COVID19: Traditional Chinese Medicine and Western Options for the Non-TCM Trained Clinician

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. 

1. 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)
2. Vitamin D: 2000IU -5000IU or higher per day (goal: blood level >=50ng/mL)
3. Omega 3 (EPA/DHA): 2500mg daily
   1. Or, perhaps better: Metagenics SPMs: 2 caps twice per day as prevention. May increase to 2 caps 3 times per day with first symptoms.
4. 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)
5. 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 
6. Real Mushrooms Reishe 415: 1 cap daily for prevention; increase to 2 caps once to twice per day with symptoms.
   1. *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.
7. 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. 
8. 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)

1. Astragalus root: 2 caps daily for prevention; increase to 2 caps 3-4 times per day with symptoms
2. 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) 
3. 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)
4. Metagenics Andrographis plus: Follow label instructions 
5. 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)
6. 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

Here is a great front-line report from Wuhan and beyond using TCM. Plus interventions for the TCM practitioner.

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