The Yoko Factor (Buffy Season 4, Episode 20)

Willow makes a sort of throw-away statement in this episode about her hope that she and Buffy will become ‘little old ladies forgetting to take their pills.’

While I could turn this into a post about patient non-compliance (and wouldn’t it be great if we had a treatment for patient non-compliance?), I will instead treat the topic of herb-drug interactions from a Chinese pharmacological point of view.  In other words, Western pharmaceuticals from an Eastern physiological perspective.  Much of this material will be derived from a seminar Jeffrey Yuen gave on the same topic in 2010.

To narrow down this particular post’s presentation of herb-drug interactions, I will focus only on the four aspects of pharmacokinetics:  absorption, metabolism, distribution, and elimination of drugs.

1. Absorption: Most herbs and pharmaceuticals are brought into the body through digestion, although some are also inhaled (insufflation).  Therefore, to assess the qualities of a drug or herbal treatment, we look at the status of the SP and ST at the start of treatment and assess how they change during the course of treatment.  Likewise, we may look at the LU and LI — both organ and channel — changes as a result of inhaled drugs.  Channel changes that would be looked for include nodules, tightness, or flaccidity.

If a patient’s tongue is red, particularly without a coat, the mucosal lining of the stomach may be compromised.  The result is an increased rate an quantity of absorption. Astringent herbs decrease intestinal motility, increasing potential absorption time, while those which move qi (especially the wei qi of the Lungs) decreases potential absorption time.  These drugs can also induce latency of a TCM-defined pathogen.  H2 antagonists inhibit wei qi, which is responsible for peristalsis.

Minerals, including calcium, mu li, and long gu, alter the acidity of the stomach, and thus should be taken 2 to 3 hours after any pharmaceuticals which reduce stomach acidity.  This will allow the normal acidity of the stomach to interact with the herbal medications.

Nourishing ST yin will likely decrease absorption of herbs and drugs, as ST yin can be thought of as including the muscosal lining of the gut; likewise with LU yin and the lining of the Lungs.

2.  Metabolism

The Liver is primarily responsible for metabolising drugs.  Drugs which increase Liver metabolism (e.g. anticonvulsants, Rifadin, long-term NSAIDS, and some sleep medications/ phenobarbitols) will mean that herbal dosage will need to be increased, in order for the herbal components to remain in the system long enough to have an effect.

The opposite case, of decreased Liver metabolism, means a decreased dosage of drugs so as not to overwhelm the patient.  Liver metabolism can slow with alcohol, sulfur dioxide (avoid those bright orange apricots), antifungals, and some antibiotics (e.g. Erythromycin) and Tagamet.

Drugs which treat neurological diseases affect Liver metabolism (via their effect on wind symptoms); in such cases do not nourish LV blood, but regulate the Liver instead.  Drugs which treat infectious diseases and which inhibit LV metabolism may give rise to damp-heat.  Be aware that this damp-heat may lead to fire-toxicity (see elimination, below).

3.  Distribution

This is the part that many scientists don’t fully understand about either herbs or drugs.  Drugs which are constantly monitored tend to be prone to improper distribution.  These drugs also happen to most often affect the blood tissue itself — e.g. Coumadin and other blood thinners.  Other drugs become active only once released from the blood protein.  Because of the relation between blood and breast milk, both herbal medicines and drugs can be released and passed onto infants through the mother’s milk.

Herbs which invigorate the blood may be change the distribution of drugs throughout the body.  Herbs which increase breastmilk may also change the distribution of drugs in nursing mothers.

Anti-hyperlipidemia drugs tend to cause blood stagnation and wind-phlegm; conversely, those herbs which eliminate wind-phlegm may interact with such drugs.  NSAIDS tend to affect the blood and give rise to blood heat and wind.

4.  Elimination

The Liver and Kidneys are primary sites of metabolic elimination. Damage to the Kidneys not only slows elimination, but can lead to auto-intoxication, which in Chinese terms can be thought of as fire toxicity (and thus treated with Jin Yin Hua and Lian Qiao).  Anti-inflammatories and drugs such as methotrexate slow elmination.  Therefore, patients taking these drugs should not only be started on a low does of herbs, which is gradually increased, but also given greater time between taking the herbs.

Alkaline agents increase the elimination of acid; citrates alkalinise the system.  Therefore, in herbal formulae which use long gu or shells, be aware that they may have a synergistic effect with alkaline drugs.

Drugs which give rise to damp-heat in the LV (e.g. certain antibacterials), or which impact wei qi can give rise to LV stagnation or exhaustion.  The LV is responsible for smoothing the relationship between wei and ying qi; if it must work harder to move wei qi, the LV can easily become deficient.  Tonifying the LV qi through regulation is beneficial in these cases.  Analgesics, when used over a long period of time, can numb the Liver.

While on the topic of hormones and hormone medication, I should point out Buffy’s impromptu diagnosis of Riley having ‘testosterone poisoning.’  Now there’s an interesting diagnosis, and one we could plausibly see in the clinic if we ever have a patient on anabolic steroids (the sort used to improve athletic performance or appearance).

One class of drugs which hasn’t been mentioned are hormone regulators and replacements.  This would include certain contraceptives, steroids, and thyroid medications.  Generally, hormones can be considered functionally similar to ye-thick fluids.  A simple acupuncture formula to regulate hormones is KD2, SP8, and KD21 and ST25.  Alternately, one could use KD20, SP18, ST42, and CV12.

KD-2 is the most yang point on the KD-channel, and it has  branch which goes to SP8, earth pivot; ST25, celestial pivot and KD21, Dark Gate (doubly yin) round out the nourishing and enlivening actions of this point prescription.

ST42 nourishes the jin-fluids of the eyes, CV12 accesses the fluids of the ST, while SP18 celestial cleft and KD20 free the grain, both relate to ST fluids and movement.

Herbally, the best ye-fluid formula I’ve come across is Zeng Ye Tang, Generate the Fluids Decoction, composed of Xuan Shen, Mai Men Dong, and Sheng Di Huang (some use Shu Di Huang), modified accordingly.  Some modifications include Wu Wei Zi and Ren Shen for yang or hormone deficiency with difficulty consolidating fluids; Ge Gen and Sheng Ma to raise the fluids and generate jin-thin fluids; Sang Ye can likewise be added for its moistening and outward moving properties. Qu Mai and Mu Tong, of course, are a good choices for moving the ye-fluids into the SI meridian; the SI meridian is responsible for ye-fluids.  To guide the formula to the SI Channel Divergence, I would also add some Sang Bai Pi.

I have never tried using this formula with Gui Zhi, Bai Shao, and Gan Cao, which have the properties of freeing the collaterals and relaxing the muscles to increase fluid absorption, but I might not rule it out.  Certainly, in Riley’s case, he perhaps needed a little bit of sedation, so a bit of muscle relaxation and cooling off might be in order — definitely add some Ge Gen (relax the upper back) and Zhi Zi (to cool the blood and go to the TW; otherwise, for heat in the blood with some stagnation, I would use Mu Dan Pi).

Zeng Ye Tang is used in cases of ye-fluid deficiency.  In cases of excess, regulate fluids through the Triple Warmer mechanism and with qi moving medicinals.  Qi moving medicinals tend to be drying, so be sure to balance the drying action on the ye-fluids with jin-fluid preserving herbs (wu wei zi, shi gao, sang ye).

As always, these posts are for informational purposes only.  If you have questions about herb-drug interactions, please see a qualified herbal practitioner in concert with your prescribing physician(s).  Do make certain all prescribing physicians are aware of all pharmaceuticals you are taking, and do not haphazardly combine herbal supplementation (i.e. in doing so you create your own formula inadvertently) without consulting a qualified herbalist.

Happy Slayage!


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