Blood Moving herbs and Rx anticoagulants

[Guest guest]

I seem to be coming across this issue more frequently.

 

Do dit dar jow's (topical formulas for trauma and related stuff) containing

blood movers and shakers pose an interaction risk in patients on

anti-coagulants?

 

Joe

[Guest guest]

John Chen, pharmD, L.Ac. has said in lectures that if a patient is on any

coumadin derivative, that acu-herbalists should be cautious about giving

dang gui or blood-moving herbs. He said that more acupuncturists have

gotten sued over this issue than any other drug-herb combination in the U.S.

 

other major drug-herb combos to watch out for?

 

K

 

 

On Sat, Dec 26, 2009 at 3:18 PM, <jlb wrote:

 

>

>

> I seem to be coming across this issue more frequently.

>

> Do dit dar jow's (topical formulas for trauma and related stuff) containing

> blood movers and shakers pose an interaction risk in patients on

> anti-coagulants?

>

> Joe

>

>

>

 

 

 

--

 

 

""

 

 

www.tcmreview.com

 

 

 

[Guest guest]

With all due respect, there have been few if any studies done on such

interactions, and such proposed interactions are largely speculative. There is

little or nothing to indicate that huo xue yao/blood quickening medicinals are

pharmacologically similar to blood thinning pharmaceutical drugs. The

possibility that external application of tieh da jiao/dit da jow formulas could

aggravate the effects of blood thinners is pretty slim.

 

While there may have been law suits over this issue, they are the result of

ignorance on the part of the lay public, biomedical, and Chinese medical

communities. We talk about evidence-based medicine, but decisions on treatment

here are being based on gossip and fear.

 

Would Western medicine allow such speculation to drive clinical practice and use

of drugs?

 

 

On Dec 26, 2009, at 11:35 PM, wrote:

 

> John Chen, pharmD, L.Ac. has said in lectures that if a patient is on any

> coumadin derivative, that acu-herbalists should be cautious about giving

> dang gui or blood-moving herbs. He said that more acupuncturists have

> gotten sued over this issue than any other drug-herb combination in the U.S.

>

> other major drug-herb combos to watch out for?

>

> K

>

> On Sat, Dec 26, 2009 at 3:18 PM, <jlb wrote:

>

> >

> >

> > I seem to be coming across this issue more frequently.

> >

> > Do dit dar jow's (topical formulas for trauma and related stuff) containing

> > blood movers and shakers pose an interaction risk in patients on

> > anti-coagulants?

> >

> > Joe

> >

> >

> >

>

> --

>

>

> ""

>

>

> www.tcmreview.com

>

>

[Guest guest]

I'm interested in the acupuncturists being sued aspect of this story. Did he

mention whether or not practitioners had been sued for adverse events their

treatments generated? My understanding is that there are very few documented

adverse events involving anticoagulants and herbs in the U.S. so I'd be curious

as to how many L.Ac.'s in have actually been sued, on what grounds, and what the

outcome was.

I've talked w/ a variety of physicians and pharmD's who have suggested that

measuring prothrombin time once a week should be enough to ascertain whether or

not adding blood moving herbs to a protocol when the patient is on

anticoagulants is creating a risk and thus adjust the levels of drugs and/or

herbs.

Ben

 

 

johnkokko

Sat, 26 Dec 2009 23:35:29 -0800

Re: Blood Moving herbs and Rx anticoagulants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

John Chen, pharmD, L.Ac. has said in lectures that if a patient is on any

 

coumadin derivative, that acu-herbalists should be cautious about giving

 

dang gui or blood-moving herbs. He said that more acupuncturists have

 

gotten sued over this issue than any other drug-herb combination in the U.S.

 

 

 

other major drug-herb combos to watch out for?

 

 

 

K

 

 

 

On Sat, Dec 26, 2009 at 3:18 PM, <jlb wrote:

 

 

 

>

 

>

 

> I seem to be coming across this issue more frequently.

 

>

 

> Do dit dar jow's (topical formulas for trauma and related stuff) containing

 

> blood movers and shakers pose an interaction risk in patients on

 

> anti-coagulants?

 

>

 

> Joe

 

>

 

>

 

>

 

 

 

--

 

 

 

 

 

""

 

 

 

 

 

www.tcmreview.com

 

 

 

 

[Guest guest]

Z'ev,

this is a major problem with giving herbs to patients in hospitals,

because almost everyone who is bed-ridden is on a coumadin derivative.

We should be cautious about over-dosing with patients on these strong

pharmaceuticals,

yet I agree with you that many patients are not getting the best care

because of the big " fear " that's out there. We should get studies out

there, so that the medical establishment becomes more objective about the

drug-herb interactions.

 

K

 

 

On Sun, Dec 27, 2009 at 8:59 AM, <zrosenbe wrote:

 

> With all due respect, there have been few if any studies done on such

> interactions, and such proposed interactions are largely speculative. There

> is little or nothing to indicate that huo xue yao/blood quickening

> medicinals are pharmacologically similar to blood thinning pharmaceutical

> drugs. The possibility that external application of tieh da jiao/dit da jow

> formulas could aggravate the effects of blood thinners is pretty slim.

>

> While there may have been law suits over this issue, they are the result of

> ignorance on the part of the lay public, biomedical, and Chinese medical

> communities. We talk about evidence-based medicine, but decisions on

> treatment here are being based on gossip and fear.

>

> Would Western medicine allow such speculation to drive clinical practice

> and use of drugs?

>

>

> On Dec 26, 2009, at 11:35 PM, wrote:

>

> > John Ch

[Guest guest]

Ben,

as I remember from taking his weekend lecture is that ~20 acupuncturists in

this country have been sued and lost as of 2006 lecture (don't know if they

all lost their licenses). Maybe we can get some verification on this. Is

John Chen on this list? Greg Sperber should know.

 

Pgs. 28-29 of Chen's 'Chinese Medical Herbology and Pharmacology'

" The highest risk of clinically-significant interactions between herbs and

drugs that have sympathomimetic, anticoagulant, antiplatelet, diuretic and

antidiabetic effects. "

ie. Ma huang, Dan shen, Dang gui, Chuan xiong, Tao ren, Hong hua, Shui zhi,

Fu ling, Zhu ling, Che qian zi, Ze xie, Zhi mu, Shi gao, Xuan shen, Cang

zhu, Shan yao, Huang qi.

 

 

K

[Guest guest]

Thanks John. Anticoagulants are notoriously sensitive. Leafy green foods are

contraindicated with Coumadin. I think the only safe way, at this point in

time, to use anticoagulants with herbs is testing coagulation function up to

several times per day. Also, out-patient status doesn't provide enough

safeguards, at least during first week of use.

 

I neglected to make my question sufficiently specific. What's the interaction

risk with topical formulas such as Zheng Gu Shui or Ching Wan Hung, or Stop

Itching, etc.?

 

Joe

[Guest guest]

John,

I am talking mainly about private practice patients, not in hospital

settings, but in hospitals we are in 'biomedicine territory', in other words,

hospitals have their own protocols, some based on evidence, some not. I simply

have patients monitor their blood levels of coumadin and derivatives.

 

In California, the state board just reduced the percentage of questions on

herbal medicine on the state licensing exam from 17 to 10 percent, filling the

gap with biomedical questions. This was based on a survey of practitioners

which showed a reduction in the use of herbal medicine, largely out of fear of

drug-herb interactions. This is a major problem for us in the present, and the

profession needs to make an effort to separate fact from fantasy on both ends of

the spectrum.

 

 

On Dec 27, 2009, at 9:43 AM, wrote:

 

> Z'ev,

> this is a major problem with giving herbs to patients in hospitals,

> because almost everyone who is bed-ridden is on a coumadin derivative.

> We should be cautious about over-dosing with patients on these strong

> pharmaceuticals,

> yet I agree with you that many patients are not getting the best care

> because of the big " fear " that's out there. We should get studies out

> there, so that the medical establishment becomes more objective about the

> drug-herb interactions.

>

> K

>

> On Sun, Dec 27, 2009 at 8:59 AM, <zrosenbe wrote:

>

> > With all due respect, there have been few if any studies done on such

> > interactions, and such proposed interactions are largely speculative. There

> > is little or nothing to indicate that huo xue yao/blood quickening

> > medicinals are pharmacologically similar to blood thinning pharmaceutical

> > drugs. The possibility that external application of tieh da jiao/dit da jow

> > formulas could aggravate the effects of blood thinners is pretty slim.

> >

> > While there may have been law suits over this issue, they are the result of

> > ignorance on the part of the lay public, biomedical, and Chinese medical

> > communities. We talk about evidence-based medicine, but decisions on

> > treatment here are being based on gossip and fear.

> >

> > Would Western medicine allow such speculation to drive clinical practice

> > and use of drugs?

> >

> >

> > On Dec 26, 2009, at 11:35 PM, wrote:

> >

> > > John Ch

>

 

 

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

 

 

 

 

 

 

 

[Guest guest]

I think you are overstating the case. The information/studies I've found say to

keep foods high in Vit. K at steady levels, neither greatly increasing or

decreasing intake, not avoiding them altogether. I think the same can be said

for herbal medicines as well, use cautiously but not eliminate altogether.

 

There are no studies on interactions between external applications of herbal

liniments and coumadin, but the best route would be to try it out cautiously in

small amounts and see how the patient responds.

 

 

On Dec 27, 2009, at 10:23 AM, jlb wrote:

 

> Thanks John. Anticoagulants are notoriously sensitive. Leafy green foods are

contraindicated with Coumadin. I think the only safe way, at this point in time,

to use anticoagulants with herbs is testing coagulation function up to several

times per day. Also, out-patient status doesn't provide enough safeguards, at

least during first week of use.

>

> I neglected to make my question sufficiently specific. What's the interaction

risk with topical formulas such as Zheng Gu Shui or Ching Wan Hung, or Stop

Itching, etc.?

>

> Joe

 

 

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

 

 

 

 

 

 

 

[Guest guest]

Z'ev,

 

Will you describe for us how you have patients self monitor their concurrent

use of herbs and anticoagulants-if I understand you correctly you said you do

this.

 

Ben

 

 

 

 

zrosenbe

Sun, 27 Dec 2009 12:29:51 -0800

Re: Blood Moving herbs and Rx anticoagulants

 

 

 

 

 

I think you are overstating the case. The information/studies I've found say to

keep foods high in Vit. K at steady levels, neither greatly increasing or

decreasing intake, not avoiding them altogether. I think the same can be said

for herbal medicines as well, use cautiously but not eliminate altogether.

 

There are no studies on interactions between external applications of herbal

liniments and coumadin, but the best route would be to try it out cautiously in

small amounts and see how the patient responds.

 

 

On Dec 27, 2009, at 10:23 AM, jlb wrote:

 

> Thanks John. Anticoagulants are notoriously sensitive. Leafy green foods are

contraindicated with Coumadin. I think the only safe way, at this point in time,

to use anticoagulants with herbs is testing coagulation function up to several

times per day. Also, out-patient status doesn't provide enough safeguards, at

least during first week of use.

>

> I neglected to make my question sufficiently specific. What's the interaction

risk with topical formulas such as Zheng Gu Shui or Ching Wan Hung, or Stop

Itching, etc.?

>

> Joe

 

 

Chair, Department of Herbal Medicine

Pacific College of Oriental Medicine

San Diego, Ca. 92122

 

 

[Guest guest]

Joe,

 

Having worked on books on Chinese herb-drug interactions with both Fred Jennes

and Greg Sperber, as far as I know, the ONLY Chinese medicinal which has been

PROVEN to potentiate the anti-coagulative effects of warfarin (Coumadin) is Dan

Shen (Radix Salviae Miltiorrhizae). Other than that, all other supposed Chinese

med-warfarin intereactions are only theoretical possibilities (unless there's

new evidence since Greg's book came out which I don't know about). While

warfarin has a very narrow TI and care needs to be taken with patients on

warfarin, I also think we, as a profesion, should not become overly paranoid

about this.

 

When we read about herb-drug interactions, we need to know how to read the

literature intelligently. By this, I mean the ability to assess the degree of

evidence for a putative interaction. If a source says some Chiense med " may "

cause such and such an interaction with a particular Western drug, that

typically means that this supposition is only hypothetical based on abstract

chemistry but that there's not a single shred of actual in vitro or in vivo

evidence for it in terms of laboratory studies, case histories, cohort studies,

RCTs, etc. I can't tell you how many practitioners call Blue Poppy about this

kind of issue. They read " may cause " and don't seem to understand exactly what

that means. Pretty much the entire Chinese herb-drug interaction literature is

written in just these terms -- " may cause. " " May cause " categorically does not

mean " does cause. " All medicine, be it Western, Chinese, Tibetan, Ayruvedic, or

Hottentot involves constant benefit-risk analysis. I really fear that we're

becoming so risk averse as a group that we are eventually not going to be able

to practice internal medicine at all.

 

In any case, I know a number of Western CM practitioners who routinely prescribe

Chinese meds to patients on warfarin without adverse drug-herb interactions. The

key seems to be small initial trial doses, close monitoring, really good

patient-practitioner communication, and regular prothrombin testing (but not

necessarily more frequent than is done as standard care in any case).

 

I really do worry about us all losing the ability to think rationally about

benefit-risk analysis and the willingness to take reasonable risks.

[Guest guest]

No, their physicians do this. . . I just tell the patients to watch for any

change in blood levels of the medication. . . so far there's never been a

problem.

 

Z'ev

On Dec 27, 2009, at 1:32 PM, ben zappin wrote:

 

>

> Z'ev,

>

> Will you describe for us how you have patients self monitor their concurrent

use of herbs and anticoagulants-if I understand you correctly you said you do

this.

>

> Ben

>

>

>

> zrosenbe

> Sun, 27 Dec 2009 12:29:51 -0800

> Re: Blood Moving herbs and Rx anticoagulants

>

> I think you are overstating the case. The information/studies I've found say

to keep foods high in Vit. K at steady levels, neither greatly increasing or

decreasing intake, not avoiding them altogether. I think the same can be said

for herbal medicines as well, use cautiously but not eliminate altogether.

>

> There are no studies on interactions between external applications of herbal

liniments and coumadin, but the best route would be to try it out cautiously in

small amounts and see how the patient responds.

>

>

> On Dec 27, 2009, at 10:23 AM, jlb wrote:

>

> > Thanks John. Anticoagulants are notoriously sensitive. Leafy green foods are

contraindicated with Coumadin. I think the only safe way, at this point in time,

to use anticoagulants with herbs is testing coagulation function up to several

times per day. Also, out-patient status doesn't provide enough safeguards, at

least during first week of use.

> >

> > I neglected to make my question sufficiently specific. What's the

interaction risk with topical formulas such as Zheng Gu Shui or Ching Wan Hung,

or Stop Itching, etc.?

> >

> > Joe

>

>

> Chair, Department of Herbal Medicine

> Pacific College of Oriental Medicine

> San Diego, Ca. 92122

>

>

[Guest guest]

Thank you all for your responses. They're quite useful and timely. My

question is prompted by an educational issue. The opinions at the school at

which I teach (and agitate) are overwhelmingly against the use of herbs of

any kind when the patient is taking an anticoagulant. My position is that

each patient and his/her cost benefit analysis should be considered

individually. Instructors of the other position state categorically that

herbs shouldn't be used if the patient is taking pharmaceuticals.

 

A comprehensive ban is IMO an example of defensive medicine. By limiting

the domain of topics, a comprehensive ban limits the knowledge and skill

bases of future practitioners.

 

I've needled many people who were taking anticoagulants but have had I've

had only a handful of experiences with herbs and anticoagulants.

 

The first was formative for me. During my last year in school one of

my clinic supervisors from China approved and encouraged the use of a

formula containing Dan Shen for a patient. I learned a great deal from this

experience because of the patient's special circumstances. Call the patient

Mary. Mary was severely mentally ill and on out-patient status due to the

lack of beds in the hospital. Because of her several medical conditions she

was seen at the hospital and had blood tests daily. The day after she

began taking the blood thinning formula her clotting times increased enough

that the chief resident called the school and spoke with my supervisor.

They agreed to taper the dose of the herbal formula to discontinuation over

the next few days. Mary's clotting times returned to pre-Dan Shen values.

The MD was excited about Dan Shen and it's " possibilities " . I never heard

of any resulting collaborative research but they were trying to put it

together.

CONCLUSION: Blood Stasis herbs and anticoagulants increase each others

potency. I know one anecdote doesn't warrant a conclusion but considering

the stakes, I need a higher comfort level.

 

The next experience involved a fellow - John - who was in-patient. The only

serious medical conditions he had centered around post heart bypass surgery,

which consisted of monitoring and maintaining factors affecting

a harmoniums blood flow. He was taking Coumadin. His debilitating leg pain

and restless leg syndrome seemed to me to come from severe blood deficiency.

I talked with him and then his attending MD's about using Dang Gui Bai Shao

Tang. They weren't horrified by the notion. To the contrary, they liked

the idea because John's pain had a serious and chronic debilitating impact

on his life. So they considered it the way they would any other drug

addition about which interaction data was sparse. In practical terms that

meant checking clotting times times twice a day during the first three days

of use and beginning with a small dose followed by incremental increases

each day for the first few days. When the dose plateaued, the testing was

decreased to one time a day. John did quite well. His clotting times did

increase but his Coumadin dose was adjusted and the clotting times stayed

within desired limits.

CONCLUSION: With the right skills and equipment, using Blood Stasis herbs

with anticoagulants is relatively safely accomplished.

 

The third experience didn't involve anticoagulants. It involved dermal

patch substance delivery systems. " Joan " was admitted to the hospital

after having fallen asleep with a heating pad against her Fetanyl

(an opioid agonist - painkiller) patch. In addition, she had neglected to

remove the prior patch. The heat caused the new patch to release large

amounts of Fetanyl very prematurely. In these circumstances, the two

patches combined were enough to kill her. Fortunately she was resuscitated

at the ER. There are several powerful drugs that use the patch delivery

system and many other topically delivered prescription drugs (via salves,

liniments, sprays). IMO, moxibustion smoke penetrates the skin.

 

QUESTION: To what degree must topical herbs be taken into account regarding

herb-drug interaction?

 

Like it or not, I'm having to find real and useful answers about these kinds

of things for my students.

 

So, I need even more of your thoughts.

 

TIA, Joe

 

 

 

[Guest guest]

While I can't recall a specific event at the moment, I've encountered

problems with herbs and anticoagulants. The question I have is would this

happen with San Qi ginseng since it is also used to stop bleeding.

 

Michael

 

 

 

On Behalf Of

Sunday, December 27, 2009 10:08 PM

 

Re: Blood Moving herbs and Rx anticoagulants

 

No, their physicians do this. . . I just tell the patients to watch for any

change in blood levels of the medication. . . so far there's never been a

problem.

 

Z'ev

On Dec 27, 2009, at 1:32 PM, ben zappin wrote:

 

>

> Z'ev,

>

> Will you describe for us how you have patients self monitor their

concurrent use of herbs and anticoagulants-if I understand you correctly you

said you do this.

>

> Ben

>

>

>

> zrosenbe

> Sun, 27 Dec 2009 12:29:51 -0800

> Re: Blood Moving herbs and Rx anticoagulants

>

> I think you are overstating the case. The information/studies I've found

say to keep foods high in Vit. K at steady levels, neither greatly

increasing or decreasing intake, not avoiding them altogether. I think the

same can be said for herbal medicines as well, use cautiously but not

eliminate altogether.

>

> There are no studies on interactions between external applications of

herbal liniments and coumadin, but the best route would be to try it out

cautiously in small amounts and see how the patient responds.

>

>

> On Dec 27, 2009, at 10:23 AM, jlb wrote:

>

> > Thanks John. Anticoagulants are notoriously sensitive. Leafy green foods

are contraindicated with Coumadin. I think the only safe way, at this point

in time, to use anticoagulants with herbs is testing coagulation function up

to several times per day. Also, out-patient status doesn't provide enough

safeguards, at least during first week of use.

> >

> > I neglected to make my question sufficiently specific. What's the

interaction risk with topical formulas such as Zheng Gu Shui or Ching Wan

Hung, or Stop Itching, etc.?

> >

> > Joe

>

>

> Chair, Department of Herbal Medicine

> Pacific College of Oriental Medicine

> San Diego, Ca. 92122

>

>