Chinese Medicine considerations for COVID19:
I do indeed want our readership to be clear that the ideal scenario allows that individuals are evaluated and treated by trained Chinese Medicine clinicians and given individualized prescriptions (we hold this in high regard in Functional Medicine). If access is limited, however, Chinese patent formulas have a long record of effective use in pandemics, including influenza and SARS Cov1, and are worthy of our consideration as Western trained clinicians. DrKF
I am sitting in my office in a 100% otherwise empty building. Our trip to California was canceled early last week, our local getaway to Mystic, CT to make up for the canceled CA trip was canceled today.
Our local Whole Foods looks like this (really?):
And our go-to supplement company’s current most common refrain is:Temporarily Unavailable Fortunately, many of the TCM recommendations I’ll make today haven’t gotten a lot of attention yet and are still in supply.
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What isn’t in this blog brief: hand washing how-to, hand sanitizer recipes, social distancing, COVID19 numbers, the US testing debacle, pharmaceutical antivirals. These are all covered in abundance elsewhere. Some are addressed in this very nice write-up on our site from pediatrician Dr. Lizzie Bird
Today, my goal is to bang out what *I think* may be critical botanical and nutraceutical interventions for COVID19 (SARS Cov2) prevention and treatment. Note that the evidence is scant, but we need to make some educated decisions. What I’m writing about is what I’m considering personally and recommending for my family, staff, friends and patients.
Incidentally, maintaining sanity is essential. After I finish this first brief, I am heading out on my bike for some mental and physical decompression. Turn off the 24-hour news feed and join me in spirit. We need each other now, albeit six feet away… But be sensible! Continue to huddle and cuddle with the ones you love, all the more so to compensate for the people you dare not touch.
In the coming few days, we will write about FxMed considerations addressing the reported potential fallout to heart and lungs (cardiomyopathy and loss of lung function in certain vulnerable individuals). I might take a stab at the ACE2 conversation, but it’s been covered very well here and on Peter Attia’s recent COVID19 podcasts. Everything is fluid right now, so these areas could change as more reports emerge.
Treatment: Evidence-informed Traditional Chinese Medicine (TCM) considerations for COVID19 gleaned from SARS Cov1 and H1N1
[Again, I am not covering the avoidance strategies and background basics or pharma considerations in this blog. Listen to Peter Attia’s podcasts 97 & 98 for a rundown of these areas. Any complete COVID19 plan requires enacting these pieces. For a good, if scary, big COVID19 picture, consider reading this medium.com piece.]
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At this early stage, there is still a dearth of outcome data, although there is a very large prevention trial using TCM underway in 23 provinces in China. However, if you look at its viral sibling, SARS Cov1 and its cousin, H1N1, you’ll see trials in humans, reviews (including Cochrane), in vitro data and (perhaps most importantly?) a very long historical record of interventions for pandemics. Much of this research is logically— when you think about these endemic COVID19 predecessor viruses originating in Asia—employing Traditional Chinese Medicine (TCM). Additionally, some of the most compelling science on TCM has come out of Hong Kong, where the traumatic memories of the SARS outbreak are still keenly felt, and where COVID19 hasn’t taken hold of this very crowded city in the same way it has in the West and Middle East (early and aggressive action to block the spread of COVID-19 will have also played a big role here). Note that TCM clinical research is frequently criticized for being of lower quality, although the notoriously discerning Cochrane did find enough studies for a review publication, and concluded that TCM was as effective or more so than pharma antivirals.
I reached out to my friend and colleague Dr. Winston Cardwell for a straight-forward Clinical Guide to TCM for the non-TCM clinician. Scroll the end of this blog for an exact reprint. I am grateful to Dr. Cardwell for taking the time to generate this guide for us. I am following Dr. Cardwell’s recommendations as he’s written them, plus adding some western ideas that I cover below.
Validating to me as I was researching TCM, in addition to the COVID19 prevention formula, was this review citing three studies on SARS Cov1 using TCM. You’ll see that NONE OF THOSE in the TCM-prescribed groups developed SARS Cov1. The largest of these studies (N= 3,561) was in Beijing, followed by N =1,063 in Hong Kong. Participants were all health care workers on the front lines of SARS Cov1. The common intervention used in both groups was Yupingfeng powder, very close (the same?) to the Chinese patent formula recommended as our first go-to by Dr. Cardwell called Jade Windscreen. The top ingredient in Jade Windscreen is astragalus. [Wikipedia entry on Chinese patent medicine]
If you can find it, stock up on Jade Windscreen now, and if you’re treating children, get Children’s Jade Defense. Take as directed by Dr. Cardwell below.
You’ll see he recommends purchasing through The Golden Flower Chinese Herbs Company because they are very clean-sources and third-party tested [neither of us have financial ties to this company]. However, if GFC is out of his recommendations, go to any reputable professional distribution company (e.g Natural Partners/Fullscript) and see what’s on hand. We need to be mindful around obtaining good quality product, so if you simply cannot access Winston’s recommendations now, lets look at some of the main botanicals used in these formulas that we can access readily in the West (with the caveat being that we lose efficacy when we apply our Western model to Eastern medicine. However, in the COVID19 pandemic, we are doing the best we can with what we’ve got, and the botanicals I list are well-used as antivirals by us.)
Top two botanicals used in a recently COVID19 prevention formula, administered in 23 provinces in China are:
- Astragalus
- Licorice
Additional botanicals known in the West shown to be active against SARS Cov1 (in vitro, in vivo):
- Scutellaria Baicalensis (scutellarein; inhibits SARS-Cov enzymes)
- Artemisia annua (demonstrated to have anti SARS effect from screening analysis)
- Buplerum (prevents early stage infection, including attachment and penetration)
- Andrographis
Quenching the cytokine storm. In part, it might be our own immune system – made dysfunctional, imbalanced in its hyper response to certain viruses (COVID19, influenza) – that needs interruption. Two key interventions are topping my list:
- Omega 3 fatty acids for their ability to generate specialized pro-resolving lipid mediators (SPMs). Or, since some of us who are vulnerable to COVID19, like diabetics, don’t make SPMs efficiently, take SPMs directly.
- Palmitoylethanolamide (PEA): 600mg daily for prevention; increase to 600mg tid at first sign.
Pullin it together: Some options with dosing suggestions to consider for the non-TCM trained clinician.
- Vitamin C: 1000mg daily as prevention; increase to 1 gram per hour x 6 hours per day with first symptoms (reduce dose slightly if you develop loose BMs)
- Vitamin D: 2000IU -5000IU or higher per day (goal: blood level >=50ng/mL)
- Omega 3 (EPA/DHA): 2500mg daily
- Or, perhaps better: Metagenics SPMs: 2 caps twice per day as prevention. May increase to 2 caps 3 times per day with first symptoms.
- PEA: 2 caps daily for prevention; increase to 2 caps three times per day with first symptoms. Continue for six weeks (research on PEA is in influenza- link above)
- Real Mushrooms 5 Defenders (Turkey Tail, Reishi, Maitake, Shitake, Chaga) providing >20% beta-D-glucans: 1 caps daily for prevention; increase to 2 caps twice a day with symptoms
- Real Mushrooms Reishe 415: 1 cap daily for prevention; increase to 2 caps once to twice per day with symptoms.
- *Mushrooms are highly complex. Certain compounds are immunostimulating. Is this a problem in COVID19, or a benefit? We don’t know the answer. I am personally taking 5 Defenders.
- Zinc lozenges: Allow lozenge to dissolve slowly, bathing the throat in zinc (zinc ions are potently antimicrobial); repeat until sore throat is improved. Total zinc should be 60mg-100mg per day x 1 week or so. Can go longer, but you will deplete copper if you stay high-dose.
- N-acetylcysteine: 600mg daily as prevention; increase to 600mg bid (note that the research on NAC is limited to animal studies and a small, equivocal human meta-analysis looking at acute respiratory distress syndrome)
Botanical options (or use Dr. Cardwell’s TCM formulas below. I don’t recommend combining these w/the TCMs)
- Astragalus root: 2 caps daily for prevention; increase to 2 caps 3-4 times per day with symptoms
- Licorice root: 30 drops in small amount of water daily as prevention; increase to 3-4 times per day with symptoms. (Recommend Gaia herbs alcohol-free licorice root; note that licorice can be potassium wasting)
- Artemisia annua: 1 cap daily for prevention; increase to 1 cap 3 times per day with symptoms (Recommend Thorne’s Artecin; avoid with liver disease or history of abnormal liver function tests)
- Metagenics Andrographis plus: Follow label instructions
- Scutellaria baicalensis or S. lateriflora (note that S. baicalensis is what is contained in TCM, and traditionally considered the antimicrobial form of Scutellaria, although both forms do have the bioactive compound scutellarien): 10-60 drops repeat up to 4 times per day. May have antihypertensive, anxiolytic effects. (Wise Woman and Herb Pharm have S. lateriflora tinctures)
- Look at Metagenics Nazanol, it’s got Scutellaria baicalensis, astragalus and siler root plus other botanicals. Metagenics Candibactin BR has Scutellaria baicalensis, licorice and others
Dr. Cardwell’s Clinical Guide to TCM for COVID19 for the Non-TCM Clinician
Pulse evaluation is always going to be the best and most effective however is not always available.
For those not able to be evaluated by a Chinese Medicine Practitioner, the following differentiation of symptoms, timing of disease process and use of indicated formulas is practical and effective. These are meant to be adjuncts to the basics of avoidance of disease, hand-washing, showering at the end of the day, getting good sleep, eating well (avoiding sugar and refined carbohydrates; eating warm, cooked fresh foods, keeping alcohol intake to a minimum, maintaining water intake, taking supplemental nutrients such as vitamin C and vitamin D3, etc)
The indications listed below are generalizations and not requirements for formula administration, simply keynote symptoms.
The product names are from The Golden Flower Chinese Herbs company (using Taiwan-sourced herbs; third-party tested, and free of herbicides, pesticides, heavy metals and contaminants) with the traditional names of the formulas in parentheses; other sources of the formulas exist but dosing may be different yet the frequency should remain the same.
Botanical Prevention:
Jade Windscreen Formula (Yu Ping Feng San): 6 per day for prevention; discontinue at onset of any URI symptoms and begin one of the following:
Children’s Jade Defense Formula (Xiao Er Zi Yu Feng): for children unable take pills -1/2-1 tsp per day; discontinue at onset of any URI symptoms and begin one of the following:
Early Onset of Symptoms:
Viola Clear Fire Formula (Di Ding Qing Huo Pian): consider if mild upper respiratory symptoms -3 tabs 3 times a day until fully well
Yin Chiao Formula (Yin Qiao San): consider if mild symptoms + sore throat is present -3 tablets every 4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Chai Hu Shu Gan Formula (Chai Hu Shu Gan Pian): consider if alternating chills and feverish -3 tablets every 4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Children’s Clear and Release Formula (Yin Qiao Gan Mao Fang): for children unable take pills -1/2-1 tsp every 4 hours until symptoms abate, then take 3 times a day until fully well
Fever, head, eye and nose symptoms with sore throat and swollen glands:
Andrographis Formula (Chuan Xin Lian Kang Yan Pian): general, strong antiviral -3 tablets every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Pu Ji Formula (Pu Ji Xiao Du Yin): consider if swollen glands and sore throat predominant -3 tabs every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Zhong Gan Ling Formula (Zhong Gan Ling Pian) consider if with body aches as well: 3 tablets every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Fever, head, eye and nose symptoms with dry cough:
Mulberry and Lycium Formula (Xie Bai San): consider if body aches also present -3 tabs every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Siler & Platycodon Formula (Fang Feng Tong Sheng San): consider if more feverish and hot -3 tabs every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Children’s Clear Lung Formula (Xiao Er Zi Qing Fei Fang): for children unable take pills -1/2-1 tsp every 4 hours until symptoms abate, then take 3 times a day until fully well
Gastrointestinal manifestations:
Wu Hua Formula (Wu Hua Tang): consider if diarrhea or other GI involvement -3 tablets every 3-4 hours until symptoms abate, then take 3 tabs 3 times a day until fully well
Agastache Tummy Syrup (Huo Xiang Zheng Qi Gao): for children unable take pills -1/2-1 tsp every 4 hours until symptoms abate, then take 3 times a day until fully well
Post-infection recovery support:
Lilly Preserve Metal Formula (Bai He Gu Jin Tang) consider if residual cough, mild wheezing, dry nose and dry lips present -3 tabs 2 times daily until fully well
Restore the Lung Formula (Bu Fei Tang): consider if residual dry cough, mild sweating and fatigue remains -3 tabs 2 times daily until fully well
Six Gentlemen Formula (Liu Jun Zi Tang): consider if slight fatigue, possibly mild cough remains -3 tabs 2 times daily until fully well
These are cookie cutter solutions that could cause more harm than good. It is a mangled approach. We are not dealing with a common cold or flu. Covid-19 is a rapidly changing pathogen in the human system and can quickly become a matter of life or death if herbs are prescribed by the unqualified. If Chinese herbs are to be considered please do your patients a favour and refer out to a experienced, qualified Chinese medicine herbalist in your area. Non-TCM practitioners should not endeavour to treat a Covid-19 case with Chinese herbs as it serves neither the patient nor does it raise the integrity and usefulness of Chinese medicine. I would hope that you write a follow-up post addressing these issues.
Thank you, Nicole. I did anticipate this blog might incur some push back. I agree that Chinese Medicine clinicians should be consulted when possible.
Dr Fitzgerald
I do have a question about vitamin C/ascorbic acid for someone with dietary oxalate issues (and no kidney disease). Is there another option with similar benefits or could high doses used with calcium citrate be an option? Are you aware if natural sources of vitamin C from goji berry, acerola cherry, rosehips, camu camu, kakadu plum, acai berry, maqui berry, amla etc offer similar benefits without causing oxalate issues?
Thanks you for this very comprehensive article. I know very little about TCM but the botanical and nutritional sections are very helpful. I am curious if TCM approaches like the ones you describe were/are used in China?
I think the recommendation for NAC is a bad one. It dries out mucus membranes, and this is a time we need our mucus membranes to be well lubricated.
Thanks, Em. I agree that mucus membranes do indeed need to be well-lubricated. We were just discussing this on our rounds meeting. I am also keeping a lightly steaming pot of water on the stove to keep my winter dry home humidity up a bit. See Dr. Bird’s post, also. While NAC is mucolytic, I have not experienced is as a drying agent. DrKF
Hi Dr. Fitzgerald,
Why not include vitamin A as part of the overall daily nutritional protocol for helping to prevent and treat viral infections? I’m not up to speed on the current scientific research confirming the effectiveness of vitamin A in prevention of viral infections but I know various physicians over many, many years have recommended using vitamin A to support the integrity of the epithelial mucosa barrier in preventing viral infection and other types of infection. Reading from Dr. Royal Lee’s early writings on vitamin A, as well as Dr. Harry Eidenier from Biotics Research and Dr. Alan Gaby, they have all utilized vitamin A, it seems, for viral infections, some of them using high dosages and some of them not. My training is in TCM as a licensed acupuncturist and trained in Chinese herbal medicine. I’ve trained with Standard Process in nutrition over the last 20+ years. On a completely anecdotal level, I’ve come to think of vitamin A as the “wei qi” vitamin i.e. the vitamin that strengthens the “defensive qi” level. This is completely a personal interpretation on my part and curiosity and not something substantiated by Chinese medicine. This is based in part on Dr. Royal Lee’s writings on vitamin A. He often used his Cataplex ACP, Calcium Lactate(recent research on the function of the calcium “cloud” in immune response to pathogens is fascinating), and Cataplex F and Cataplex E along with Catalyn for his protocol in treating virus infections. He would dose every 30 minutes or 60 minutes through out waking hours “until relief”. Then lower the frequency of dosing. Then once completely symptom free, continue a protocol for infection for another 3 weeks. And he mentions using spleen therapy because. at the time, he felt that the spleen was the “master of immune defense” in the body which interestingly echoes some of the earliest writings on the spleen in Chinese medicine. Of course this brings up a whole discussion that the Chinese view of the spleen and the western medical view of the spleen are very different and not synonymous. But, never the less, Dr. Lee saw spleen therapy effective for infections in the clinic. I realize you can’t list everything in your list of nutritional support for viral infection, but never the less, it puzzled me that vitamin A was left out of the discussion. I don’t know where vitamin A is at in terms of its current use in functional medicine in regards to viral infections. What do you think? Thanks for all this info, though I do agree with Nicole that one gets into foggy territory when one attempts to self-prescribe complex Chinese herbal formulas without a clear, precise, careful diagnosis in relationship to phase of illness, signs, symptoms, tongue, and pulse etc.
Kindest regards, Larry
Thank you for your thoughtful comments, Larry. Vitamin A: I need to buy a little time on my response here. I am a fan, and have prescribed plenty of high dose A… I am wondering about vitamin A use when there is a vitamin D deficiency or insufficiency… Could this be an issue? if you follow our content, I’ll work on forming a thought around that idea. And I’ll look to see whether there is anything out there on vitamin A and SARS Cov1 or MERS. My initial searches yielded nothing of note.
For the blog and using Chinese patent formulas, I absolutely agree– as I said to Nicole– access to a practitioner trained in Chinese Medicine is optimal, but in many cases not possible. I think the small clinical guide that I posted (to our clinician audience) isn’t unreasonable. DrKF
Hi Dr. Fitzgerald,
Yes, I see what you mean about the issue of vitamin D deficiency or insufficiency and vitamin A. Sounds like there is an issue with long term use of high dosage of vitamin A with Vitamin D deficiency. I recall reading an article from Chris Masterjohn stating his premise that vitamin A protects against vitamin D toxicity and vitamin D protects against vitamin A toxicity.
He writes:
“When a severe imbalance between vitamins A and D favors vitamin A, phosphorus accumulates at the expense of calcium and bone loss ensues. When such an imbalance favors vitamin D, the production of vitamin K- dependent proteins greatly exceeds the capacity of vitamin K to activate them. This results in defective proteins, which in turn fail to direct calcium away from soft tissues and into bones and teeth. This results in soft tissue calcification, including the formation of kidney and bladder sotnes, and the calcification of blood vessels and aortal valves.” He writes elsewhere that some have proposed a ratio of vitamin A to vitamin D intake of 4 to 1, 5 to 1, even 8 to 1. I realize this all gets more complex depending upon the individual person’s nutritional state.
– From Wise Traditions, Fall, 2012.
Yes, and as for the clinical guide on TCM, the upside is that people will have more resources and choices to draw on with the knowledge you shared so that they can get all the support they can!! 3 last thoughts and then I’ll let go, I promise. I realize these are lengthy exchanges but in the spirit of sharing information during these unusual times: The Institute for Traditional Medicine in Portland Oregon, founded and directed by Subhuti Dharmananda has an interesting formulation. You may know about it already. It’s called “Baicalcumin”. It’s essentially a combination of 7 Chinese herbs that have good evidence of anti-viral effects (and apparently anti-cancer effects for some of the herbs). You could consider using Baicalcumin more in the application of a nutraceutical rather than strictly a full traditional Chinese medicine diagnosis but Shubuti’s approach, in my opinion is definitely to combine and utilize the 2 approaches in an integrated fashion. Do the full diagnosis according to TCM and then utilize the research done on these herbs in their “anti-viral” properties. Secondly, and I know I’m shooting from the hip here, but I’ve read about some physicians using potassium iodide to treat the polio virus in the 50s. I realize using oral iodine is a delicate matter and process that needs to be done safely but it was written about as a “virucide”. At the time, J.F. Edward, M.D. wrote an article entitled “Iodine: Its Use in the Treatment and Prevention of Poliomyelitis and Allied Diseases”. He was correlating iodine deficiency as a potential vulnerability for infection. Dr. Royal Lee also wrote about utilizing “protein bound iodine” in the treatment of viral infections. That’s a whole other discussion for sure. Lastly, I read a statement from MarcoPharma that is recommending the use of high dose proteases, on an empty stomach, for attacking the “envelope corona virus” as a part of treatment with their “Marcozyme” product. Okay, I am officially letting go now, and won’t keep you any longer Kara. Thanks again for looking into vitamin A and its balance with vitamin D. Hope all is well there in Connecticut.
-Larry
I couldn’t help but cringe at some of the TCM formula suggestions – I agree with Nicole 100%, unfortunately with Chinese herbal formulas (even patent pills) taking the wrong one can not only not help, but can make the pathogen stronger/body weaker and be dangerous. Please be careful and consult with a trained Chinese herbalist who has NCCAOM certification!
I do indeed want our readership to be clear that the ideal scenario allows that individuals are evaluated and treated by trained Chinese Medicine clinicians and given individualized prescriptions (we hold this in high regard in Functional Medicine). If access is limited, however, Chinese patent formulas have a long record of effective use in pandemics, including influenza and SARS Cov1, and are worthy of our consideration as Western trained clinicians. DrKF
Hello! Thanks for the recommendations. For prevention and for general health, this is a good list of supplements. I think that such supplements will come in handy, and not only during a pandemic, but it is also a great way to maintain our health. Often even consuming a normal amount of vegetables and other products, we do not get enough vitamins and minerals. I will definitely bookmark this article and in case of infection I will use your recommendations, thank you for that, good luck!