reference range for

the drug. Dosage information is just like textbook TCM, it is not

meant to limit the practitioner or say that this is the only valid or

possible approach. It is just a baseline of knowledge that has been

deemed useful by many clinicians. I'm just reporting the trends of

our colleagues, not selling dogma.

 

BTW, Shang Han Lun doses were " monster doses " by modern standards.

 

Eric

 

 

 

 

[Guest guest]

I think that I do not go

to Asia to learn how to treat, but more importantly learn how to think. I

think one learns how to treat from ones own patients. They are our

teachers. What do others think?

>>>>>>

Jason i have to agree with you. I found my short experience in China very

informative as to CM thinking but it had very little relevance to my pt here.

The set of problems and more importantly the experience and communication of

clinical data is so different that one must learn from ones practice.This in

part is why i have for years tried to get people to write more on their own

experiences instead of having worship of " Chinese sources. " I feel the same

about classical literature, while it is food for thought and enriching in scope

it is of little direct relevance.

 

 

 

 

 

 

 

 

-

Saturday, March 31, 2007 6:58 AM

RE: Granules dosage

 

 

Eric,

 

I wanted to say one more thing about dosage of granulars, because every

couple of months the same thing comes up, 12-18 grams in Taiwan! For

example, in September Eric Brand wrote:

 

" Is giving someone 9-12 grams of powdered herbs per day ethical when the

standard of care is at least

12-18 grams of approx. 5:1 extract per day? Can we advertise this as Chinese

medicine even though we are giving a fraction of the medicine

that is used in Chinese " medicine " ? "

 

My answer is, I see no ethical issues nor have any problem calling " 6 grams

of granulars a day " Chinese medicine. I am curious what other's dosage

ranges are. I personally start at about 10g / day. My other colleagues start

at around 6g a day. The real question is what range gets results for our

population set. If one blindly gives 18 grams a day without really asking

these questions (and looking at the variables I mentioned in the previous

email) and just does it because " this is how they do it in China / Taiwan "

then this is not thinking critically, and somewhat irresponsible. For most

patients that I see the " Standard of care " is where things break down. BTW-

these comments are not directed at Eric or anyone else, because I know

personally that Eric has thought much about this topic and his above

statement is just to provoke thought. I have just used it as a springboard.

 

Since there is such a huge difference in treating in the States versus Asia,

one could ask why I keep going back there to study? I think that I do not go

to Asia to learn how to treat, but more importantly learn how to think. I

think one learns how to treat from one's own patients. They are our

teachers. What do others think?

 

-

 

_____

 

On Behalf Of Eric Brand

 

No one is being dogmatic or failing to think critically. There are

many things that work and many different ways to prescribe and dose.

All types of new acupuncture techniques with no historical basis have

been shown to work, and many many applications of Chinese herbs have

been shown to be effective in doses far lower than their textbook

Chinese doses- just look at a major European work like the ESCOP

Monographs by Theime. The current state of knowledge isn't the apex

of all that is possible or effective, and there are many things that

work.

 

Dose is variable and needs to be determined flexibly based on the

individual. Certainly there is no reason to use two aspirin tabs

without first seeing whether one will do the trick, but everyone

should know that the standard dose range is 1-2 (or more) tabs. If

you want to split one tab into 9 pieces it may well work for your

patients (and they probably won't get many adverse effects!), but

don't criticize the PDR for providing the standard reference range for

the drug. Dosage information is just like textbook TCM, it is not

meant to limit the practitioner or say that this is the only valid or

possible approach. It is just a baseline of knowledge that has been

deemed useful by many clinicians. I'm just reporting the trends of

our colleagues, not selling dogma.

 

BTW, Shang Han Lun doses were " monster doses " by modern standards.

 

Eric

 

[Guest guest]

Jason, Eric, and everyone,

 

Besides the acumulated experience of CM doctors in Taiwan, the 18 grams a day

thing is only a convenient guideline for a facility which sees many patients a

day. It is also a way to avoid each patient's inquiry about why they are getting

so little or so much; just imagine the 100 or 200 patients you see in a day

asking a simple question like this!

 

Using a different dosage also reduces what a CM doctor has to " think " about.

A good CM practitioner thinks a lot about a given patient's situation. My

mentors in Taiwan don't necessarily use 18 grams a day. What I gathered is, the

larger the facility, the more " standardized " dosage they use.

 

I don't use that much either here in US or in Taiwan. In fact, when I give a 8

or 10 grams/day dosage to treat a cold a la SHL the patients here and those in

Taiwan respond about the same way. Using 10 grams/day, I have been successful in

treating more challenging problems.

 

So, for your survey, my dosage ranges from 6 to 14 grams a day.

 

Mike L.

 

wrote:

Eric,

 

I wanted to say one more thing about dosage of granulars, because every

couple of months the same thing comes up, 12-18 grams in Taiwan! For

example, in September Eric Brand wrote:

 

" Is giving someone 9-12 grams of powdered herbs per day ethical when the

standard of care is at least

12-18 grams of approx. 5:1 extract per day? Can we advertise this as Chinese

medicine even though we are giving a fraction of the medicine

that is used in Chinese " medicine " ? "

 

My answer is, I see no ethical issues nor have any problem calling " 6 grams

of granulars a day " Chinese medicine. I am curious what other's dosage

ranges are. I personally start at about 10g / day. My other colleagues start

at around 6g a day. The real question is what range gets results for our

population set. If one blindly gives 18 grams a day without really asking

these questions (and looking at the variables I mentioned in the previous

email) and just does it because " this is how they do it in China / Taiwan "

then this is not thinking critically, and somewhat irresponsible. For most

patients that I see the " Standard of care " is where things break down. BTW-

these comments are not directed at Eric or anyone else, because I know

personally that Eric has thought much about this topic and his above

statement is just to provoke thought. I have just used it as a springboard.

 

Since there is such a huge difference in treating in the States versus Asia,

one could ask why I keep going back there to study? I think that I do not go

to Asia to learn how to treat, but more importantly learn how to think. I

think one learns how to treat from one's own patients. They are our

teachers. What do others think?

 

-

 

_____

 

 

On Behalf Of Eric Brand

 

No one is being dogmatic or failing to think critically. There are

many things that work and many different ways to prescribe and dose.

All types of new acupuncture techniques with no historical basis have

been shown to work, and many many applications of Chinese herbs have

been shown to be effective in doses far lower than their textbook

Chinese doses- just look at a major European work like the ESCOP

Monographs by Theime. The current state of knowledge isn't the apex

of all that is possible or effective, and there are many things that

work.

 

Dose is variable and needs to be determined flexibly based on the

individual. Certainly there is no reason to use two aspirin tabs

without first seeing whether one will do the trick, but everyone

should know that the standard dose range is 1-2 (or more) tabs. If

you want to split one tab into 9 pieces it may well work for your

patients (and they probably won't get many adverse effects!), but

don't criticize the PDR for providing the standard reference range for

the drug. Dosage information is just like textbook TCM, it is not

meant to limit the practitioner or say that this is the only valid or

possible approach. It is just a baseline of knowledge that has been

deemed useful by many clinicians. I'm just reporting the trends of

our colleagues, not selling dogma.

 

BTW, Shang Han Lun doses were " monster doses " by modern standards.

 

Eric

 

 

[Guest guest]

> I am curious what other's dosage

> ranges are.

 

I think one of the biggest things that affects granule dosage is cost.

At the PCOM clinic, I try to keep the cost to about $3/day, which

keeps the prescriptions generally hovering around 12g/day of granules.

I'd say that I generally use between 10-14g/day; I go a bit higher

when money isn't an issue or for a more acute case, but generally my

decision has more to do with economics than efficacy. If I am

combining singles in granule form, I usually use 0.5-2.0 grams of each

medicinal per day, with most of the ingredients ending up around one

gram per day. For a standard pack that would get 10 g of bai zhu and

15 g of huang qi, I'll use 1.0 g bai zhu and 1.5 g huang qi, which

means that my granule doses are probably about half my raw doses if I

assumed an average 5:1 conversion. Assuming that extraction ratio, a

five-gram daily dose of crude bai zhu is quite modest by anyone's

standards, so I don't see how I am someone seen to represent the

megadosing side of the spectrum. While both my raw and granule doses

are typical and not the least bit cavalier in terms of being unusually

heavy or light, I am generally pleased with the results. I expect the

granules to be a bit slower but I get good compliance.

 

Nonetheless, my dosing habits are mostly based on the price to the

patient when it comes to granules. My dosage of the raw herbs is just

standard- of course it varies by case but it is really just middle of

the road. I only mention the Taiwanese typical range because not

everyone knows what the typical dose range for granules is, and some

people might find it helpful. Even the frequency of the 18g figure

has more to do with economics than anything else in Taiwan, because

the national insurance only pays for 6g doses (given TID=18g/day, or

in severe cases QID). Consequently, 18g-24g forms the upper end of the

dose range and many doctors prescribe at 18g so that their patients

can get the most mileage possible from their insurance. 18g is not

the least bit high as far as general dosing goes, since it is only

about 90g/day of crude drugs (assuming an average 5:1 extraction

ratio). This is about the same or even slightly lower than the

typical Taiwanese raw prescription.

 

In the context of the quote from Jason, it is worth pointing out that

even the lower dose range of 6g/day of extract powders is still about

three times the dose that the original thread was talking about

(9g/day of unconcentrated raw powders).

 

Eric

[Guest guest]

I think there's a lot of truth in that. . but what would I know, not

having been to China? Raising seven children and the kosher laws

always made it difficult for me to travel. I just study as much as I

can in order to learn how to think in terms of pattern

recognition. . .and my patients have been teaching me practical

medicine for a long time.

 

 

On Mar 31, 2007, at 6:58 AM, wrote:

 

>

> Since there is such a huge difference in treating in the States

> versus Asia,

> one could ask why I keep going back there to study? I think that I

> do not go

> to Asia to learn how to treat, but more importantly learn how to

> think. I

> think one learns how to treat from one's own patients. They are our

> teachers. What do others think?

>

> -

>

 

 

 

 

[Guest guest]

Alon,

I would also like to hear much more from our colleagues in the

West on their experiences with Chinese medicine. Precious little has

made it to print.

However, I do disagree about the value of classical literature.

As Jason mentioned, learning to think Chinese medicine is very

important, and such texts as the Nan Jing and Shang Han Lun serve

that role for me. Then I have to translate that into present day

circumstances.

 

 

On Mar 31, 2007, at 9:28 AM, Alon Marcus wrote:

 

> Jason i have to agree with you. I found my short experience in

> China very informative as to CM thinking but it had very little

> relevance to my pt here. The set of problems and more importantly

> the experience and communication of clinical data is so different

> that one must learn from ones practice.This in part is why i have

> for years tried to get people to write more on their own

> experiences instead of having worship of " Chinese sources. " I feel

> the same about classical literature, while it is food for thought

> and enriching in scope it is of little direct relevance.

 

 

 

 

[Guest guest]

Zev

I agree with you about learning to think CM, however it needs to our CM, so i

also think it is important to study classical literature but i still say it has

little relevance to my patients

 

 

 

 

 

 

 

 

-

Saturday, March 31, 2007 8:33 PM

Re: Granules dosage

 

 

Alon,

I would also like to hear much more from our colleagues in the

West on their experiences with Chinese medicine. Precious little has

made it to print.

However, I do disagree about the value of classical literature.

As Jason mentioned, learning to think Chinese medicine is very

important, and such texts as the Nan Jing and Shang Han Lun serve

that role for me. Then I have to translate that into present day

circumstances.

 

On Mar 31, 2007, at 9:28 AM, Alon Marcus wrote:

 

> Jason i have to agree with you. I found my short experience in

> China very informative as to CM thinking but it had very little

> relevance to my pt here. The set of problems and more importantly

> the experience and communication of clinical data is so different

> that one must learn from ones practice.This in part is why i have

> for years tried to get people to write more on their own

> experiences instead of having worship of " Chinese sources. " I feel

> the same about classical literature, while it is food for thought

> and enriching in scope it is of little direct relevance.

 

[Guest guest]

Pardon the newbie questions (we were just getting into granules when I

was in school so I had mostly just experience with raw) -

 

Are most of you using complete formulas + singles for modification, or

just add all singles to make your Rx?

 

Do you patients tolerate the taste ok? I encapsulated granules a

couple of times, but won't spend my time doing that for each patient..

plus, 9gms of granules fit in 18 500mg caps. I seem to recall that a

Tbsp is about 9gms - is that what you tell patients to use for dosing?

 

I had trouble mixing the granules and water, do you put the water or

powder first? I always think of how hard it can be to add coco powder

to milk and try to get it to dissolve.

 

Cheers,

Geoff

 

, Mike Liaw <mikeliaw wrote:

>

> Jason, Eric, and everyone,

>

> Besides the acumulated experience of CM doctors in Taiwan, the 18

grams a day thing is only a convenient guideline for a facility

[Guest guest]

Geoff

i mix singles, as to mixing its best to first add a little water to the powder

and mix well, then add the rest of water or juice if the patient cannot tolerate

the taste. Since i use singles i like the herbs to steep in hot water for a few

minutes first

 

 

 

 

 

 

 

 

-

G Hudson

Monday, April 02, 2007 8:56 AM

Re: Granules dosage

 

 

Pardon the newbie questions (we were just getting into granules when I

was in school so I had mostly just experience with raw) -

 

Are most of you using complete formulas + singles for modification, or

just add all singles to make your Rx?

 

Do you patients tolerate the taste ok? I encapsulated granules a

couple of times, but won't spend my time doing that for each patient..

plus, 9gms of granules fit in 18 500mg caps. I seem to recall that a

Tbsp is about 9gms - is that what you tell patients to use for dosing?

 

I had trouble mixing the granules and water, do you put the water or

powder first? I always think of how hard it can be to add coco powder

to milk and try to get it to dissolve.

 

Cheers,

Geoff

 

, Mike Liaw <mikeliaw wrote:

>

> Jason, Eric, and everyone,

>

> Besides the acumulated experience of CM doctors in Taiwan, the 18

grams a day thing is only a convenient guideline for a facility

 

 

 

 

 

 

[Guest guest]

Jason, Eric, et al.,

 

I have been using powdered extracts since about 1995 and really appreciate

both their clinical effectiveness and the compliance that generally comes with

their use. I have used KPC products since about 1997, mainly due to species

correctness issues that Andy Ellis was bringing to the profession's attention at

that time.

 

I dose from about 6 to 18 grams depending on acuteness or chronicity of the

illness I am treating and the constitutional issues of the individual patient.

As a general rule I use 9 grams per day and find that dosage to be very

effective clinically. It is generally only when faced with an acute infection or

other acute problem that I would use more than 9g/day.

 

I also differ from the Taiwanese practitioners in that I primarily use singles

combined to create a formula. I do use formula bases if, and only if, I am

comfortable with the formula as it comes in the standard form without the

ability to change the dosage of or eliminate any of the constituents of that

formula. I do believe there is a synergy created with the cooking of a formula

so I generally have my patients make a tea with the extracts as a way to help

alleviate this problem, though I recognize this will not eliminate the problem.

So, if using a formula, I prefer the smaller formulas as a starting point,

something like er chen (wan) or si wu (tang).

 

All that being said, I still prefer to use bulk herbs whenever possible and

generally try to get patients to, at least, try it. Often they find it not as

bad as they thought it would be, and the effectiveness outweighs the negative

part of cooking, smelling, and tasting. Of course, this will not last forever.

Thus, chronically ill patients will often switch over to powdered extracts. This

often poses a bit of a problem for me since I use a lot of " Western " herbs, many

of which are not available as a powdered extract. So, I have to give them a

tincture along with the powdered extract or a tea if necessary.

 

That's my two cents.

 

Thomas

 

 

 

 

 

Honolulu, HI

 

www.sourcepointherbs.org