Other Antagonists of Death Receptors A20

•

age

•

weight

•

disease severity

•

disease diagnosis

•

medicinal strength

erly (i.e., those over 60) should also receive half doses due to the decline in function of the digestive system as well as the liver and kidneys. Because the elderly do not metabolize med-icines as quickly as younger adults do, medmed-icines stay in their systems longer. The second thing to take into account is a patient’s weight or body mass. The larger the patient’s body, the more medicine they typically will require to catalyze changes in that mass of cells. That means a patient who weighs 300 pounds will require significantly more medicine than a patient who weighs 150. Below are tables presenting standard guidelines of dosing according to age and weight.

A

-

-D

G

0-1 month 1/18-1/14 of adult dose 1-6 months 1/14-1/7 of adult dose 6-12 months 1/7-1/5 of adult dose 1-2 years 1/5-1/4 of adult dose 2-4 years 1/4-1/3 of adult dose 4-6 years 1/3-2/5 of adult dose 6-9 years 2/5-1/2 of adult dose 9-14 years 1/2-2/3 of adult dose 14-18 years 2/3 to full adult dose 18-60 years full adult dose 60 years + 3/4 adult dose or less

W

-

-D

G

30-40 lbs. 20-27% of adult dose 40-50 lbs. 27-33% of adult dose 50-60 lbs. 33-40% of adult dose 60-70 lbs. 40-47% of adult dose 70-80 lbs. 47-53% of adult dose 80-100 lbs. 53-67% of adult dose 100-120 lbs. 67-80% of adult dose 120-150 lbs. 80-100% of adult dose 150-200 lbs. 100-133% of adult dose 200-250 lbs. 133-167% of adult dose 250-300 lbs. 167-200% of adult dose Patients who are more than usually sensitive to foods, herbs, or drugs should begin with smaller than usual doses.

The third factor is disease severity. In Chinese medicine, the more severe or acute a disease, the higher the doses we usual-ly administer. That is because we are trying to achieve results as quickly as possible in order to minimize pain and suffering as well as the possibility of irreversible damage.

The fourth factor is the disease diagnosis. The disease diagno-sis tells us the natural history of the condition, for instance, whether it is self-limiting, relapsing-remittent, chronic, pro-gressive, disabling, fatal, etc. In acute diseases of expected short duration, we typically prescribe high doses to knock the disease out as quickly as possible, while, in chronic, lingering, slowly progressive diseases, we typically prescribe lower doses in a more user-friendly form of administration so that we can assure good patient adherence over a long period of time. For example, in a relapsing-remittent disease such as MS, we may prescribe high dose decoctions during relapses and low dose ready-made medicines during remittent stages.

The fifth factor in determining dosage is somewhat more dif-ficult to deal with at the moment due to some companies not transparently telling practitioners how to assess the strength of their medicines. As stated above, without knowing how strong a medicine is, how can we determine what its dose should be? Perhaps, since practitioners have not asked for this information, these companies have not figured there is a need for it. However, if we ever intend to earn the status, respect, and earnings of Western MDs, we must eventually practice medicine, albeit Chinese medicine, at the same professional level, and that means prescribing individualized dosages of medicines to individual patients. Therefore, one of the first questions when considering prescribing a Chinese ready-made medicine to a patient is, “How strong is that medicine?”

Since most Chinese ready-made medicines are made from extracts, one way of answering that question is to know the concentration ratio used in making that medicine. If a

medi-cine is a 5:1 extract, that means that five pounds of bulk herbs were used to make one pound of finished medicine. If it is a 7:1 extract, it means that seven pounds of bulk herbs were used to make one pound of finished medicine, and, if it is a 12:1 extract, it means that 12 pounds of bulk herbs were used to make one pound of finished medicine. The assumption here is that the higher the concentration ratio, the more potent the medicine.

However, that still does not tell us everything we need to know. In standard professional Chinese medicine, the aver-age daily dose of a single medicinal is nine grams (9g). If there are 10 ingredients in a formula, that means a dose of 90 grams per day made into decoction. If we want our patient to receive the equivalent of not less than 90 grams of Chinese medicinals per day for the remedial treatment of active disease, then we would need to prescribe 18 grams per day of a 5:1 extract, 12.6 grams per day of a 7:1 extract, nine grams per day of a 10:1 extract, and only six grams per day of a 15:1 extract. In real life, if a patient is also receiving acupuncture, they might not need the equivalent of 90 grams per day since, unlike in China, they are being treated by more than one modality. So maybe we could cut the dose down to 60 or even 45g per day. In that case, it would only take nine grams per day of a 5:1 extract, 4.5 grams per day of a 10:1 extract, and three grams per day of a 15:1 extract.

(See chart on p. 75)

Since, typically, unwanted side effects are directly pro-portional to increased dose, in general as prescribing physicians, we want the low-est dose which will achieve the intended therapeutic

starting patients with chronic diseases with low doses and then raising those doses, increment by increment, until one achieves the intended therapeutic effect with either no or the least adverse reactions. In closing, if you’re not getting the results you expect from Chinese ready-made medicines, A) raise the dose and B) consider using a higher concentration extract.

Final note:For those of you who treat infants and young chil-dren, the question commonly arises as to the best way to administer Chinese medicine to our young patients. First of all, very young children may be less resistant that you pre-sume to taking decocted Chinese medicine. We suggest the easiest way to administer it is to use an eye-dropper, giving 1-2 droppers between 3-8 times per day, depending upon the severity of the child’s condition. This is easier than dealing with pills or capsules, which small children often cannot swallow. For breast-feeding infants, it is also acceptable to cre-ate a paste from extract powders and rub a small amount on the mother’s nipple, administering with the breast milk.

Problem Based Learning Exercises

1.Two patients present the same patterns suggesting that they should take the same Chinese herbal formula. One patient is a 45 year-old male of medium build. You decided that he should take a decoction made from a total of 150 grams of Chinese medicinals per day. The other patient is a six year-old child.

Using standard age dosing guidelines, what should be the total daily dose of Chinese medicinals expressed in grams?

2.Another two patients present the same patterns suggesting once again that they should both take the same Chinese herbal formula. The patients are both middle-aged adults. However, one weighs 160 pounds and the other weighs 240 pounds. You decided to give the 160-pound patient a daily dose of six grams of powdered extract per day. Based on weight differential alone, how many grams should you give per day to the 240-pound patient?

3.Dao Chi San (Abduct the Red Powder) is for the treatment of heart-small intestine fire causing heart palpitations, vexation, agitation, and restlessness, sores on the tip of the tongue, and short, scanty, difficult, burning, and painful urination with dark-colored urine or hematuria.

A. Is this an acute or chronic condition?

B. Based on the above answer, what should be the daily dose of this formula when given in decoction?

4.Liu Wei Di Huang Wan (Six Flavors Rehmannia Pills) and Bu Zhong Yi Qi Tang (Supplement the Center & Boost the Qi Pills) are given to a patient with a tendency to high blood glucose presenting with qi and yin dual vacuity and liver depression qi stagnation in order to secure and consolidate the treatment

effects from more aggressive remedial therapy. At the moment, the patient’s blood sugar is within normal limits, but you don’t want the patient to regress. How are you going to decide how many of each pills to advise the patient to take?

5.Your patient refuses to drink bulk-dispensed, water-based decoctions because they taste bad, smell up her house, and take too long to cook. You’ve decided that she needs to take the equivalent of 200 grams per day of bulk-dispensed herbs based on the severity and nature of her condition. She will, however, take powdered extracts and you have the same formula from a company that makes 5:1 extracts. How many grams of this extract must the patient take per day in order to get the equiva-lent of 200 grams of bulk medicinals in decoction?

6.Your patient has an acute earache due to liver fire flaming upward and you want him to take at least 2-3 days’ worth of Long Dan Xie Gan Tang (Gentiana Drain the Liver Decoction) in decoction form. How are you going to explain to him the neces-sity/benefits of taking his Chinese medicinals in this form?

7.What are the standard daily doses in decoction given in Bensky & Gamble for the following commonly used medicinals:

A. Sha Ren (Fructus Amomi)

B. Pu Gong Ying (Herba Taraxaci Mongolici Cum Radice)

C. Bai Jiang Cao (Herba Patriniae Heterophyllae) D. Chai Hu (Radix Bupleuri)

E. Ban Xia (Rhizoma Pinelliae Ternatae) F. Huang Qi (Radix Astragali Membranacei) G. Dang Shen (Radix Codonopsitis Pilosulae) H. Chuan Xiong (Radix Ligustici Wallichii)

I. Sheng Di (uncooked Radix Rehmanniae Glutinosae) J. Bai Zhu (Rhizoma Atractylodis Macrocephalae) K. Fu Ling (Sclerotium Poriae Cocos)

L. Gan Jiang (dry Rhizoma Zingiberis Officinalis) M. Xiang Fu (Rhizoma Cyperi Rotundi)

N. Dang Gui (Radix Angelicae Sinensis) O. He Shou Wu (Radix Polygoni Multiflori) P. Ji Xue Teng (Caulis Milletiae Seu Spatholobi)

8.Your patient with a chronic condition says that she has multi-ple chemical sensitivities. Do you start her on the standard daily dose? Why?

9.You plan on combining acupuncture and internally adminis-tered Chinese herbal medicine with your patient. How does this affect the dose of Chinese herbal medicinals you plan on admin-istering? Why?

10.Why should a patient with coronary artery disease (CAD) and unstable angina pectoris be given a higher dose of Chinese medicinals than a patient with asymptomatic CAD?

11.Why should a patient with rheumatoid arthritis (RA) which is currently in remission be given a lower dose of Chinese medi-cinals than a patient with active RA?

12.Why should a patient with kidney failure be given a higher dose of Chinese medicinals than a patient with interstitial cysti-tis?

We have all had the experience of “tuning out” a constant noise or smell. When the body receives a constant stimulus, over time, it tends to discount and filter out that stimulus.

When the body filters out and discounts the effects of a medicinal substance, this is referred to technically as habitua-tion. Habituation may be defined as the progressive decrease in responsiveness to repetitive stimuli.¹ In modern Western medicine, this is a well known phenomenon. M. Leandri, author of an article titled “Therapy of Trigeminal Neuralgia Secondary to Multiple Sclerosis” published in issue #5, 2003, of Expert Review of Anticancer Therapy, in speaking about the medical treatment of trigeminal neuralgia, writes, “Whatever the drug, habituation and loss of efficacy are likely to occur sooner or later.”² In discussing what to do about this phe-nomenon, Leandri goes on to say:

Dosage should be as low as possible for the risk of habituation . . . and therapy should be slowly tapered off from time to time.

When forced to increase dosage, always check the neurological conditions, beside the usual biological checks as indicated. If side effects appear, cautiously switch to another compound . . .³

CHAPTER 6

The Phenomenon of Habituation in