Articles

ABSTRACT

Hepatitis C (HC) is a major cause of liver disease with 150,000 to 170,000 reported cases annually in the United States.  Up to 80% of HC virus (HCV) infected individuals become chronic carriers with risk of developing cirrhosis and hepatocellular carcinoma.  Interferon-a (IFN a) the current and only FDA approved HC treatment, exhibits a low long-term remission rate (~ 20%).  IFN-a, however, is prohibited in acute hepatitis and is not effective in treating cirrhosis, as well as demonstrates many side effects, some potentially serious. Chinese herbal medicine provides better HC treatment with higher remission rate, fewer side effects, and lower cost when compare to IFN-a. Traditional Chinese medicine classifies HC into three types: 1) damp accumulation in liver and gall bladder. 2) weaker kidney, and 3)  stagnation of liver.  Accordingly, the treatment consists of  1) removing damp, 2) tonifying the kidney, 3) moving Liver qi and transforming Phlegm, as well as 4) reducing toxin accumulation and cooling Blood.  The effects of Chinese herbal medicine has been documented clinically and experimentally and appeared to be mediated by inhibiting HCV replication, correcting disordered microcirculation of liver, restoring aberrant immunologic function, facilitating hepatocyte regeneration, and providing deficient trace elements.  The effects of Chinese herbal medicine in treating HC can be easily monitored through sequential measuring blood liver function enzymes.  Formula for treating  individual patient would be carefully prepared based on individual condition.  In summary, HC can be effectively treated by using Chinese herbal medicine with minimal to no side effects and with a low cost.

INTRODUCTION

HC is caused by HCV.  Both cytocidal replications of HCV and immunologically mediated events have been implicated for its pathogenesis.  The incubation period for HCV hepatitis ranges from 12 to 180 days.  Most cases are considered to be asymptotic.  Symptoms are non-specific and consist mainly of fatigue, headache, anxiety and drowsiness.  A clinical feature quite characteristic of HCV is episodic elevations in serum transaminases, with intervening normal or near normal period.  At least 80% of individuals infected with HCV become chronic carriers and about 10-20 % of the patients will develop cirrhosis and is at risk for hepatocellular carcinoma.  CDC estimated that HCV causes about 85,000 new cases of chronic hepatitis each year in the USA.  Indeed, HCV is the leading cause of chronic liver disease in the Western world.

The histologic hallmark of progressive diseases is piecemeal necrosis.  With continued loss of hepatocytes, subsequent fibrous septum formation, and accompanied hepatocyte regeneration, cirrhosis occurs.  Liver biopsy could provide useful staging information in HCV hepatitis.

Approved drug for the treatment of HCV hepatitis by FDA is alpha interferon (INF-a). Approximately 40% of patients will respond to interferon for a six-month treatment, showing the normality of the liver transaminase tests and reduced hepatocytes inflammation.  However, among them who responded to the treatment, approximately 60% will relapse several months following the therapy.  Only about 20% to 30% of the cases treated with INF-a enjoy a long-term remission.  Moreover, patients with cirrhosis are less likely to respond to INF-a therapy, and INF-a can not be applied for acute infections.  INF-a could cause many side effects and some of them are serious.  They include fatigue, muscle pain, flu-like symptoms, autoimmune disorders, severe depression and psychotic states, poor appetite, hair loss, insomnia, and bone marrow depression.  It is noteworthy that a relatively high proportion of patients treated with INF-a showed an increase of serum ALT during or after therapy, suggesting that INF-a induce liver damage.

APPROACH OF TRADITIONAL CHINESE MEDICINE FOR TREATMENT OF HC

HC incidence is high in China, accounting for one third of world HC cases.  Treatment modalities of HC have been extensively studied in China.  It is well documented that Chinese herbal treatment is more effective than INF-a expressed by higher remission rate, long term effect, minimal side effects, and low cost.  Physicians in China employ an integrated approach for HC.  Diagnosis of HC is made via serology study, enzyme biochemistry, and liver biopsy.  Herbal medicine in certain formula is applied to patients.  The experiments and clinical observations showed that extracts of herbs used in treating HC have pharmacological effects of anti-viral, anti-inflammatory, anti-fibrosis, and correcting aberrant immunologic function.  Chinese herbal medicine could heal damaged liver cell, clear jaundice and cease and reverse cirrhosis.

Virus elimination depends on the host immune system.  It has been documented that extracts of herbs used in treating HC, Acanthopanax bark, Epimedium, Siberian solomonseal rhizome, Honeysuckle flower, and Dandelion can reinforce functions of mononuclear-macrophage system, Astragalus root, White atractylodes, and Scrophularia root can reinforce humoral immunity, Ginseng, Codonopsis root, Lucid ganoderma, and lycium fruit can reinforce cellular immunity.  These herbs can facilitate repairing injured hepatocytes caused by dysfunctioned immune system.  Immune regulatory effects of herbs Licorice root, oldenlandria, Scutellaria root, Tripterygium wolfed hook and Millettia stem can suppress aberrant auto-immunity in chronic active hepatitis.

Another group of herbs has potent effects in reducing inflammation of liver and normalizing elevated ALT and AST, by stabilizing damaged cell membrane of hepatocytes.   Herbs of Schizandre Fructus, Silybum marianum and Artichoke are effective in normalizing elevated ALT and AST in 75% of cases studied and reducing elevated ALT and AST down to 84% to 97 % of patients’ ALT and ASTs.  The average time for reducing or normalizing the enzymes is about 8 to 12 weeks.  By applying a formula consisting of extracts of Schixandrae Fructus, Silybum marianum and Artichoke as principle ingredient together with Salvia root, Lucid ganoderma, and Liquorice root, I have experienced a high successful rate in normalizing liver function enzymes within three months.  To clear jaundice, especially during acute stage of HC, herbal formulae containing Capillaris Herb could be used. Gardenia Fruit and Rhubarb Rhizome are effective in less than three weeks.

Liver cells have strong ability to regenerate.  The regeneration is closely related to intake of trace elements, such as zinc and strontium.  HC patients show significantly deficiency of trace elements in the blood and hair.  Enrichment of trace elements in herbs of Astragalus root, White attractylodes, Codonopsis root, Bupleurum root, and Lycium fruit explains their effectiveness in treating HC.

Herbs of Chinese angelica root, Salvia root, Peach seed, and Curcuma root are effective in decomposing collagen, and promoting liver cell regeneration.  These herbs then can be used to normalize liver function and prevent cirrhosis.

It has been documented that HC patients have obvious microcirculation disorders, which include increased abnormal vascular loops and diminished or completely obstructed blood flow in capillaries in the liver and in other tissues. This is consistence with the theory of blood stagnancy in traditional Chinese medicine on HC expressed by purplish tongue, dark ring around eyes, enlarged capillaries, body ache, and choppy pulse. By applying herbs of Salvia root, Millettia stem, Achyranthes root, Ligusticum rhizome, and Pseudoginseng, an effect of invigorating circulation and expelling blood stasis occurs.

CLASSIFICATION OF HC AND ITS TREATMENT BY CHINESE HERBAL MEDICINE

The following presents a traditional Chinese medicine approach for classification and treatment of HC based on differentiation of HC (characteristics of individual patient). The treatment would be tailored to individuals based on clinical presentation.  Furthermore, treatments are also modified at different stages of the patient’s disease.  Chronic HC can be classified into three types based on my experience.

1.  Dampness pathogen accumulation in liver and gall bladder

The toxic pathogen of HCV causes obstruction of qi and leads to illness.  HCV pathogen is not a wen-re/warm-hot toxic pathogen.  Although it directly enters yin and blood, there are no clinical manifestations of heat in yin and blood, which is commonly expressed as rashes, scarlet tongue, delirium, tendencies to damage the blood or cause bleeding.  HC pathogen is a yin-natured, toxic, damp-type pathogen.  This pathogen has an obstructing nature of damp, and a congealing nature of yin.   It can be accumulated to become toxic, blocking collaterals, damaging qi and obstructing flow of yang qi.  This is indicated by knotted mass under ribs, telangiectasis, and darkened face.

2.  Weak Kidney

Weaker Kidney and Jing qi, weaker qi and blood, and less efficient channel and collateral circulation occur following aging.  Accordingly, when yin du (contagious pathogen) enters yin xue (nutritive qi and blood), it then obstructs yin and blood in the zang fu (viscera), and resides stubbornly deep within body.  Thus treatment must be effective in tonifying Kidney, restoring energy and nourishing blood.

Kidney deficient patients, especially those in middle or old age, are easily infected by HCV.  Studies in China showed a positive correlation between age and HC, with patients in the 60-70 age group were most affected.  Studies in Japan showed similar results.  It has been found that predominantly damp-heat cases were mainly associated with pathological manifestations of mild hepatitis, whereas those with predominantly stagnation-related conditions almost all were chronic hepatitis or liver cirrhosis, and every case in the series was over 40 years of age.

Treatment modality: Tonifying Kidneys

The most common subtype of this group is Kidney qi deficiency and Kidney yang deficiency, followed by Kidney yin deficiency.  A judicious amount of Kidney yang tonics should be applied by taking Ba Ji Tian (Morindae Officianalis, Radix), Hu Lu Ba (Trigonellae Foeni-graeci, Semen), Xian Ling Pi (Epimedii, Herba), Xian Mao (Curculiginus Orchioidis, Rhizoma), Tu Si Zi (Cuscutae, Semen), and Wu Wei Zi (Schisandrae Chinensis, Fructus).  Some Kidney yin tonics should be added in order to seek yang from within yin.  In general, less Kidney tonics should be used in acute mild case, and more kidney tonic should be used in chronic case.  Large dose of raw Huang Qi (Astragali, Radix, 30g) can be very effective to treat HC, because hepatitis C congeals yin, damages qi and blocks yang.

3.  Stagnation of Liver Qi

Liver and Spleen disharmony is common in HC, expressed by Liver oppressing a weak Spleen or Liver qi blockage of Spleen.  Nature of HC pathogen – congealing accumulation, low-grade heat symptoms, qi blockage, damp obstruction and phlegm formation, usually appears with stagnant blood blocking the collaterals.  Toxicity, stagnation, phlegm and damp occur and they interact with each other.  Treatment modality is to move liver qi, transform phlegm by using qi movers listed below: Chai Hu (Bupleuri, Radix), Chen Pi (Citri Reticulatae, Pericarpium), Qing Pi (Citri Reticulatae Viride, Pericarpium), Xiang Fu (Cyperi Rotundi, Rhizoma), and Hou Po (Magnoliae Officianalis, Cortex).  Above herbs should be combined with following phlegm cutters: Ban Xia (Pinelliae Ternata, Rhizoma), Zhe Bei Mu (Fritillariae Thunbergii, Bulbus), and Kun Bu (Algae, Thallus).   Formula should be carefully formulated in order to reduce any possibility to exacerbate congealing and obstructing. Commonly used formula to reduce phlegm accumulation are Er Chen Tang (Two-Cured Decoction or Citrus and Pinellia), and Xiao Xian Xiong Jia Zhi Shi Tang (Minor Sinking Into the Chest Decoction plus Zhi Shi).

OTHER MODALITIES USED IN TREATING HC WITH CHINESE HERBAL MEDICINE

-         Moving and cooling blood and reducing toxin accumulation.

When pathogen enters and works in blood, herbs being capable of reaching blood should be used.  However because pathogen tends to congeal yin and become toxic, these so called blood herbs should not be too cold, sticky, or passive.  Instead, herbs with a property of moving without staying (zou er bu shou, to move the blood and open the collaterals) should be used.  When HC pathogen is not responding to treatment, it is usually because the illness has entered collaterals, rather than channels.   Collateral-opening herbs are then needed to reach this area to clear the pathogen.  Ji Xue Teng (Spatholobus), by both nourishing and moving blood, and opening collaterals, is effective for this condition.  Anti-toxin herbs, which can reduce toxic accumulation, move blood and open collaterals, are listed below: Bai Hua She She Cao (Oldenlandiae Diffusae, Herba), Chi Shao (Paeonia Rubra, Radix), Da Huang (Rhei, Rhizoma), Hu Zhang (Polygonum cuspidatum, Radix), Dan Shen (Salviae Miltiorrhizae, Radix), Mu Dan Pi (Moutan Radicis, Cortex), Zi Cao (Lithospermi seu Arnebiae, Radix), and Yu Jin (Curcumae, Tuber).

In febrile disease, one method used in treatment is to vent heat from yin out to qi, as the heat can be more easily dispersed, followed from the qi out to the surface.  The idea is to lead the heat out from its deep position in the body to a more superficial location and preventing the illness from worsening.  Whether this technique should be used for a given hepatitis C patient depends upon circumstances.  When patients have mild symptoms and with no history of IV drug use or blood transfusion, small amounts of herbs, which assist yang and reduce toxicity in order to bring the pathogen out to the surface, can be used.

CHANGE OF YOUR LIFESTYPES

Eat a low-protein, low-fat diet. Digesting protein puts an inordinate workload on the liver, so I recommend strongly limiting your intake of concentrated protein foods, such as meat, fish, and diary products.  One ounce serving of tofu will give you all the protein you need for the day. Eat plenty of starches, vegetables and fruits.

Take some standard antioxidant formula. You can help your immune system fight the hepatitis C virus by taking the supplemental formula I recommend to all my patients: 1,000 to 2,000 mg vitamin C and 25,000 IU mixed carotenoids at breakfast; 400 to 800 IU vitamin E and 200 mg selenium at lunch; and 1,000 to 2,000 mg vitamin C at dinner.

Strictly avoid all alcohol and tobacco. Alcohol is toxic to the liver and can accelerate liver disease, while smoking takes a major toll on the immune system.

Try to avoid all drugs, whether prescribed, over-the-counter, or illegal. Most drugs are metabolized by the liver. Even common painkillers such as acetaminophen, when combined with alcohol, have been shown to cause severe liver damage.

Drink plenty of water. Flushing your kidneys with lots of good-quality water will allow your body’s purification system to do its job and take some of the workload of detoxification off of the liver.

Take frequent steam baths or saunas. Sweating helps the body eliminate toxins and also reduces the liver’s workload. Be sure to replace lost fluids by drinking plenty of pure water at the same time.

Get plenty of rest. Give your immune system an edge by cutting down on unnecessary expenditures of energy, while maintaining a gentle exercise regime.

Manage stress. Effectively coping with stress is considered to be a crucial component in managing viral and autoimmune chronic hepatitis. Connect with nature through practicing TAI CHI CHUAN,

APPENDIX:

BLOOD TESTS IN HAPATITIS C

Detection o f hepatitis:

ALT (SGPT) / AST (SGOT)

These tests are indicators of the extent of inflammation in liver.  In acute hepatitis, the enzyme level in blood can be up to thousand units in chronic hepatitis.   Patterns of ALT (single peaks, double peaks and multiple peaks) reflect progress of HC and its prognosis.  The pattern of ALT peaking and then gradually reducing indicates remission.  If within the first 3 months of the disease, there are more instances of double peaks or multiple peaks of ALT activity, there is a tendency to be chronic.

Alkaline phosphatase/Gamma GTP

These tests are indicators of inflammation in the bile ducts. They can be elevated in hepatitis.

Gamma globulin

It is elevated in hepatitis.

The first of these four tests are sometimes referred to as liver function tests.

Detection of `hepatitis C.

RIBA II.

Viral RNA  (Measuring hepatitis C virus in the blood.   It is more sensitive than RIBA II is.

Tests for functioning of the liver

Protime (PT)

Measuring ability of blood to coagulate. It is elevated when the liver does not synthesize enough of the ingredients that cause blood to coagulate.

Albumin

A serum protein synthesized by the liver. It is low when a damaged liver is not able to keep up with its synthesis.

Key words:

du/toxin: a pathogen which has accumulated locally so that its influence is intense”; it has no relation to “dirtiness

Qi:  Energy.

Differentiation:  an analysis of characteristics of individual patient.

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