Wednesday, March 26, 2008

G6PD Deficiency & Chinese herbs

[Hundreds of forbidden drugs] Parents whose child with glucose-6-phosphate dehydrogenase (G6PD) deficiency have this nightmare of guarding against drugs or medicines which may cause contraindications of hemolytic anemia (breakup of red blood cells) to their child. There are indeed many drugs or medicines which are forbidden to be used for children with this genetic disease. A little search of the web will reveal hundreds of them. And it’s definitely a terrible nightmare for any parents.

[Confusion over unsafe Chinese herbs] Whenever I talk about children diseases the topic of G6PD deficiency will be touched by concerned parents asking about the safety of taking Chinese herbs for their children with the disease. Often time the parents are confused as there are plenty of different sayings and beliefs in the society; many of which, it comes to me, are misunderstandings and unsubstantiated conceptions.

[Sulfur vs. sulfa] There was once a woman who mistook sulfur (a substance commonly used to preserve dried Chinese herbs in a safely controlled quantity) for sulfa (also sulpha, a SO2-based medicine of Sulfonamides/Sulphonamides/Sulfones/Sulphones group which is known to be offending drug of G6PD deficiency) medicine refused all kinds of Chinese herbs treatment for her baby. I had to explain the differences between the two substances (and the fact that they are completely different except for close spelling and pronunciation) and clarify some other misunderstandings she had had.

I hope this writing can help shed some light on the issue.

[Unsafe Chinese herbs] After much search of medical literature and clinical findings I’ve concluded that there are six (6) Chinese herbs which should not be prescribed for babies/children with G6PD deficiency. And they are:

1) 黄连/川连; Huang Lian / HuangLian / Chuan Lian; Rhizoma Coptidis; Coptis Root / Golden Thread
Huang Lian, mainly yielded in the province of Si Chuan (四川), China. It's therefore also called Chuan Lian (川连). Bitter in flavour, cold in property. Acting on heart, stomach, liver & large intestine channels. It clears away heat, dries dampness, purges fire and clears toxins. Commonly used to treat diarrhea, high fever and suppurative infections of the damp-heat type. Dosage: 2-10g. Caution: Very bitter & cold; overdose or prolonged use may interrupt stomach function.

2) 牛黄; Niu Huang / NiuHuang; Calculus Bovis; Bezoar
Bitter in flavour, cold in property. Acting on the liver & heart channels. It relieves convulsion, resolves phlegm to induce resuscitation and clears heat and toxins. Commonly used to treat epidemic febrile diseases with high fever, spasm, convulsion & unconsciousness due to phlegm-heat in pericardium, and sore throat, throat ulcers, canker sores in mouth of toxic heat. Dosage: 0.2-0.5g. Caution: Cautious for pregnancy; Not suitable for non excess-heat type.

3) 金银花; Jin Yin Hua / JinYinHua; Flos Lonicerae; Honeysuckle Flower
Bitter in flavour, cold in property. Acting on the lung, stomach and large intestines channels. It clears heat and detoxifies, removes heat from the blood and arrests dysentery. Commonly used to treat epidemic febrile disease at the early stage, high fever, sores, carbuncles, furuncles, and diarrhea and dysentery with purulent and bloody stool. Dosage: 10-15g.

4) 腊梅花; La Mei Hua / LaMeiHua; Flos Chimonanthi Praecocis; Wintersweet Flower
Sweet & mild bitter in flavour, neutral in property. Acting on the lung, stomach and spleen channels. It relieves heat stroke, promotes body fluid, regulates qi flow. Commonly used to treat heat stroke, thirst, abdominal pain. Dosage: 5-10g.

5) 珍珠; Zhen Zhu / ZhenZhu; Margarita; Pearl
Sweet and salty in flavour, and cold in property. Acting on heart and liver channels. It tranquilizes the mind and arrests convulsion, improves acuity, removes nebula, removes toxin and promotes granulation. Commonly used for palpitation, insomnia, convulsion and epilepsy, nebula, throat ulcers, carbuncles, skin pigmentation. Dosage: 0.1-0.3g.

6) 熊胆; Xiong Dan; XiongDan; Fel Ursi; Bear Gall
Bitter in flavour and cold in property. Acting on the liver, gall bladder and heart channels. It clears away heat and toxic materials, relieves convulsion and spasm, clears liver heat to improve vision. Commonly used to treat high fever, convulsion, epilepsy, mouth ulcers, sore throat, heaty and reddish eyes and nebula. Dosage: 0.25-0.5g. Caution: Not suitable for weak-cold type.

[Unknown mechanism] The mechanism of how these 6 Chinese herbs come to interact and cause hemolysis among G6PD deficient patients are pretty much unknown. There 6 herbs were shortlisted based mostly on clinical reports of unfortunate incidents than controlled laboratory experiments.

[Rather be safe than sorry] Commonly used Chinese herbs for me are about 400 types. A typical herbal prescription may have 8 to 16 herbs (or more or less, depending on the need), prescribed after proper TCM (traditional Chinese medicine) diagnosis including tongue reading and pulse taking methods. Subtracting 6 unsafe herbs from 400 doesn’t affect much the choice I have over herbs I prescribe remedies/prescriptions for my young patients. Without these six herbs, the selection of herbs combination to treat illnesses is still endless. If in doubt, I’ll always put safety at first criterion and choose other alternative herbs which share similar nature and functionality with that of G6PD deficiency offending herbs. After all, safety, always, comes first.

There are indeed a few other Chinese herbs which are listed in some websites as unsafe Chinese herbs in addition to the six I mention here. These other herbs are, to my findings, not substantiated and not clinically proven to be so.

[Parents’ responsibility] Parents with G6PD deficient child should always check if certain OTC (over-the-counter) prescriptions contain any one of these 6 ingredients and choose not to use them if found so. It’s everyone’s responsibility to know what they are taking by checking out the individual ingredients. They should bring their child to qualified physicians for proper prescription which suits the symptoms as well as the body syndromes; and which contains no such unsafe ingredients.

1) Associazione Italiana Favismo - Deficit di G6PD

Thursday, March 20, 2008

Rheumatoid Arthritis (RA) & Chinese medicine

[Diagnosis of Syndrome] Herbal treatment for Rheumatoid Arthritis (RA) depends on the diagnosis of TCM syndrome. The diagnosis of conventional medicine may have it determined as RA; TCM diagnosis has yet to be determined. Different patients with RA may display different pulses, tongue impressions, facial impressions, physical changes to joints and etc. A same disease falls on different body constituents gives rise to different manifestations. A TCM physician takes all clues into account and concludes a syndrome for a particular patient.

[Typical Syndromes] There are six to seven typical syndromes of RA. A body may have heat and wetness accumulated at joints and some have more heat than wetness and some the other way round. A body may also be lacking of fluid nourishment and thus inability to cool blood, giving rise to another syndrome of yin deficiency. A body can be too weak to wall off climactic changes, which is the case of weak qi (energy). A body may show great swollen knees with minimal sub symptoms and this is usually the syndrome of weakness in the three lower yin channels.

Understanding syndromes for many people can be a difficult task as people these days no longer live in tune with the nature. Simple differences between summer and winter and what they can do for our bodies are frequently ignored by us.

[Importance of proper diagnosis] Suggesting prescriptions without proper diagnosis of syndrome is unprofessional and unethical. Not only does it not help but it may even worsen the conditions. Each syndrome may also differ as a body can have a combination of those said syndromes. A prescription can have from 12 to 18 (or more or less) individual herbs with different amount in adjustment to the need of the specific body. Without proper consultation and diagnosis of syndrome, the direction is aimless.

[Corticosteroids Replacement] Having said that, there are some herbs (雷公藤 [Lei Gong Teng, Radix Tripterygium Wilfordii (1st pic), Property: bitter, pungent, warm, toxic; Channel tropism: liver, spleen, kidneys; Effects: Ridding wind & wetness, unblock channels & blood stagnation], 昆明山海棠 [Kun Ming Shan Hai Tang, Radix Tripterygium Hypoglaucum (2nd pic), Property: bitter, pungent, cold, toxic; Channel tropism: liver, kidneys; Effects: Ridding wind & wetness, unblock channels & promote blood circulation, reduce swelling & stop pain], for example) which have been known to have the effects of promoting CRH and ACTH, encouraging the body itself to generate natural hormone -- instead of relying on cortisone or prednisone which have severe side effects. The patients using the herbs rely less on conventional steroid-based medicine.

RA can have serious effect in the long run if not treated well. The patient should make an effort to see a physician to determine the syndrome, and thus obtain corresponding prescriptions. Any kinds of treatments, synthetic drug or natural herbal, with prolonged or inappropriate dosages or consumptions, will pose unwanted and unfortunate results. Long term supervision is necessary.

Tuesday, March 18, 2008

Open source health care system

Open source IT applications in healthcare is a relatively new topic as information technology doesn’t creep into medicine field that fast and widespread, especially in the practice of small clinics.

[Problems faced] Similar to the issue of standardization of linux desktop or other environments for that matter, open source healthcare standardization faces difficulty in interoperability and sharing of data. This is especially true when the open medical IT world is in infancy era.

[Ready? Not quite so.] Members of medical associations are not yet exposed to a few things that are essential elements of the healthcare system like electronic medical record (EMR) or electronic health record (EHR) and clinic efficiency. When even the most infant stage has not been attained, the water isn’t muddy enough to create more creative life form. This is currently what’s happening in many of the developing countries.

[Open source vs. Proprietary] And quite typically enough, infant stages of IT medical applications are usually dominated by proprietary solutions because these closed source solutions offer rigid and seemingly more user-friendly interface even though they’re usually more costly. Not having to tweak with difficult and messy coding of open source feeds well for many people looking for “fire-and-forget” application. Doctors and medical physicians are just human beings who could be as short-sighted. Good things don’t come easy. Those that come easy aren’t usually good. But hey, “I want it and I want it now!” is the attitude of spoilt modern generation. In the end, proprietary are chosen over open source solutions, initially. Almost always the case.

[Idealistic view] The idealistic solution is that the open source solutions will be the de facto standard used by the majority of the doctors. One day. Hopefully sonner.

[History repeats itself] This is a long and challenging task. With members from the developing nations learn from the mistakes made by those in the developed nations. If human beings learn well, we don’t have to repeat the mistakes.

[Evidence-based medicine & Open source] Dr. Molly Cheah, president of Primary Care Doctors’ Organization Malaysia (PCDOM), puts it this way: “Using open source in healthcare is almost similar as evidence-based medical practice processes. How can the processes in medicine be improved? You share.” I find this rather interesting and in line with many of the evidence-based traditional medicine practice. You find a better treatment method or a better explanation of disease mechanism and you pass it on to others so that others can improve upon it and keep passing it on to others too. “There is freedom to use, improve, share and collaborate.”

[My vision of IT usage in medicine] A mature system of medical IT software package should not be just handling of patients’ records and streamlining clinic or hospital efficiency, it should also cater for analysis of symptoms, patients’ profiles, with that of syndromes. For example, the package should help to analyze how two similar patients differ in treatment reactions and how different body constituents or syndromes give rise to different efficacy of the treatments and so on. From the point of view of a physician, this is what counts for the benefit of the patients.

For now, I can’t wait to lay my fingers on Gnu General Public License (GPL) software…

1) Open Source Health Care Alliance,
2) International Open Source Network an initiative of the United Nations Development Programme's (UNDP) Asia Pacific Development Information Programme (APDIP),
3) Primary Care Doctors' Organisation Malaysia,