journal of integrative veterinary therapies

March 2012 Volume 2, Issue 1 journal of integrative veterinary therapies contents veterinary chinese medicine

5 Herbal Therapy in a Dog with Severe Atopic Dermatitis Leilani Alvarez DVM

13 A Chinese Medical Approach to Cholangiohepatitis in the Dog Lauren A Bauer DVM

22 Integrative Management of Canine Allergic Bronchitis with Veterinary Chinese Herbal Medicine Tom Schell DVM DABVP (eq)

28 Use Of Huo Xiang Zhing Qi San for the Treatment of Recurrent Diarrhea in a Juvenile Poodle Dr Grace S Y Li western veterinary herbal medicine

35 Monograph: Alkaloids Holly Mash BVSc IVAS MRCVS

40 Monograph: Radix Astragali Mary Ellen Sayre DVM

43 Holly’s Herb Walk Holly Mash BVSc IVAS MRCVS

47 Study shows how Primates learn about Herbal Self-Medication CIVT Staff regulars 3 JIVT: An introduction

34 Clinical Pearls of Wisdom

49 Research Updates

52 About JIVT

The Peer Review Board encourages

JIVT: An introduction contributions to the Journal on all areas

The Journal of Integrative Veterinary of integrative veterinary medicine. Therapies (JIVT) is a quarterly publication of Instructions for contributions are on the CIVT. The Journal publishes material on all last page. For full instructions go to www. aspects of integrative veterinary medicine civtedu.org, membership, journal. including Chinese and Western herbal Editorial Committee: Barbara Fougere, medicine, natural nutrition, environmental Lyndy Scott, Karen Goldrick, Steve medicine, philosophy, history, clinical cases Marsden and Joanna Milan. and commentary. The College was founded in 2008 and The Journal is peer reviewed. is the world’s first distance education Members of the Peer Review Board are: institution specializing in evidence based natural medicine for animals. Our mission Steve Marsden DVM ND MSOM Lac Dipl is to provide international leadership in CH RH (AHG) Edmonton, Canada delivery of comprehensive and quality Susan Wynn DVM RH (AHG) CVA CVCH veterinary natural medicine education that Atlanta, USA is evidence based. We aim to bridge science and tradition to benefit animal health Barbara Fougere BSc BVMS BHs (Comp and wellbeing by integrating the best of Med) MHSc (Herb Med) CVA CVBM CVCP natural medicine and conventional health MOrd D&T CMAVA MNHAA Sydney, care practices. We encourage an ecological Australia and environmentally aware approach to the health of our animals, ourselves, our Nancy Scanlan DVM MSFP CVA communities and our planet. California, USA Joyce Harman DVM MRCVS CVA Washington, USA Letters to the Editor We welcome and encourage your letters Richard Palmquist DVM and feedback. We envisage that your Los Angeles, USA words will be part of a vibrant and ongoing dialogue within a growing community of Jean Dodds DVM Los Angeles, USA integrative veterinarians and allied health Lyndy Scott BSc BVMS MBA MANCVS FAICD professionals. Perth, Australia Email your letters to [email protected] Hue Karreman DVM Lancaster County, USA

civtedu.org JIVT 2(1) March, 2012 3 civtedu.org JIVT 2(1) March, 2012 4 Herbal Therapy in a Dog with (Haliwell 2006). Appropriate diagnosis of Severe Atopic Dermatitis AD is based on the patient’s signalment, Leilani Alvarez DVM clinical signs and history of disease (Favrot et al. 2010). Favrot’s criteria for diagnosis of AD include five of eight satisfying criteria, which yield a sensitivity of 85% and specificity of 79% to differentiate dogs with

AD from dogs with chronic or recurrent

prutitus without AD (Table 1). Dogs with AD usually have skin lesions consisting of erythematous macules, patches and papules. However, in most patients, the skin lesions are due to self-induced trauma, including excoriations, alopecia, lichenification and hyperpigmentation (DeBoer & Hillier 2001). The areas most commonly affected include Abstract the face, concave ear pinnae, ventral neck, Herbal therapy provided effective axillae, groin, abdomen, perineum, ventral treatment for a dog with severe atopic tail and extremities. One must also be dermatitis that had been refractory to careful to rule out other pruritic conditions, conventional therapies. A combination which can mimic AD including scabies, of conventional therapies, acupuncture, demodicosis and infectious bacterial and herbal medicines and dietary changes were yeast pyodermas. used to treat the patient and, in the last Experts in the field of dermatology have 15 months, the condition has been well agreed that intradermal tests and allergen- managed with the integrated approach. specific IgE tests cannot be used as the sole This case demonstrates that herbal therapy means of diagnosing AD (Hillier & DeBoer can be a successful treatment option for 2001). Instead, results from these tests can refractory atopic dermatitis cases or as be used to implement allergen-avoidance complementary treatment for patients with interventions and targeted immunotherapy dermatologic problems. against select allergens. Introduction Current practice guidelines on successful Atopic dermatitis (AD) is a common treatment of AD state that a combination dermatologic diagnosis in dogs consisting of several interventions and treatments of chronic relapsing pruritic skin (Olivry et is often necessary to achieve satisfactory al. 2010). Dogs are genetically predisposed results (Olivry et al. 2010). These measures to this inflammatory skin condition, which include: Identification and avoidance of is characterized by specific clinical features flare factors (such as fleas, food, dust mites, associated with IgE antibodies, usually pollens or other environmental allergens); directed against environmental allergens improvement of skin and coat hygiene and civtedu.org JIVT 2(1) March, 2012 5 care; and reduction of pruritus and skin history of aggression and anxiety issues lesions with pharmacological agents (such since she was first acquired as a puppy. as glucocorticoids, antihistamines, essential Prior to presentation, the patient had been fatty acids, tacrolimus and cyclosporine). treated by a board-certified dermatologist for three years, including treatments Herbal medicine has shown some with hyposensitization injections, promise in the treatment of AD. Several antihistamines, steroids, antibiotics, human studies have demonstrated that Atopica® (cyclosporine) and medicated a combination Chinese herbal medicine, baths. Despite these therapies, the patient’s Zemaphyte® is helpful in the management symptoms were not well controlled. of atopic eczema (Chung 2008, Hon et al. 2007, Zhang 2005, Xu et al. 1997). Intradermal skin testing revealed she was Zemaphyte®contains Ledebouriella reactive to several tree pollens, house saseloides (pictured next page), Potentilla dust mite and tobacco. Serum IgE testing chinensis, Clematis armandii, Rehmannia for aeroallergens revealed positive titers glutinosa, Paeonia lactiflora, Lophatherum to several species. The dermatologist gracile, Dictamnus dasycarpus, Tribulus developed a vaccine combining these terrestris, Glycyrrhiza glabra (licorice) and results with those of the intradermal Schizonepeta tenuifolia) skin test and the patient received the As well, in a randomized double-blind appropriate course of hyposensitization placebo-controlled trial with dogs it was injections. After six months of weekly shown that Phytopica® (Intervet-Shering injections, the owner reported the Plough), a Chinese herbal supplement and pet’s pruritus was not improved and a derivative of Zemaphyte®, significantly she continued to have flare-ups. The reduced the dose of methylprednisolone dog also received Staphage Lysate required to control pruritus as compared to injections for over a year. The owner placebo (Schmidt et al. 2010). Phytopica® reported the injections helped initially, contains Rehmannia glutinosa, Paeonia but the dog continued to have severe lactiflora and Glycyrrhiza uralensis (licorice). outbreaks with bloody excoriations, An earlier randomized, controlled study on especially in summer time. After almost the same product showed favorable results two years, Staphage Lysate injections in the treatment of atopic dogs compared were continued but hyposensitization to placebo (Nagle et al. 2001). injections were discontinued. Case presentation Most recently, she had some relief with A 7-year-old, female spayed German the antihistamine, hydroxyzine, and initial Shepard dog, weighing 67 lbs (~ 30 kg) relief with Temaril P® (trimeprazine 5 mg and living primarily indoors, presented in and prednisolone 2 mg), but these were early summer with a primary complaint of no longer helping. The owner bathed the severe atopy that had not responded to pet every 2 to 3 days with hypoallergenic conventional medicine. Her allergies first shampoo. The pet had had an episode manifested when she was a year old and of severe colitis six months prior to had worsened over the years. She had a presentation. When presented, she had a

civtedu.org JIVT 2(1) March, 2012 6 great appetite and no current vomiting, We elected to continue the essential fatty diarrhea, coughing or sneezing. acids but discontinued the Temaril P®. We changed the diet to fresh raw frozen food Conventional evaluation with high protein and low carbohydrate, On Iiitial exam, the pet was bright alert using cooling proteins including fish, soy and responsive and had normal vital signs. or rabbit. She also received five weekly Her demeanor was anxious and fearful. acupuncture treatments aimed at reducing On physical exam, she had severe moist pruritus, inflammation and to calm her erythematous lesions in the periocular anxiety. (In TCVM these treatments were region, ventral abdomen, inguinal region, Wind and Heat clearing and Shen calming). medial thighs and perianal region. There were crusting excoriations over the trunk Within two weeks of treatment, the owner and flanks. The dog was extremely pruritic reported she was much better, less itchy and was itching incessantly throughout the and calmer. On presentation, she had exam. Her current medications included fewer skin lesions, mild to moderate, in Temaril P® – 1 tablet daily and Omega 3 comparison to presentation. Her tongue fatty acids 1000 mg daily. Her diet consisted was red and her pulse strong. of commercial dry kibble (Innova) and On the fourth week of treatment, which dehydrated food by the Honest Kitchen, was at the end of July and historically Thrive variety (chicken and quinoa). Her her worst season, she had a flare-up. clinical presentation and history fit with She had multifocal excoriations and Favrot’s criteria for an accurate diagnosis of erythematous macules on the face, AD (see Table 1). Her assessment was severe medial front legs, caudal ear pinnae, atopic dermatitis, anxiety disorder and a perianal region, as well as swollen and history of colitis. erythematous front paws that were warm Traditional Chinese Veterinary Medicine to the touch. Her tongue was red and her (TCVM) evaluation pulse strong and bounding. The owner described the pet as very protective and food aggressive. She barked and attacked other dogs and was generally irritable and compulsive. Her TCVM Constitution was interpreted as Wood. Her tongue was purple-red and the pulse was strong and slippery. She had active acupuncture points at BL 15, BL 22, LI 4. Her TCVM assessment was long standing Damp leading to Blood Heat, Liver Yang Rising and Wind. We initiated herbal therapy with Long Dan Er Miao San (Kan Essentials) 1250 mg (2½ tabs) orally two-three times daily.

civtedu.org JIVT 2(1) March, 2012 7 We started Temaril P®- three tabs orally following initial presentation), at which twice daily for three days, then once daily time the owner reported her skin had never for seven days to decrease inflammation looked better. On exam, she had a beautiful and Cefpodoxime (a third generation shiny coat and no active lesions. Her tongue cephalosporin) 150 mg orally once daily was pink and the pulse was still strong but for seven days to treat the suspected more moderate at the superficial level. pyoderma We switched the herbal formula During the following summer, the patient’s to Long Dan Xie Gan Tang (Kan Essentials) worst allergy season, she continued to do – 1½ tabs orally three times daily for a well on the Qing Ying Tang, although we stronger Heat clearing effect. did use low doses of Temaril P®- 1-2 tabs On recheck one week later (five weeks once daily to help control her allergies. after initial presentation), the dog was During a phone conversation with the significantly improved. She had mild owner 18 months after staring herbal pin-point papules on the ventral base therapy, she reported her pet’s skin has of her neck and no other active lesions. never looked better and she could not be Her tongue was red and pulse strong. On more pleased with how well she was doing. recheck the following week (six weeks after Discussion presentation), her skin was still doing well This patient shows signs of severe Damp but she had an episode of colitis and was Heat as evidenced by the strong slippery still itchy around the perianal region. On pulse, inflamed skin with excoriations exam, she had an anal gland impaction. Her and history of colitis. The long-standing tongue was red and wet and pulse slippery Damp has led to stagnation as evidenced and strong. Her anal glands were expressed by the purple-red tongue. The underlying and we added an additional herb, Si Miao cause is likely Damp accumulating in the San (Kan Essentials) – two tabs orally in the Spleen, in part from the carbohydrate rich morning and reduced Long Dan Xie Gan and highly processed diet (dry kibble). Tang to two tabs orally in the evening. Carbohydrates and processed foods have On recheck 11 weeks following a higher glycemic index and lower content presentation, she continued to do well. The of vitamins and minerals. Processed owner reported she was more playful and foods, therefore, are less nutritious and calmer. On exam, she had mild erythema promote more inflammation and insulin around the perianal region and medial resistance. The combination of herbs thighs, but there were no open lesions. and unprocessed raw foods promotes Her tongue continued to be red and pulse improved bioavailability of nutrients, strong and wide. At this point, we changed increased insulin sensitivity and improved her herbal formula to Qing Ying Tang (Kan blood flow to inflamed areas to help limit Essentials) – two tabs by mouth two-three and resolve them. times daily. The pet’s previous diet was mostly The patient was not seen again until chicken, which is very warming from a spring of the following year (nine months Chinese medical perspective. As the Damp

civtedu.org JIVT 2(1) March, 2012 8 accumulates, it stagnated the Triple Burner (Phellodendron and Atractylodes) clear leading to genital inflammation (as noted Heat and dry Damp in the Lower Burner, in the perianal and inguinal erythema and but have warming effects in the Middle active BL 22). As the Heat accumulated, it Burner to protect the Spleen. Atractylodes, transferred to the Heart and Liver leading Mulberry leaf and Dictamnus have Wind to the behavioral problems of anxiety, expelling effects. Kochia drains Damp and aggression and irritability. In addition, relieves itch. Red Peony and Peony tree bark the Liver Heat manifested in periocular move Blood and relieve itch. erythema. The Heat transferred to the Blood The formula was switched to Long Dan leading to severe itching and Blood Heat. Xie Gan Tang to have a stronger cooling Aggression is a sign of Liver Yang rising, action and to focus more on clearing Heat while itching is a sign of External Wind. from the Liver channel which was likely Long Dan Er Miao San is a combination of leading to the dominance aggression. Si Er Miao San and Long Dan Xie Gan Tang, Miao San was added when the patient which treat severe Damp Heat. Long Dan developed colitis, a sign of Spleen Qi Cao, Huang Qin and Gardenia clear Heat deficiency and Damp. Si Miao San contains from the Liver and Heart and dry Damp. Phellodendron and Atractylodes, which Bupleurum and Huang Qin promote both tonify Spleen and dispel Damp. movement through the Triple Burner. Phellodendron is also Heat clearing. Coix Rehmannia cools Blood while protecting further supports the Spleen and helps stop Yin damaged by the Heat and drying diarrhea. Achryanthes is a Blood mover that effects of the other herbs. Plantain seed, helps decrease inflammation and relieve Poria and Ze Xie drain Damp. Er Miao San Blood Heat. Although the patient improved

Table 1. Favrot’s 2010 criteria for canine atopic dermatitis (Favrot et al. 2010)

1. Onset of signs under three years of age 2. Dog living mostly indoors 3. Glucocorticoid-responsive prutitus 4. Prutitus sine material at onset (ie alesional prutitus) 5. Affected front feet 6. Affected ear pinne 7. Nonaffected ear margins 8. Nonaffected dorso-lumbar area A combination of five satisfied criteria has a sensitivity of 85% and a specificity of 79% to differentiate dogs with AD from dogs with chronic or recurrent pruritus, without AD. Adding a sixth fulfilled parameter increases the specificity to 89%, but decreases the sensitivity to 58%. civtedu.org JIVT 2(1) March, 2012 9 significantly with the combination of Long can benefit patients with AD that have Dan Xie Gan Tang and Si Miao San, the failed conventional approaches (Kobayashi patient continued to have a red tongue et al. 2004). The present patient achieved with strong pulses, indicating there was still unparalleled improvement in AD symptoms a strong component of Blood Heat. with much lower doses of conventional medications than used historically, The patient has been best managed with indicating a significant contribution of the Qing Ying Tang, a formula that helps acupuncture, herbs and diet change to the clear severe Heat pathogens that have dog’s health and overall quality of life. invaded the Blood. It contains Rehmannia, Scrophularia and Ophipogon, which Summary/Conclusions clear Heat and protect Yin. Honeysuckle, This case report is an example of a Forsythia and Coptis dispel Heat pathogens, challenging clinical manifestation of while Lopatherum cools Heart Fire to help severe atopic dermatitis that failed expert relieve aggression and Salvia moves and conventional dermatologic management. cools Blood. Atopic dermatitis can be very frustrating for any clinician to manage. This Rehmannia glutinosa (Di Huang – pictured report demonstrates that using herbal next page), the first ingredient in Long Dan medicines and integrated therapies can Er Miao San and also in Qing Ying Tang, has be successful in the management of these multiple anti-inflammatory effects (Kim challenging cases. 1999, Park 2009). It was shown to help specifically with AD by enhancing T-hyper 2 References lymphocytes respond to allergens (Sung et Chung, L 2008, ‘Antioxidant profiles of a al. 2011). In a recent study, modified Si Miao prepared extract of Chinese herbs for the San extract was shown to have significant treatment of atopic eczema’, Phytother Res., anti-inflammatory effects by inhibiting April 22, vol. 4, pp. 493-9. nitrous oxide, tumor necrosis factor-alpha and Interleukin-6, among other pathways DeBoer, J & Hillier A 2001, ‘The ACVD task (Fan et al. 2010). force on canine atopic dermatitis (XV): fundamental concepts in clinical diagnosis’, Further, a Chinese herbal formula Vet Immunology Immunopathol, vol. 81, containing Angelica sinesis (Dang Gui) and pp. 271-6. Astragalus membranaceus (Huang Qi) was shown to decrease eosinophilic infiltration Egli, K et al 2002, ‘Evaluation of the in asthmatic mice and helped in the usefulness of sensitization to aeroallergens treatment of AD in dogs (Lin et al. 2011). as a model for canine atopic dermatitis in genetically predisposed Beagles’, Am J Vet Combining Chinese herbal medicines Res, vol. 63, no. 9, pp. 1329-1336. with acupuncture has been shown to be more beneficial in improving patients’ Fan, J, Liu, K, Zhang, Z et al. 2010, symptoms than Chinese herbal medicine ‘Modified Si-Miao-San extract inhibits the alone (Salameh et al. 2008) and using release of inflammatory mediators from herbal therapies along with diet change lipopolysaccharide-stimulated mouse civtedu.org JIVT 2(1) March, 2012 10 medicine concoction for treatment of atopic dermatitis: a randomized, double- blind, placebo-controlled study’, Br J Dermatol, vol. 157, no. 2, pp. 357.

Kim, H, An, C, Jung, K et al. 1999, ‘Rehmannia glutinosa inhibits tumor necrosis factor-alpha and interleukin-1 secretion from mouse astrocytes’, Pharmacol Res, vol. 40, pp. 171-176.

Kobayashi, H, Takahashi, K, Nobuyuki, M et al. 2004 ‘An alternative approach to Atopic Dermatitis: Part I- Case Series Presentation’, eCAM, vol. 1, no. 1, pp. 49-62.

Lin, C, Liou, C, Chiang, C et al. 2011, ‘Dangui macrophages’. JEthnopharmocol, vol. 129, Buxue Tang attenuates eosinophilic no. 1, pp. 5-9. infiltration and airway hyperresponsiveness Favrot, C, Steffan, J, Seewald, W et al. 2010, in asthmatic mice’. Ann Allergy Asthma ‘A prospective study on the clinical features Immunol, vol. 107, no. 6, pp. 501-509. of chronic canine atopic dermatitis and its diagnosis’, Vet Dermatology, vol. 21, pp. 23- Marsden, S. 2008, Lecture Notes, CIVT 1002 IVAS 30. Course in Chinese Herbal Medicine. College of Integrative Veterinary Therapies, pp. 96-98. Haliwell, R 2006, ‘Revised nomenclature of veterinary allergy’. Vet Immunol Nagle, T, Torres, S, Horne, K et al. 2001, Immunopathol , vol. 114, pp. 2007-2008. ‘A randomized, double-blind, placebo- Hillier, A & DeBoer, D 2001, ‘The ACVD controlled trial to investigate the efficacy task force on canine atopic dermatitis and safety of a Chinese herbal product (PO7P) (XVII): intradermal testing’, Vet Immunol for the treatment of canine atopic dermatitis’, Vet Immunopathol, vol. 81, pp. 289-304. Dermatol, vol. 12, no.5, pp. 265-274. Hillier, A, Kwochka, K & Pinchbeck L 2000, ‘Reactivity to intradermal injection of Olivry, T, DeBoer, D, Favort, C et al. 2010, extracts of Dermatophagoides farinae, ‘Treatment of canine atopic dermatitis: Dermatophagoides pteronysssinus, house 2010 clinical practice guidelines from the dust mite mix, and house dust in dogs International Task Force on Canine Atopic suspected to have atopic dermatitis: 115 Dermatitis’. Vet Dermatol, vol. 21, pp. 233-248. cases (1996-1998)’, J Am Vet Med Assoc, vol. 217, no. 4, pp. 536-540. Olivry, T et al. 2002, ‘Randomized controlled trial of the efficacy of cyclosporine in the Hon, K, Leung, T, Ng, P et al. 2007, ‘Efficacy treatment of atopic dermatitis in dogs’, J Am and tolerability of a Chinese herbal Vet Med Assoc, vol. 221, no. 3, pp. 370-377. civtedu.org JIVT 2(1) March, 2012 11 essentials of western veterinary herbal medicine

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Park, SH, Kim, SK, Shin, IH et al. 2009, ‘Effects of AIF on Knee Osteoarthritis ivas Patients: Double-blind Randomized certification vbma Placebo-controlled Study’. Korean J Physiol Pharmacol, vol. 13, no. 1, pp. 33-37. in veterinary chinesegraduate Salameh, F, Perla, D, Solomon, M herbalprogram in et al. 2008, ‘The effectiveness of medicine combined Chinese herbal medicine and acupuncture in the treatment of atopic of western dermatitis’. J Altern Complement Med, Oct 14, vol. 8, pp. 1043-8. veterinary Steffan, J, Parks, C & Seewald W 2005, ivas civt certification herbal ‘Clinical trial evaluating the efficacy on demand – start when it suits you! and safety of cyclosporine in dogs with in veterinary chinese medicine atopic dermatitis’. J Am Vet Med Assoc, herbal medicine vol. 226, no. 11, pp. 1855-1863. start now or join the next “I am still loving this course”. Dr Kris August, USA Schmidt, V, McEwan, N, Volk, A et al. ON DEMAND group in 2012! ‘The glucocorticoid sparing efficacy of “I cannot praise this Do chronic cases frustrate you? Don’t you wish there was PhytopicaTM in the management of enroll and study when it stimulating, exciting and something more you could offer? Then learn how to expand your fascinating course canine atopic dermatitis: a randomized, treatment options with Western Herbalsuits Medicine. you. Developed in highly enough!” double blind, placebo-controlled trial’. collaboration with VBMA, Drs Susan Wynn and Barbara Fougere Dr Holly Mash, UK (authors of the textbook Veterinary Herbal Medicine) are your Vet Dermatol, vol. 21, pp. 91-104. “I am enjoying this teachers on this course. This comprehensive program bridges course enormously.” tradition‘‘the and sciencemost and wonderful will develop your thing expertise to to safely Sung, Y, Yoon, T, Jang, J et al. ‘Topical Dr Astri Hagenlord, Norway and effectivelyme is that integrate Chinese herbal medicine Medicine into your practice. application of Rehmannia glutinose ... fills in these huge, frustrating extract inhibits allergen-induced n Online learning – study when it suits you gaps in Western medicine atopic dermatitis in NC/Nga mice’. J n Case support throughout n Recognitionand givesof prior learning me tools available I never Ethnopharmacol, vol. 134, no. 1, pp. 37-44. n VBMA members receivedreamed a 5% discount of...” n Free VBMA & CIVT membership if enrolling in whole course Xu, X, Banerjee, P, Rustin, M & Poulter CIVT student

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civtedu.org JIVT 2(1) March, 2012 12 A Chinese Medical Approach to then presented for euthanasia. He had dropped down to 69 pounds (~31 kg).

Cholangiohepatitis in the Dog The internist and the owners had given Lauren A Bauer DVM up. The owners, however, did agree to try the herbs previously prescribed. The dog responded and was subsequently seen on a weekly to bi-weekly basis for Chinese

herbs, acupuncture, diet instructions and

gastrointestinal symptom management using conventional medicine. Over the next five months the dog continued to improve in energy, appetite and laboratory values. To date he is markedly improved. This paper offers an overview of the role of Chinese Herbal Medicine, acupuncture and Abstract case management including conventional A 7½ year-old, male intact Golden therapies, diet and supplements Retriever presented for alternative therapy in the treatment of autoimmune for liver failure. He had weighed 103 cholangiohepatitis in the dog. pounds (~47 kg) until just recently. At the Introduction time of initial presentation he weighed 78 Cholangiohepatitis is a common pounds (~34 kg). disorder in the cat but uncommon in A month before initial presentation he the dog. It is an inflammation of the biliary tree as well as the surrounding stopped eating and started vomiting. hepatocytes (Magne & Shell 2004). He was diagnosed by ultrasound and Ultrasound and biopsy confirmed biopsy at a specialty hospital as having the diagnosis of lymphoplasmacytic cholangiohepatitis with biliary stasis cholangiohepatitis with bridging fibrosis and cirrhosis. Autoimmune disease and biliary cysts. After anaerobic and was suspected. While at the specialty aerobic culture of the area ruled out hospital he also developed a corneal ulcer, an infectious cause, an immunologic complicated by keratoconjunctivits sicca component to this condition was (KCS) and required a graft. suspected. He came into our hospital for supplemental The purpose of this case reports is to help. Herbs were prescribed but the owner show the value of an integrative approach did not use them as the dog’s internist to liver disease using herbal medicine, advised not to. The dog was not seen acupuncture, supplements and diet in at our clinic for the next four weeks. He addition to conventional drugs. civtedu.org JIVT 2(1) March, 2012 13 Presentation Over-Controlling the Spleen and Stomach Initially, the dog presented on October with Rebellious Stomach Qi. The severe 7, 2010 after being treated at a specialty Damp Heat resulted in a Triple Burner (TB) hospital for the previous three weeks. The Obstruction which gave rise to the sudden owners were seeking another opinion on onset of signs, elevated cholesterol and his condition of acute lymphoplasmacytic high liver enzymes. cholangiohepatitis with gastrointestinal Si Miao San for Damp Heat and Xiao complications of vomiting, diarrhea and Chai Hu Tang for TB Obstruction were anorexia with profound weight loss. He was recommended. Suggestions were made on multiple medications. (See Appendix 2 to add homemade foods that were Qi and for the dog’s initial medication list). Blood tonics. It was recommended that all Blood work, ultrasound and liver biopsy current medications be continued at this confirmed severe liver failure. (See time. Appendix 1 for laboratory values). The owners called the next day and said On physical examination, the dog was they had talked with their internist who profoundly thin with muscle wasting. said not to use any of the supplements or He weighed 78 pounds, down from his herbs because the internist was not familiar previous weight of 103 pounds. He was with them. I did not see the dog again for severely icteric, 3% dehydrated and four weeks. lethargic with a subdued Shen (mind). He had a corneal graft in his right eye that was On November 4, 2010, the owners returned healing. There was a dry, yellow discharge for euthanasia. They had stopped all the from this eye and he held his eyelids medications from the specialists and had halfway shut. His nose was dry and flaky. given up as their dog was not getting His mucous membranes were pale and very better. He was not eating and would vomit yellow. He had a 2/6-grade heart murmur several times every day. The specialists had with a normal heart rate. His abdomen implied that the dog was not improving was painful. His temperature was normal. and the prognosis was poor. At that point, I He got up occasionally in the exam room suggested giving the herbs a try since they to vomit bright yellow stomach fluid that had nothing to lose. They agreed. contained pieces of grass and a few kibbles of dog food. Physical exam revealed a dog that now weighed only 69 pounds (~34 kg). He had The TCVM (Traditional Chinese Veterinary lost an additional eight pounds in the last Medicine) physical exam revealed a pale four weeks. His previous weight had been and dry Tongue. His Pulse was deep, weak 103 pounds. His Tongue was pale, icteric and slippery. His abdominal area was warm and dry. His Pulse was deep, soft and weak. and painful. His conventional diagnosis of His TCVM disease pattern had not changed. cholangiohepatitis with biliary stasis and He still had Damp Heat in the Liver, Liver cirrhosis with an immune component is stated above. Blood Deficiency, Liver Over-Controlling the Spleen and Stomach with Rebellious His TCVM diagnoses are Damp Heat in Stomach Qi. The severe Damp Heat had the Liver, Liver Blood Deficiency and Liver resulted in a TB Obstruction. civtedu.org JIVT 2(1) March, 2012 14 The dog was put on Xiao Chai Hu Tang but albumin was dropping. I saw the dog and Si Miao San, both at three tablets BID. weekly to for the next month. The owners were instructed to continue Denamarin (milk thistle and Sam-E) at His weight stabilized and then started to 950 mg once daily. Zinc was added at increase. His ALT and ALK PHOS values 50 mg once daily to help with copper improved, with some fluctuations, while his accumulation in the liver. Hepagen-C, a albumin level was slowly dropping from 2.4 liver supplement and anti-oxidant, was to 1.7 (normal value 2.5 – 4.0). His appetite added at two tablets daily. The vomiting improved only slightly but the owners were was controlled with a Cerenia injection (3.1 able to force feed the dog regularly. Daily cc) and Cerenia tablets at 120 mg once daily vomiting and loose stools with blood were for the next three days. Regular vitamin routine. Cerenia was used on an as-needed B-12 injections (2 cc) were injected into basis for vomiting, with instructions not to the acupuncture Association points for the use more than three to four days in a row. Gall Bladder, Liver, Spleen and Stomach (BL His right dry eye continued to produce tear 18, 19, 20 and 21 respectively). The owners secretions. His Tongue remained pale and made a diet of chicken and rice and were dry and his Pulse slippery throughout force feeding this combined with Hill’s LD this period. canned food. On 12/15/10, the owner had fed a rich canned dog food and the dog had vomiting Si Miao San consists of four herbs to treat and diarrhea. He felt warm with a pale, cases of Damp Heat. Together these four wet Tongue and slippery Pulse. His TCVM herbs tonify the Spleen, Drain Damp and diagnosis was Spleen Qi Deficiency with Clear Heat. They are especially useful in Damp Heat and Rebellious Stomach Qi. Liu cases of Damp Heat in combination with Jun Zi Tang (Six Gentlemen) was ordered Spleen Qi Deficiency. for the patient. Baytril injection, Baytril Xiao Chai Hu Tang is used for TB tablets, subcutaneous fluids, vitamin B Obstruction and Shao Yang disorders. and injectable Cerenia were given (see The dog’s symptoms fitted this diagnosis: Appendix 3 for medication and herbal vomiting, Qi Deficiency (weakness), doses).The dog improved by the next day separation of Yin and Yang due to the and the owners were instructed to avoid Middle Burner Obstruction resulting in a rich and high fatty foods. lack of Source Qi production, very high liver Liu Jun Zi Tang is used in patients with Qi enzymes, KCS due to Yang trapped in the Deficiency. It will strengthen the Spleen, Upper Burner and a slippery Pulse, from harmonize the Stomach and relieve pain the Yang trapped peripherally in the Upper while promoting Qi flow (Xie 2010). It is Burner (Marsden, 2010a). used in patients with cranial abdominal pain, fatigue, nausea, poor appetite, a pale One week later, on 11/10/10, the pet was Tongue and deep weak Pulses. more energetic with good Shen. His tongue was pale pink and dry. His pulse was deep On 12/29/10 the dog was better than at the and weak. He was still not eating well. previous visit, but still had problems with There was improvement in liver values anorexia, some vomiting and soft stools. civtedu.org JIVT 2(1) March, 2012 15 The Tongue was pale, pink and dry. His Qi Stagnation and Spleen Qi Deficiency. Pulse remained slippery. Blood values were Its actions are to Disperse Liver Qi, relieve improving except for albumin. The dog was Stagnation, Tonify Spleen Qi and Nourish put on Liu Jun Zi Tang at three tablets BID Blood (Xie 2010). This is a good formula for for the gastrointestinal symptoms. liver disorders when albumin is low. The Chai Hu (pictured left) herb stimulates The dog’s pattern was changing from an RNA synthesis in hepatocytes, which may Excessive TB Obstruction to a Deficient lead to increased albumin production Liver Blood condition. The low appetite (Marsden and Wynn, 2003). The Minister was most likely the result of a Liver Spleen herbs, Dang Gui (Angelica) and Bai Shao disharmony. Xiao Yao San was chosen Yao (Paeonia) tonify and build Blood, because it is one of the best formulas increasing blood flow. This increase in for Liver Blood Deficiency resulting in circulation may also help with albumin hypoalbuminemia (Marsden 2010b). production (Marsden 2010a). A novel protein was introduced using Royal Canin Rabbit and Potato Limited Ingredient diet. The idea was to combat any inflammatory bowel disease that was creating or adding to the gastrointestinal symptoms of anorexia, vomiting and diarrhea. If there was inflammation in the intestines, it could contribute to the liver inflammation via the bile duct just as the liver inflammation can contribute to gastrointestinal inflammation. Over the next few visits, the pattern was becoming less Blood Deficient but On 1/6/11, it was noted vomiting had persistently Spleen Qi Deficient. The pet decreased since starting on Liu Jun Zi had very good energy. He was eating his Tang. The Tongue was pale and dry and novel protein diet fairly well. There was no the Pulse still deep and slippery. The dog significant vomiting but stools were still was more energetic. The stomach area was soft. His Tongue was moister than before less painful and rubbing this area caused but still pale. His Pulse was soft. Liver values him to scratch with his rear foot. He no had reduced to near normal levels. The longer guarded his abdomen. Xiao Yao San herbs, diet, acupuncture and vitamin B-12 was started at two tablets BID for the Liver were continued. Blood Deficiency. Xiao Chai Hu Tang and Si On 2/10/11 the dog was reported to be Miao San were both discontinued. Liu Jun very energetic at all times. He was running Zi Tang was continued. up the stairs and jumping into the car. Xiao Yao San is a Deficiency formula used The neighbors commented on how good in cases of Liver Blood Deficiency, Liver he seemed. His Tongue was moist and a civtedu.org JIVT 2(1) March, 2012 16 normal pink color. His Pulse was not as (Can Zhu), dries Damp and strengthens deep and weak as before, but still slippery. the Spleen to eliminate Dampness He still had occasional soft stools. The in the Middle Jiao. The Minister herb, owner had been feeding him a quarter of Phellodendron (Huang Ba), predominantly his old food, dry Eukanuba, because he removes Damp Heat in the Lower Jiao. The liked it. A test for albumin only was run and Adjuvant herb, Coix (Yi Yi Ren), smoothes the value had improved to 2.0. The owner the channels and joints to help tendon was instructed to be stricter with his diet. and ligament stiffness (Bi Syndrome) and It was considered best to eliminate his old removes Damp. The Messenger herb, diet at this time and probably forever. Achyranthes (Huai Niu Xi), descends the herbs’ effect to the Lower Jiao to eliminate Three weeks later the dog was doing Damp Heat (Xie 2010). well. His appetite was excellent with no vomiting. His energy levels were back to Together these four herbs Tonify the normal. His weight had increased to 80 Spleen, Drain Damp and Clear Heat. They pounds (~35 kg). This case will continue to are especially useful in cases of Damp Heat be monitored and adjustments made. Diet in combination with Spleen Qi Deficiency. will be a very important factor in the long- Xiao Chai Hu Tang was originally designed term maintenance of this dog. for Shao Yang Patterns. It consists of the Discussion King herb, Bupleurum (Chai Hu). This This dog originally was overweight with herb cools and ascends and relieves Liver many symptoms of Damp and Damp Heat Qi stagnation. It decreases ALT enzymes including dermatitis, otitis and arthritis. His and prevents hepatic necrosis and cell diet consisted of dry commercial dog food degeneration (Marsden 2010b). Chai Hu until the time he became ill. stimulates RNA synthesis in hepatocytes, which may lead to increased albumin The Spleen Qi deficiency from the production (Marsden & Wynn 2003). inadequate diet led to manufacture of Damp and Damp Heat. The Spleen failed The Minister herb, Scutellaria (Huang to manufacture sufficient Blood resulting Qin), drains Heat from the Shao Yang. It in a Liver Blood Deficiency. Damp and descends Yang from the Upper Burner Phlegm occluded the Triple Burner causing to reintegrate with the Lower Burner. Obstruction and collapse from Yin and The Adjuvant herbs consist of Pinellia Yang failing to mingle. Initially, many of (Ban Zia) and Zingiberis (Shen Jiang). the symptoms fit this pattern: vomiting, They work together to resolve Phlegm KCS, very high liver values and elevated and Stagnation in the Middle Burner. cholesterol. This action helps to reduce vomiting. The other two Adjuvant herbs are Ginseng The herbal formulas used were Si Miao San (Ren Shen) and Jujube (Da Zao) that tonify for Damp Heat and Xiao Chai Hu Tang for Qi and protect the Spleen and Stomach. TB Obstruction. The Messenger herb, Glycyrrhiza (Gan Si Miao San is indicated for Damp Heat Cao), harmonizes all of the herbs to work Patterns. The King herb, Atractylodes together (Xie 2010). civtedu.org JIVT 2(1) March, 2012 17 Numerous studies investigating this used to treat functional dyspepsia and formula focus on hepatoprotective and malabsorption, abdominal distension, loose regenerative functions. Research done by stools and debilitation (Wang & Xie 2003). Chang et al. (2007, vol.35, no. 2), found Xiao To this is added Er Chen Tang. The King Chai Hu Tang inhibited Hepatitis B virus herb, Pinellia (Ban Xia), transforms Phlegm and exhibited anticancer effects. Research and dries Dampness. The Minister herb, done by Chen et al. (2007, vol. 32, no. 2), Citrus (Chen Pi), promotes the flow of Qi showed that Xiao Chai Hu Tang could and harmonizes the Stomach (Xie 2010). inhibit liver fibrosis and collagen induced by bile duct ligation. It also reduced the Li Jun Zi Tang is used in patients with hyperbilirubinemia by four-fold compared Spleen Qi Deficiency. It will strengthen the to the control group. Spleen, harmonize the Stomach and relieve pain while promoting Qi flow. It is useful in After several months, the dog became cases of anorexia and chronic inflammatory more Deficient and less Excessive. The bowel disease. dropping albumin was of concern. The Liver Blood Deficiency continued Xiao Yao San is a Deficiency formula used to Over-control the Spleen resulting in cases of Liver Blood Deficiency, Liver in numerous gastrointestinal issues, Qi Stagnation and Spleen Qi Deficiency. being a depressed appetite, vomiting Its actions are to Disperse Liver Qi, and soft stools with blood. These issues relieve Stagnation, Tonify Spleen Qi and were addressed with the formulas Liu Nourish Blood. Jun Zi Tang for gastrointestinal issues and Xiao Yao San for Liver Deficiency, The King herb, Chai Hu (Bupleurum), including hypoalbuminemia. relieves Liver Qi Stagnation. The Minister herbs, Dang Gui (Angelica) and Bai Shao Liu Jun Zi Tang is based on Si Jun Zi Tang Yao (Paeonia) tonify and build Blood to with the addition of Er Chen Tang. soothe the Liver. The three Adjuvant herbs, Si Jun Zi Tang (Four Gentlemen) is a basic Qi Bai Xhu (Atractylodes), Fu Ling (Poria) and tonic. The King herb, Ginseng (Ren Shen) is Gan Cao (Glycyrrhiza) tonify the Spleen. a sweet, warm herb that tonifies the Qi and Gan Cao also works with Bai Shao Yao to strengthens the Spleen. The Minister herbs reduce painful spasms. The Messenger are Atractylodes (Bai Zhu) a bitter and warm herbs have different functions. Wei Jiang herb that serves to drain Damp and strengthen (Zingiberi) harmonizes the Middle Burner the Spleen, and Poria (Fu Ling) that aids and Bo He (Mentha) aids Chai Hu’s actions in strengthening the Spleen and draining of relieving Liver Qi Stagnation and cooling Damp. Poria also balances the warm nature of the heated liver (Xie 2010). Ginseng and Atractylodes by eliminating Heat. Xiao Yao San should be considered when The Messenger herb, Glycyrrhiza (Zhi Gan Cao), Spleen deficiency signs seem at the root of harmonizes the formula and also invigorates a Liver Blood Deficiency. For instance, when the Spleen (Xie 2010). gastrointestinal signs are most prominent Clinical studies have reported a recovery and include vomiting and anorexia. One of rate of 92.3% when Si Jun Zi Tang was the most common laboratory abnormalities civtedu.org JIVT 2(1) March, 2012 18 responding to this formula is low blood References albumin (Marsden 2010b). Chang, JS, Wang, DC, Liu, HW, Chen, MC,

Soon after starting these two herbal Chiang, LC & Lin, CC 2007, ‘Sho-saiko-to (Xiao- formulas, there was improvement in the Chai-Hu-Tang) and crude saikosaponins inhibit dog’s appetite, liver values and albumin hepatitis B virus in a stable HBV-producing cell levels. His energy was notably enhanced. line’, AJCM, Vol. 35, no. 2, pp. 341-351, cited in Xie, H 2010, Xie’s Chinese Veterinary Herbology, Vitamin B-12 treatments were given almost Ames, Iowa, Blackwell Publishing, p. 425. every time the dog was seen. Vitamin B-12 is a good treatment for Liver Blood Deficiency (Jilin et al. 1995). Vitamin B-12 Chen, MH, Chen, JC, Tsai, CC, Wang, WC, injected into the acupuncture Association Chang, DC, Lin, CC & Haieh, HY 2007, ‘Sho- points for the Liver, Gall Bladder, Spleen and saiko-to prevents liver fibrosis induced by Stomach enhanced the treatment of the bile duct ligation in rats’, AJCM, vol. 32, no. 2, liver cholangiohepatitis and gastrointestinal pp. 195-207, cited in Xie, H 2010, Xie’s Chinese issues. Zinc supplementation was instituted because it is known to reduce lipid Veterinary Herbology, Ames, Iowa, Blackwell peroxidation, has antifibrotic properties, Publishing, p. 425. prevents hepatic copper accumulation and can reduce the severity of hepatic Jilin, L & Peck, G 1995, Chinese Dietary Therapy, encephalopathy (Marchesini et al. 1996, New York, Churchill Livingstone, cited in Mars- Sokol 1996). Hepagen-C and Denamarin, liver den, S 2010, Course Notes for CIVT 1002 Chinese antioxidants, were used because, according to Herbal Medicine, internet course, p. 174-175. Rutgers and Biourge (2006, p.147): “Many liver diseases result in increased generation of free Magne, ML & Shell, L 2004, ‘Cholangiohepati- radical and oxidant stress. Supplementation tis’, VIN Associate Database, pp. 1-2. with antioxidants will therefore help to reduce oxidative liver injury”. Marschesini, G, Fabbri, A, Bianchi, G et al. 1996, Conclusion ‘Zinc supplementation and amino-acid-nitro- This case clearly demonstrates the value gen metabolism in patients with advanced of Traditional Chinese Medicine when cirrhosis’, Hepataology, vol. 23, pp. 1084-1092, conventional western medicine does not cited in Pibot, P, Biourge, V & Elliott, D 2006, result in improvement. The owners tried a Encyclopedia of Canine Clinical Nutrition, EU, multi-drug approach to this difficult and Aniwa SAS, p. 146. uncommon liver condition under the care of a highly trained, board-certified, veterinary Marsden, S 2010a, Severe Liver Failure, CIVT internist. Only when the outcome was bleak Case Discussions. were they willing to try alternative therapy combined with minimal conventional Marsden, S 2010b, Course Lectures for CIVT therapies. This case shows a positive outcome 1002 Chinese Herbal Medicine, internet course. with integrative medicine and the largely untapped positive results that Chinese Marsden, S 2010c, Course Notes for CIVT 1002 Chi- Herbal Medicine can bring. nese Herbal Medicine, internet course: pp. 174-175. civtedu.org JIVT 2(1) March, 2012 19 Appendix 1. Weight and laboratory values

Date Weight Alk ALT CHOL GGT TBili DBili ALB BUN HCT/ in Phos (112- (0- (0- (0- (2.5- (7- WBC pounds (23- 328) 114) .4) .2) 4.0) 27) 212) 9/11/10 90 Off Off 523 14.8 Hct chart chart 65% 9/13/10 2409 4247 694 51 17.2 15.6 2.4 Hct 47.5% 9/18/10 9/24/10 86 10/7/10 78 10/14/10 74 4132 1478 157 9.7 2.3 20 10/29/10 70 4281 1244 389 254 12.4 12.4 2.4

11/4/10 69 WBC 17.6 11/10/10 69 2039 680 461 130 9.1 9.1 1.9 58 Hct- 35% WBC 19.8 11/18/10 69 11/24/10 68 >2000 803 4.9 4.9 2.3 35 Hct- 32% 12/9/10 74 2085 432 552 1.9 1.9 1.7 Hct 39%

12/29/10 72 1608 260 649 38 0.4 0.4 Hct42% 1/6/11 72 256 1.9 1/12/11 75 135 1.8 1/26/11 79 343 112 259 1.7 2/10/11 76 2.0 3/3/11 80 186 213 310 .1 .1 1.8 27 Hct 47%

9/14/10 ultrasound: Liver is normal size with coarse, heterogenous texture. Gall bladder is small. Multiple ultrasound guided biopsies taken. 9/14/10 culture/sensitivity of Liver: negative 9/14/10 leptospirosis titer: negative 9/14/10 liver biopsy: Mild lymphoplasmacytic cholangiohepatitis with severe bile stasis and bridging fibrosis and biliary cysts. Biopsy remarks: There is evidence of mild inflammation but also with severe bile stasis. There is fibrosis, which is bridging from portal area to portal area. This is indicative of cirrhosis. Special stains for copper: Copper level: 790 (Normal reference range 100-300)

civtedu.org JIVT 2(1) March, 2012 20 Appendix 2. Medications at initial presentation (October 7, 2010)

SamAppendix E – 425 2. mg Medications BID at initial presentation (October 7, 2010) Silybin – 35 mg BID MetronidazoleSam E – 425 mg – BID500 mg BID ActigallSilybin – – 35 300 mg mg BID BID PrednisoneMetronidazole – 20 – mg500 BID mg BID LeukeranActigall – –300 2 mg mg EOD BID ColchicinePrednisone – – 0.6 20 mg mg daily BID OndanstsetronLeukeran – 2 mg – EOD8 mg – 2 tablets BID MirtazapineColchicine – –150.6 mgmg daily–1.5 tablets daily PepcidOndanstsetron AC – 10 mg– 8 mg– 2 tablets– 2 tablets BID BID SoloxineMirtazapine – 0.8 –15 mg mg BID –1.5 tablets daily Pepcid AC – 10 mg – 2 tablets BID Soloxine – 0.8 mg BID Appendix 3. Herbal formulas and medications used in treatment

DateAppendix instituted 3. Herbal formulasHerb/medication/supplement and medications used in and treatment dose 11/4/10 to 1/6/11 Xiao Chai Hu Tang – 3 tablets BID 11/4/10Date instituted to 12/29/10 SiHerb/medication/supplement Miao San – 3 tablets BID and dose 11/4/10 to present1/6/11 DenamarinXiao Chai Hu – 950Tang mg – 3 daily tablets BID 11/4/10 to present12/29/10 ZincSi Miao – 50 San mg – daily3 tablets BID 11/4/10 to present Hepagen-CDenamarin – 9502 tablets mg daily daily 11/4/10 to 12/29/10present CereniaZinc – 50 – mginjectable daily (3.1 cc) and tablets 120 mg daily for 3 11/4/10 to present days Hepagen-C or as needed – 2 tablets daily 11/4/10 to present12/29/10 VitaminCerenia B– injectable12 – 2 cc per (3.1 treatmen cc) and tabletst 120 mg daily for 3 12/15/10-12/25/10 Baytrildays or injection as needed – (75 mg) and tablets 68 mg BID for 7 days 12/15/1011/4/10 to present Subcutaneous Vitamin B 12 – lactated2 cc per treatmenringers 600t ml 12/29/1012/15/10-12/25/10 to present LiuBaytril Jun injection Zi Tang – – 3 (75 tablets mg) andBID tablets 68 mg BID for 7 days 1/6/1112/15/10 to present XiaoSubcutaneous Yao San – lactated2 tablets ringers BID 600 ml 12/29/10 to present Liu Jun Zi Tang – 3 tablets BID 1/6/11 to present Xiao Yao San – 2 tablets BID References (continued) Canine Clinical Nutrition, EU, Aniwa SAS, pp.

Marsden, S & Wynn, S 2003, Manual of Natural 146-147. Veterinary Medicine Science Wang WB, Xie XF. 2003. Analysis of 26 exam- Rutgers, C & Biourge, V 1996, ‘Nutrition of ples of treatment of functional dyspepsia with dogs with liver disease’,in Pibot, P, Biourge, V & Si Jun Zi Tang. Journal of Chinese Medicine Elliott, D 2006, Encyclopedia of Canine Clinical 11:1961: cited in Xie H. 2010. Xie’s Chinese Nutrition, EU, Aniwa SAS, p. 147. Veterinary Herbology. Ames, Iowa: Blackwell Publishing: p 307. Sokol, RJ 1996, ‘Antioxidant defenses in metal induced liver damage’, Semin Liver Xie H. 2010. Xie’s Chinese Veterinary Herbol- Dis, vol. 16, pp. 39-46, cited in Pibot, P, Bi- ogy. Ames, Iowa: Blackwell Publishing: p ourge, V & Elliott, D 2006, Encyclopedia of 307,309,357; 428-9; 418-419; 424-425. n civtedu.org JIVT 2(1) March, 2012 21 Integrative Management of the cough for over this time, however, the cough was still present. The previous Canine Allergic Bronchitis veterinary facility had performed thoracic with Veterinary Chinese radiographs that indicated end-on bronchi in the hilar region as well as a

Herbal Medicine mild interstitial pattern. Sydney has been Tom Schell DVM DABVP (eq) allergy tested via intra-dermal technique at a specialty facility and is receiving weekly desensitization injections for grass, mold and ragweed. She is fed an organic-type diet, high in grains with no supplementation of human foods. The owner is concerned about long-term steroidal usage as well as weight gain and increased water consumption, not to mention long-term health effects. Examination and clinical progression Sydney first presented to Timbercreek Veterinary Hospital on 8.12.2010 for evaluation of a chronic, dry cough that Abstract was being treated with daily prednisone A middle-aged Jack Russell Terrier, therapy. The cough was diagnosed as being diagnosed as having chronic allergic-type an allergic bronchitis after extensive intra- bronchitis with a dry cough, presented for dermal skin testing. She was receiving weekly alternative therapy options. Throughout desensitization injections as described above. the course of treatment, the patient’s The cough improved while on the prednisone dependence on steroidal medications but was still present. The owner’s concern was was decreased and she was transitioned Sydney’s overall health as well as weight gain to a lower dosage antihistamine/steroidal since starting the steroidal therapy. combination with the use of supplemental herbs. On the initial examination, there was a slight wheezing noted in the lung fields Signalment with normal cardiac auscultation. Sydney Sydney is a seven-year old spayed female Jack Russell Terrier, with a presenting was markedly overweight. There was a dry, weight of 10.2 kg. She was being medicated honking-type cough elicited on manipulation with 5.0 mg prednisone daily for control of of the trachea. She was currently being her cough. treated by her primary veterinarian for a moist Malassezia otitis with topical otic medications. Medical history Sydney presented for evaluation of a A complete blood count and chemistry panel chronic, dry cough that has been present showed the only abnormal value was ALKP for over two years. She has been on 5.0 (see Table 1), and was associated with chronic mg of prednisone daily to help control prednisone therapy. civtedu.org JIVT 2(1) March, 2012 22 Thoracic radiographs indicated a normal indicated a red tongue with moist, white tracheal diameter with no noted narrowing. coating. The pulses were rapid, thin and had There was a bronchial pattern in the hilar a slippery component bilaterally. The TCM region with end-on bronchi noted. There diagnosis of Damp Heat was made based was marked right heart enlargement, plus on the TCM examination, with a suspected hepatic enlargement with rounded margins Yin deficient component. The red tongue noted on both views. There was no evident is indicative of Heat while the white, moist compression of the trachea by the enlarged coating is reflective of Dampness. The heart, which, if present, would contribute rapid pulse implies Heat, while the thin to the cough. The Traditional Chinese component is suggestive of Blood or Yin Medicine (TCM) examination indicated Deficiency. The slippery component of the a red/dry tongue with very superficial, pulse also supports Dampness. rapid and thin pulses. TCM diagnosis of Yin The Yin Deficiency was suspected to be a Deficiency with deficient Heat present was result of the long-term prednisone therapy, based on the exam. The herbal formula Zhi which can be very drying in nature. The Yin Bai Di Huang Wan (ZBDHW) was started Deficiency could also be a result of long at 1 teapill per 10 lbs twice daily, or 60-75 term Spleen Qi Deficiency. The ZBDHW mg/kg split BID, to tonify Yin and reduce formula was discontinued due to concern deficient Heat. Enalapril 5 mg one daily was over worsening Dampness and the formula prescribed along with CoQ10 30 mg daily Si Miao Wan (SMW) was prescribed at 1 for overall cardiac support. teapill per 10 lbs twice daily to support the It was recommended that the owner Spleen, reduce Heat and resolve Dampness. continue the current prednisone therapy, The owner was advised to continue the but reduce the dosage to 2.5 mg once daily prednisone at 2.5 mg daily along with after one week if Sydney was well clinically. CoQ10 and Enalapril as described. She was started on a canned holistic tuna- Second follow-up based diet that was grain and preservative Sydney was rechecked in one month. The free. It was hoped the canned food would cough was improved per the owner and she be less heating to the body, more cooling in had been able to reduce the prednisone to nature and support the digestive process. 1.25 mg daily. Pruritus and chewing the feet First follow-up appeared to be reduced, but still present. Sydney presented in two weeks for a No cough was noted on examination and recheck examination. The cough was noted there was a slight wheeze in the lung fields, to be unchanged per the owner and she however, the moist component was also had reduced the dosage of the prednisone improved. TCM examination indicated as recommended. On examination, the a red-mauve colored tongue with moist cough was still present but more moist coating. The pulses were rapid, thin and in nature with some wheezing noted on wiry bilaterally. The TCM examination was auscultation. The owner reported that indicative of the presence of a Stagnant Qi, Sydney becomes congested when off Heat, Dampness and Yin/Blood Deficiency. prednisone and begins to chew at her feet At this time, the presence of Dampness was and scratch diffusely. The TCM examination not as pronounced. It was still believed that civtedu.org JIVT 2(1) March, 2012 23 the Yin Deficiency was present as a result of doing well. The chemistry panel was long-term prednisone usage. repeated and reflected improvement in ALKP values (see Table 1) secondary At this time, the decision was made to to herbal therapy and reduction in switch tactics. Sydney was changed to a prednisone usage. taper course of Temaril-P®1, a low dose antihistamine/prednisone combination, Herbal treatments in order to help reduce her reliance on a During the course of Sydney’s therapy, strictly corticosteroid product and minimize three herbal formulas were utilized to health side effects. The herbal formula was help control her condition and reduce changed to San Reng Tang (SRT), ½ tsp BID, dependence on corticosteroids. or 60-75 mg/kg split BID, in order to help reduce Heat, address Spleen support and The herbal formula Zhi Bi Di Huang Wan (8 further Dampness resolution. The herbal Flavors) was utilized to tonify Kidney/Liver formula was changed from SMW to SRT due Yin, subdue Deficiency fire and clear mild to a perceived decrease in the amount of Damp Heat. ZBDHW contains Shu Di Huang Heat present as well as reduced Dampness, (Rehmannia glutinosa) which nourishes negating the need for a strong formula Blood and Liver/Kidney Yin; Shan Yao such as SMW. (Dioscorea) tonifies Q, nourishes the Spleen and tonifies Yin; Shan Zhu Yu (Cornus) Third follow-up tonifies the kidney and liver; Mu Dan Pi Sydney was checked again in 30 days (Paeonia) clears Heat, cools the blood and and seemed to be doing much better per invigorates circulation; Fu Ling (Poria) the owner. She was currently on ½ tablet resolves Damp and supports the Spleen; Temaril-P® on an every-other-day dosage, Ze Xie (Alisma) resolves Damp and clears as well as the organic canned diet which deficient Heat; Huang Bai (Phellodendron) she was tolerating very well. She was still on clears Heat, dries Damp and sedates fire; the SRT formula in addition to the Enalapril Zhi Mu (Anemarrhena) clears Heat and and CoQ10 for cardiac support. The cough nourishes Yin (Wrinkle 2008 p. 116). This was markedly improved and frequency was formula was chosen based on a red/dry dramatically reduced. The overall pruritus tongue in addition to a rapid and thin was resolved as was the feet chewing and pulse, which implied a Yin Deficiency and otic infection. TCM examination indicated Heat presence. a red/pink tongue with slight moisture coating. The pulses were less rapid but still The herbal formula Si Miao Wan (Four slightly thin in nature. Marvels) was chosen to clear Heat and resolve Dampness. SMW contains Huang She was continued on SRT, the cardiac Bi (Phellodendron) which clears Heat and medications and Temaril-P® and is currently dries Damp; Yi Yi Ren (Coix) strengthens Table 1. Laboratory Values

Lab Value Normal Range 8-12-2010 10-21-2010 ALKP 23-212 U/L >2000 U/L 642 U/L civtedu.org JIVT 2(1) March, 2012 24

Appendix. TCM Examination Findings and Interpretation Physical examination Finding or History Possible TCM Diagnosis Weight Gain Dampness Polyuria Dampness ALKP elevation Liver Blood Deficiency Liver Qi Stagnation Dry cough Yin Deficiency Q Deficiency/Stagnation Moist otitis Damp Heat Moist cough Dampness Pruritis Damp Heat Tongue – red/dry Yin Deficiency with empty Heat Tongue – red/mauve with moisture Qi Stagnation Heat, Dampness Pulse – rapid/thin Yin Deficiency with Heat Pulse – wiry Qi s Stagnation

the Spleen, resolves Damp and clears that restoring the normal flow of Lung Qi Heat; Cang Zhu (Atractylodes) dries Damp helps to resolve Dampness (Chen 2009, p. and strengthens the Spleen; Huai Niu Xi 1093). The three seeds that help to unblock (Achyranthes) tonifies the Liver and Kidney the descent of Lung Qi, transform and and activates blood circulation (Wrinkle dry Damp in the Middle Burner as well as 2008, p. 58). SMW was chosen based drain Damp are: Apricot Seed, Coix Seed on the presence of a red, moist tongue and Cardamon (Marsden 2009, p. 120). The coating and a rapid pulse with a slippery SRT formula contains a similar component component, which indicated Damp Heat. to SMW formula, Coix, which has been SMW was shown to significantly inhibit previously documented to inhibit mast cell excessive production of NO, TNF-alpha, degranulation in allergic conditions. IL-6 and the overexpression of relative genes in LPS-stimulated macrophages Sydney was changed to an organic canned (Fan 2010). This action indicates that SMW tuna -based diet which was grain and has anti-inflammatory effects by reducing preservative free in order to help reduce pro-inflammatory cytokines which may be further Heat as well as tonify the digestive present in cases of allergic bronchitis. The process. The ZBDHW and SMW formulas ethyl acetate extract of Coix also exhibited were both dosed at 1 teapill per 10 lbs body potent inhibitory activity that suppressed weight twice daily, while the SRT formula degranulation and histamine release from was dosed at ½ tsp twice daily in the food, RBL-2H3 cells, which supports an inhibitory or 60-75 mg/kg split orally BID. effect on allergic responses (Chen 2010). Discussion The final herbal formula chosen was San Allergic bronchitis typically involves an Reng Tang (Three Seeds Combination) to inflammatory response within the airways, unblock the descent of Lung Qi, resolve usually due to an inhaled allergen. In mild Damp Heat and support the Spleen. chronic cases, excessive mucus is present SRT contains Xing Ren (Apricot) which within the airways which can lead to small arrests cough and relieves wheezing; Yi Yi airway obstruction. Chronic bronchitis is Ren (Coix) strengthens the Spleen, resolves generally treated symptomatically from Damp and clears Heat; Hua Shi (Talc) clears a western perspective, commonly using Heat and resolves Damp; Ban Xia (Pinellia) glucocorticoids, bronchodilators, cough dries Damp and redirects rising Qi; Bai Dou suppressants and antibiotics (Nelson Kou (Cardamon) regulates Qi, strengthens 1992, p. 295). the Stomach and dissolves Damp; Dan Sydney had originally presented for Zhu Ye (Lopatherum) clears Heat; Hou evaluation of a chronic dry cough that was Po (Magnolia) regulates Qi, reduces believed to be an allergic type of bronchitis Stagnation, dries Damp and relieves based on prior laboratory testing. The wheezing; Tong Cao (Rice Paper) resolves condition was mildly responsive to Dampness (Marsden 2009, p. 55). SRT was corticosteroid therapy, however, there finally chosen to continue to support the were concerns over increased water Spleen, resolve Damp Heat symptoms and consumption and weight gain while secondarily tonify Yin and Blood. It is noted on medications. The initial examination civtedu.org JIVT 2(1) March, 2012 25 indicated the presence of a Yin Deficiency, was chosen to continue to reduce Damp noted by a red/dry tongue and rapid/thin Heat, but to a lesser degree than SMW, and pulses. When the herbal formula ZBDHW to continue to support the Spleen. The was implemented to tonify Kidney Yin, patient was changed to a more tolerable along with reduced a reduced dosage of combination of an antihistamine and prednisone, Damp Heat signs became prednisone, reducing the clinical impact of apparent at the next recheck, noted by the medication, and the overall cough was a moist cough as well as chewing and much improved in the long term. pruritus. The prior history of a moist otitis In reviewing this case, it is now obvious was suggestive of a Damp Heat presence, that the underlying problem was likely a but was not considered early in the course Spleen Qi Deficiency, possibly related to of therapy. With the presence of Damp diet. The Spleen Qi Deficiency likely led to clinical signs, such as weight gain and Damp formation. This became prominent moist otitis, the initial choice of ZBDHW not only in the skin but in the lungs, was improper due to most Yin tonics being which then contributed to the cough. ‘cloying in nature’ and likely to contribute The accumulation of Dampness then led to Dampness. to the formation of Heat, which depleted Prednisone is thought to be drying and Yin over time. The prednisone therapy cooling in nature and thus can help aided the condition in drying Dampness to reduce the presence of Heat and and reducing Heat, but in the process, it Dampness, but with chronic use it can further depleted Yin. The Yin Deficiency be very Yin depleting to the body. After was the most prominent clinical sign in reducing the prednisone dosage, the the early stages, but efforts to tonify the Dampness that was being controlled was Yin resulted in exacerbation of the Damp now becoming more obvious and possibly signs. In the end, Spleen Qi tonification and aggravated by the richness of the ZBDHW Damp resolution yielded the best results formula. The tongue continued to be red, and allowed us to reduce prescription indicative of Heat, but began to show a corticosteroids. Tonification of Yin should very moist coating which was suggestive be a secondary event to Spleen tonification of Dampness, especially when considering over time. a slippery and rapid pulse. It is noted the Notes side effects of polyuria/polydypsia while 1. Temaril-P®, Pfizer Animal Health on corticosteroid therapy are indicative (Trimeprazine/Prednisone) of the presence of Dampness. The herbal formula SMW was implemented at this time References to address Damp Heat and appeared to be Chen, HJ et al. 2010, ‘Mast cell dependent successful with improvement in the cough allergic responses are inhibited by ethanolic as well as reduced pruritus. extract of Coix Lachryma’, J. Agric Food Chem., Feb 24, vol. 58, no. 4, pp. 2596-601. At the next recheck, the condition was improved with reduction in Heat and Chen, J & Chen, T 2009, Chinese Herbal Dampness signs but a continued need for Formulas and Applications, 1st edn, Art of support was still evident. The formula SRT Medicine Press, California. civtedu.org JIVT 2(1) March, 2012 26

Table 1. Laboratory Values

Lab Value Normal Range 8-12-2010 10-21-2010 ALKP 23-212 U/L >2000 U/L 642 U/L

Appendix. TCM Examination Findings and Interpretation Physical examination Finding or History Possible TCM Diagnosis Weight Gain Dampness Polyuria Dampness ALKP elevation Liver Blood Deficiency Liver Qi Stagnation Dry cough Yin Deficiency Q Deficiency/Stagnation Moist otitis Damp Heat Moist cough Dampness Pruritis Damp Heat Tongue – red/dry Yin Deficiency with empty Heat Tongue – red/mauve with moisture Qi Stagnation Heat, Dampness Pulse – rapid/thin Yin Deficiency with Heat Pulse – wiry Qi s Stagnation

Fan, J et al. 2010, ‘Modified si-miao-san extract inhibits the release of inflammatory “I LOVE the course. It is mediators from lipopolysaccharide stimulated mouse macrophages’, J. amazing. I’ve studied Ethnopharmacol, May 4, vol. 129, no. 1, pp. TCVM for 15 years – 5-9. including four years of human acupuncture Marsden, S 2009, Lecture Notes for IVAS Course college – and I think in Chinese Veterinary Herbal Medicine, 2nd that I am learning edn, Sydney. more in the CIVT course than I learned Nelson, R & Couto, C 1992, Small Animal Internal in all those years…” Medicine, 2nd edn, Mosby, St. Louis, Mo. CIVT student Wrinkle, A, Stropes, L & Potts, T 2008, A Marguerite Hernandez, VMD Practitioner’s Formula Guide, 1st edn, Elemental Essentials Publishing, California. n civtedu.org JIVT 2(1) March, 2012 27 Use Of Huo Xiang Zhing Qi San to date with deworming, heartworm, flea and tick prevention. Apparently he was fed for the Treatment of Recurrent only on yoghurt and nothing else as a pup Diarrhea in a Juvenile Poodle in Japan. The new owner tried switching Dr Grace S Y Li to a dry commercial diet but reversed back to yoghurt after Elgar first developed diarrhea in June, 2009. The diarrhea was mostly pasty to liquid in consistency, with occasional blood or mucus. The first clinic visited by Elgar treated him with courses of Flagyl (Metronidazole suspension) and prescriptive diet (Royal Canin Sensitivity Control). However, the response was transient according to the owner and the diarrhea relapsed on and off after treatments. At presentation on 13/06/2010, physical examination of Elgar revealed a body weight of 1.36kg, a thin body condition Abstract (BCS 1.5/5), subnormal body temperature A juvenile canine was presented with at 37C, mild mucoid ocular discharge, a chronic recurrent diarrhea. The symptoms lacklustre coat with bacterial collarettes, included inappetence, weight loss, lack of dermatitis, a significant amount of dental thriftiness and loose stools with occasional tartar on his teeth. In addition, he had bloody and mucoid discharge. an unusually depressed, quiet attitude Conventional medicine helped, but atypical for this breed and age. No other symptoms immediately recurred when abnormalities were detected at the time. discontinued. Herbal treatment Huo Xian The initial differential diagnosis included Zhing Qi San (Agastaches Rectify the Qi infectious bowel disease (IBD), bacterial Powder) was chosen to complement overgrowth and parasitic/infectious conventional medicine for a lasting effect enteritis. A simple in-house fecal on the loose bowl motions. flotation test was performed and was

negative for parasitic ova. Another fecal Signalment sample was requested two weeks later Elgar was an 18 months old, male for a comprehensive routine analysis entire, chocolate Teacup Poodle that included checks against giardia, imported from Japan. cryptosporidium, coccidia, as well as History and diagnosis aerobic and anaerobic culture and Elgar was purchased and imported into sensitivity tests. Urinalysis (Table 1) Hong Kong from Japan at a young age. revealed moderate proteinuria and He had been fully vaccinated and was up mild bilirubinuria. civtedu.org JIVT 2(1) March, 2012 28 TableTable 1. 1. Urinalysis Urinalysis In-House 10/7/2010 10/7/2010 The only significant finding was that clostridial species were found in the

Refractometer sg = >1.05 stool samples. Leukocytes = NEG Nitrite = NEG From a Traditional Chinese Medicine pH = 6.0 (TCM) perspective, Elgar’s tongue

Blood = NEG appeared to be pale indicating Blood or

Protein = +++ Qi (especially Spleen Qi) Deficiency. His Glucose = NEG skin was not very warm to touch and Ketones = NEG Urobilinogen = NEG his pulse was soft, slippery and weak, Bilirubin = ++ which also reflected deficiency and Microscopic exam = NAD poor peripheral circulation. Combined with the description of the diarrhea and Baseline blood test values (Table 2) were all dermatopathy, tentative TCM diagnoses within normal limits. were made, being Blood Deficiency,

TableTable 2. BaselineBaseline Blood Blood Profile Profile 10/7/2010 10/7/2010 Wei Qi Invasion, Spleen (Qi and Yang)

Test Results Reference range Deficiency and Dampness Accumulation. ALB = 26 g/l 23-40 Treatment ALKP = 111 U/L 23-212 ALT = 24 U/L 10-100 Table 3 (next page) summarizes the AMYL = 638 U/L 500-1500 medications and supplements prescribed UREA = 9.4 mmol/l 2.5-9.6 during the three visits by Elgar. After over Ca = 2.6 mmol/l 1.98-3 a year of chronic diarrhea which partially CHOL = 4.36 mmol/l 2.84-8.27 responded to conventional medications CREA = 58 umol/l 44-159 alone, Elgar was fully recovered within GLOB = 27 g/l 25-45 approximately one month of combined GLU = 5.73 mmol/l 4.11-7.94 therapy of diet change, antibiotics and PHOS = 1.42 mmol/l 0.8102.19 herbal treatments. TBIL < 3 umol/l 0-15

TP = 53 g/l 52-82 The original source of Huo Xiang Zhing Qi Na = 154 mmol/l 144-160 K = 4.1 mmol/l 3.5-5.8 San (Agastaches Rectify the Qi Powder) Cl = 120 mmol/l 109-122 can be found from Tai Ping Hui Min He HCT = 39.5 % 37-55 Ji Ju Fang (Imperial Grace Formulary of HGB = 14.1 g/dl 12-18 the Tai Ping Era), 1079-85. It contains 13 1 MCHC = 35.7 g/dl 30-36.9 components in total. Elgar was treated WBC = 12 x10/L 3.3-12 orally with 0.5g three times daily of the GRANS = 9.2 x10/L 3.3-12 preparation manufactured by Sheng Chun %GRANS = 77% Tang (SCT).2 NEUT ~ 8.4 x10/L 2.8-10.5 EOS ~ 0.8 % 0.5-1.5 For persistent enteric pathogens, the L/M = 2.8 x10/L 1.1-6.3 internal Dampness and chronic clostridial %L/M = 23 % infection may be best treated with HXZQS PLT > 308 175-500 over other choices. It is the author’s opinion civtedu.org JIVT 2(1) March, 2012 29 Table 3. Treatment Response

Date Therapy Response 13/6/2010 Diet change (whole food, low residue, high Diarrhea stopped within protein low carb diet), Klacid, probiotics, 48 hrs; then liquid slippery elm for two weeks. diarrhea developed when Klacid was stopped. 10/7/2010 Klacid, slippery elm, kao pectin, bonemeal Diarrhea stopped again powder, multivitamin, omega oil, Huo Xiang within 48 hrs. Dermatitis Zhing Qi San for two weeks. resolved. 14/7/2010 Phone consultation. No relapse when Klacid was stopped. 21/7/2010 Augmentin, Metronidazole (against Normal stools and clostridial spp.), HXZQS, probiotics for two weight gain. more weeks. 14/8/2010 Stopped all conventional treatments except No relapse when all probiotics and dietary supplements antibiotics were (multivitamin, omega oil, bonemeal powder). discontinued. Coccidia- free stools. Happy dog.

that formulas such as Si Miao San may version has a stronger action of dispelling be chosen for patients with more overt Dampness as it contains double the inflammatory signs; San Ren Tang perhaps percentages of Zi Su Ye, Bai Zhi, Fu Ling, and is a little too cooling for Elgar; Wei Ling Da Fu Pi. Tang is also a good Spleen tonic which fits From a TCM perspective, Agastaches (Huo the energetics, but perhaps not as effective Xiang) releases exterior wind-cold and against a deep-seated, invading pathogen dispels Dampness. Magnolia Bark (Hou Po) such as clostridia. Other formulas such as Yi and Areca husk (Da Fu Pi) activate Qi and Guan Jian, Liu Jun Zi Tang, Bu Zhong Yi Qi dispel Dampness. Tangerine peel (Chen Pi) Tang may be too tonifying in the beginning and Pinellia root (Ban Xia) dry Dampness, and may be only given after the pathogen/ harmonize Stomach and descend rebellious Dampness has been dispelled. Qi. Perilla leaf (Zi Su Ye) and Angelica root Included on the next page for comparison (Bai Zhi) release the exterior wind-cold and is the original composition listed from dispel interior Dampness and turbidity. Chen and Chen’s ‘Chinese Herbal Formulas White atractylodes (Bai Zhu) and Poria and Application’ (C&C).1 Note the original (Fu Ling) strengthen the Spleen, dispel composition might be more warming and Dampness, and harmonize the Middle Jiao. tonifying on Spleen as it contains almost Platycodon root (Jie Geng) ventilates the four times the amount of Zhi Gan Cao Lung and resolves Dampness. Ginger (Sheng by percentage weight. In contrast, SCT’s Jiang), Jujube (Da Zao) and Liquorice (Zhi

civtedu.org JIVT 2(1) March, 2012 30

Composition by SCT C&C weight % weight % Herba Agastaches (Huo Xiang) 3.0g 10 15g 15 Magnolia Bark (Hou Po) 2.0g 6.7 10g 10 Aged tangerine peel (Chen Pi) 2.0g 6.7 10g 10 Perilla leaf (Zi Su Ye) 3.0g 10 5g 5 Angelica root (Bai Zhi) 3.0g 10 5g 5 Poria (Fu Ling) 3.0g 10 5g 5 Pinellia rhizome (Ban Xia) 2.0g 6.7 10g 10 Balloon flower root/platycodon 2.0g 6.7 10g 10 root (Jie Geng) Areca husk, areca peel (Da Fu Pi) 3.0g 10 5g 5 White atractylodes rhizome 2.0g 6.7 10g 10 (Bai Zhu) Jujube, Chinese date (Da Zao) 1.0g 3.4 amount not specified Honey prepared liquorice 1.0g 3.4 12g 12 (Zhi Gan Cao) Fresh ginger rhizome 3.0g 10 amount not specified (Shen Jiang)

Gan Cao) regulate the Spleen and Stomach hours and Elgar would become transiently and harmonize the herbs in the formula.3 happier and more energetic while on antibiotics. The diarrhea returned after Therefore, the overall actions of this completing the first two weeks of Klacid formula are to release the exterior, regulate (Clarithromycin 125mg/5ml). Klacid and Qi, harmonise Middle Jiao, expel Dampness slippery elm powder were chosen for taste and transform Damp turbidity. It is and ease of administration during the indicated for exterior cold-Damp, and deep- first visit. After further discussion on the seated interior Dampness accumulation second visit, Elgar’s owners agreed to treat in the Stomach and Intestines which 4 him with Chinese herbs using HXZQS and blocks the Middle Jiao . This manifests as a completely 100 percent home-made weakness, cold aversion, chronic diarrhea, diet supplemented with multivitamins, pale tongue and deficient pulse, as it did in probiotics, omega oil and bonemeal this case. powder, in addition to the current Results conventional medications. Two weeks later, Table 3 summarizes the response his stools remained normal; he started to corresponding to the time of treatments. gain weight and became more energetic. As expected by the owner, the diarrhea The fecal culture and sensitivity results resolved whenever antibiotics were given came back much later when Elgar was to Elgar. The diarrhea stopped within 48 already doing much better. The clostridial

civtedu.org JIVT 2(1) March, 2012 31 species isolated were found to be Pi, Zi Su Ye have aromatic oils which act resistant to Klacid all along, despite the as an disinfectant; Hou Po has a stronger clinical improvement shown by Elgar. antimicrobial action; Ge Gan works as an After discussions with Elgar’s owner, they antispasmodic and can increase phagocytic decided to play safe and not risk another ability. This formula also has anti-allergic relapse with the dog on HXZQS alone. A ability, for example Zi Su Ye, Chen Pi, final course of antibiotics (Augmentin + Liquorice are useful against external Metronidazole) which tested sensitive to 3 pathogenic attacks. clostridia was given against clostridiosis. When combined with HXZQS, the diarrhea The main Chinese pathophysiology did not relapse after the antibiotics were mechanism underlying this case is finished, much to the owner’s relief. Spleen Qi Deficiency, which results in Two months after the initial consultation, the accumulation of Dampness in the Elgar remained diarrhea-free and had Stomach and Intestines of the Middle become a much happier dog according Jiao/Burner. The poor diet since young to the owner. A final fecal culture and likely weakened the Spleen function and sensitivity test was repeated and no aggravated/depleted Kidney Qi. In the bacterial pathogens were found. cooking pot analogy as described by Dr Steve Marsden, the Middle Burner is Discussion responsible for the continuous production In terms of scientific research into HXZQS, of Qi and Fundamental Substances.6 Stasis it has been shown to be an extremely in the Middle Burner hence blocks clear Qi effective formula for the treatment of from moving upward and turbid Qi from 1 gastroenteritis. It has antispasmodic and moving downward, and it can become a antiemetic activities by relaxing the smooth self-propagating pathology. As Dampness muscle of the gastrointestinal (GI) tract. accumulates, it causes further obstruction Research with rabbits and dogs show the at the Spleen and Stomach. Pathological ability to regulate GI tract smooth muscle Damp or Yin increases and (Spleen/ motility, relieve GI spasm and help to lessen Kidney) Yang decreases, leading to less 5 colic pain. In addition, it is antifungal, heat for the cooking pot to produce antibacterial and has broad spectrum Fundamental Substances. inhibitory activity against candida, Staphylococcus aureus, Salmonella typhi, There is another self-propagating cycle bacillus species E.coli, pseudomonas and that we may detect in Elgar’s case, even some dermatophytes.1 though it is less obvious and of a lesser degree clinically. The poor diet contributed Huo Xiang contains aromatic, volatile oils to a mild form of Liver Blood Deficiency as and various flavone compounds which shown by the pale tongue, weak pulse, and have antimicrobial, antifungal actions, plus cold extremities. Liver Blood Deficiency can the ability to promote digestion by gastric lead to Liver Qi Stagnation, which impairs acid secretion as well as to suppress upper the transformation and transportation respiratory tract infection (URTI). Chen functions of the Spleen further. civtedu.org JIVT 2(1) March, 2012 32 To summarise, the TCM diagnosis of Spleen diarrhea for more than one year and had Qi/Yang Deficiency, Blood Deficiency a long history of relapses each time after and Dampness Accumulation need to be conventional drugs were discontinued. addressed. Treatment principles hence are He responded within two weeks of to clear Dampness, harmonise the Middle introducing the herbal formula and Burner, activate Qi and strengthen Spleen. remained free of his symptoms thereafter. The selection of a suitable herbal formula The successful outcome may be due is important as it should act on multiple to the combined therapy of a suitable organs and solve multiple problems diet change and introducing an herbal simultaneously. remedy to ensure a lasting recovery. Conclusion This avoided prolonged courses of The two most frequent culprits antibiotics, steroids or further invasive of clostridial enteritis in dogs are diagnostic procedures such as gut biopsy Clostridium difficile and Clostridium which are commonly recommended for perfrigens. These gram-positive IBD patients. anaerobes are capable of producing References endospores which can survive 1 stomach acid to cause disease in the Chen, JK & Chen, TT 2004, Chinese colon. C. difficle is resistant to most Herbal Formulas and Applications. Art of antibiotics and without prior culture Medicine Press, pp.1079-1082. and sensitivity testing, some common 2 Sheng Chun Tang Pharmaceutical antibiotic treatments can actually make Industrial Co Ltd, Taiwan, phone + 886-6- it possible for C. difficile to overgrow other bacteria in the dog’s gut and cause 2325155-7. pseudomembranous colitis. C. perfrigens 3 Chen, JK & Chen, TT 2004, Chinese is a part of the normal flora and it is Medical Herbology and Pharmacology. Art often found in sick dogs without being of Medicine Press, pp. 43-44, 81-83, 365- the cause of the illness. Therefore, IBD cannot be ruled out and one should still 369, 479-481, 867-871. tackle this case integratively with the 4 Marsden S 2008, Chinese Veterinary correct antibiotics, food therapy and Herbal Medicine Lecture Notes. College of supportive alternative therapies, such as Integrative Veterinary Therapies, pp. 3-16, Chinese herbs. 22-24. The patient diagnosed with suspect 5 IBD and clostridial enteritis had Chinese Medical Research Centre Editing a comprehensive work up with Group (2002), Sheng Chun Tang Quick conventional diagnostic procedures Guide to Formulas, 4th edn, pp. 464-465. and was treated integratively with both 6 conventional medications and an herbal Marsden, S & Wynn, S 2002, Manual of formula named Huo Xiang Zheng Qi Natural Veterinary Medicine: Science and San. This dog suffered from chronic Tradition, Mosby, Missouri. n civtedu.org JIVT 2(1) March, 2012 33 Clinical Pearls of Wisdom I have formulated this combination for Priceless pearls from CIVT faculty several patients and have been impressed members with its efficacy and safety. l100 mls l Echinacea 1:2 20 ml l Glycyrrhiza glabra 1:1 or 1:2 20 ml l Hyperiucm perforatum standard extract 20 ml l Thuja accidentalis 1:5 10ml l Uncaria tomentosa 1:2 30ml l Dose 0.5 1 ml per 10lb/5kg twice daily You could also use lemon balm tea topically. I’ve seen patients which chronic papillomas respond within days, they just drop off. This could be coincidental, Saw Palmetto for Urethral Obstruction however, most patients seen have a Dr Steve Marsden history of previous surgical removal or Dr Steve Marsden suggests using saw chronicity over months. palmetto, Serenoa repens/serrulata, for Gaining TCM Insights from Lab Results urethral obstruction in order to abort Dr Steve Marsden impending obstruction. He uses a glycerite at 3-5 ml every 30-60 minutes Using Biochemistry and Hematology to until the cat urinates, then scales help with TCM diagnosis: back. The liposterolic components are l Low RBC, platelets or WBC: Blood extracted into glycerin and urethral deficiency relaxation is confirmed by ultrasound. l Low Liver enzymes, BUN, cholesterol or albumin: Liver Blood deficiency Herbal Treatment for Multiple Papillomas l Mild to moderate liver enzyme in Dogs elevations: Liver Blood deficiency Dr Barbara Fougere l High ALP: Damp Heat l Splenomegaly (due to neoplasia Dogs that present with multiple or immune reactions): Triple Burner papillomas, oral or otherwise, can be Obstruction treated with herbs that have documented l High triglycerides: Damp or Blood stasis systemic antiviral activity. These include l Amylase/ lipase elevations: Middle Jiao St Johns Wort, echinacea, pau d’arco, disharmony thuja and cats claw. Topical herbs include l Ultrasound – hyperechoic or large licorice, calendula and lemon balm. St organs: pathological excess, eg Qi or Johns Wort is not considered effective for Blood stasis, Damp Heat naked viruses, papovaviruses, (warts) but l Ultrasound – hypoechoic or small I have included it as an anti-inflammatory, organs: deficiency in substance stored by vulnerary herb. that organ, eg Kidney essence. n

civtedu.org JIVT 2(1) March, 2012 34 Monograph: Alkaloids (eg ergotamine). The name may derive from Holly Mash BVSc IVAS MRCVS the discoverer’s name, eg lobeline (after L’Obel), or from its physiological action (eg emetine). Alkaoids are found in 15-30% of all flowering plants and are particularly abundant in the Fabaceae, Lilacea, Ranunculaceae, Solonaceae and Papaveraceae families. They include the well-known substances that many may take every day: caffeine and nicotine, as well as the medical drugs morphine and cocaine. The most widely occurring alkaloids are caffeine and berberine. While the higher plants are the major source of alkaloids, they are also known to occur in lower Introduction plants such as horsetails, in algae, fungi, Alkaloids are a highly potent class of microorganisms and in insects. Over 10,000 secondary metabolites in plants that have different alkaloids have been isolated from been used as medicines for centuries. over 300 plant families. They may be found Alkaloids are heterocyclic, contain nitrogen, in roots, rhizomes, leaves, bark, fruit or generally have a potent action and are of seeds. More than 40 alkaloids may occur in limited distribution in nature. Although a single plant. their role in plants is not fully understood, Chemistry alkaloids are generally believed to be an Alkaloids are a large and diverse group evolutionary defense measure against of chemical compounds that are not herbivores, insects and pathogens such as easy to classify. Their actions are highly bacteria, fungi and viruses. Other possible specific, with each alkaloid having unique roles include transfer of growth factors properties. However, certain alkaloid and transfer or storage of specific acids, groups tend to be confined within certain as alkaloid levels have been shown to be plant families and are usually grouped higher at times of rapid growth. according to their chemical structure. The term alkaloid was first applied by Typical alkaloids are alkaline organic Meissner, a German pharmacist and derives compounds containing one or more from the fact that early isolates from nitrogen atoms, each connected to at least plants were alkaline in nature. However, two carbon atoms within a heterocyclic not all alkaloids are alkaline. The names of ring system. Most alkaloids are derived at most alkaloids end in –ine, but they may least partly from amino acids as their direct originate from the generic name of the precursors, while a few are derived from plant (eg., hydrastine), from a specific name isoprene units (terpenoids). Alkaloids are (eg cocaine), or from the common name generally insoluble in water (the notable civtedu.org JIVT 2(1) March, 2012 35 exception is caffeine) and soluble in alcohol. and hypotensive effects. The only rule Alkaloid salts are more water-soluble which common to alkaloids is that they all tend to led to their historical use as anaesthetic be potent in their actions; hence very small agents, being added to the organic solvents doses exert significant clinical effects. ether and chloroform. Some well-known alkaloids, such as Alkaloids have variable bioavailability, atropine (in Belladonna) and datura (in frequently being oxidized by the Thornapple species) in the Nightshade, or cytochrome P450 enzyme system in Solonaceae, family contain atropine and the liver to form N-oxide compounds scopolamine. These are tropane alkaloids that are non-toxic and water soluble. In and muscarinic receptor antagonists. The addition, they are irreversibly bound and strong anticholinergic activity of these are precipitated by tannins, which is why herbs is responsible for their muscle they should never be combined in a herbal relaxant action and their use in the formula as they would not be absorbed. treatment of smooth muscle spasm and In certain circumstances this precipitation associated pain. can be usefully harnessed, such as for the treatment of alkaloid toxicosis or overdose.

Pharmacology and potential veterinary indications A key feature of alkaloids is their strong bitter taste and, because many act as poisons in their natural state, this is nature’s way of reminding animals they should not be eating the plant. As well as a deterrent, the bitter taste of most alkaloids acts as digestive stimulant. Many have the ability to cross the blood brain barrier, giving central nervous system effects that are either stimulatory or depressant. In Another group of alkaloids are the purine fact, much of our understanding of the alkaloids, which are methylated xanthines mechanisms of neurotransmitters and that form weak, pharmacologically active receptor sites comes from research into the bases. There are three methylxanthines, all pharmacodynamics of alkaloids. of which are present in the most popular stimulant beverages —coffee and tea. Nowadays alkaloids are widely used Caffeine is found in a number of botanically either as isolated compounds or as semi- unrelated species, including Coffea arabica synthetic derivatives in the pharmaceutical (Rubiaceae), Camellia sinensis (Theaceae) or industry. Their diverse array of actions tea, Cola nitida (Sterculaciaceae - pictured includes analgesia, local anesthesia, cardiac above) or kola nut and Paullinia cupana stimulation, respiratory stimulation and (Sapindaceae) or guarana. Caffeine is bound related vasoconstriction, muscle relaxation, to chlorogenic acid in raw coffee beans with toxicity, anti-neoplastic as well as hyper- the roasting process liberating the caffeine civtedu.org JIVT 2(1) March, 2012 36 and other compounds that contribute to have potential action to enhance immune coffee’s aroma. Purine alkaloids generally function and help fight infection. The exert a stimulating effect on the therapeutic uses of isoquinoline alkaloids nervous system. mirror these effects. They are used in animals with bacterial or viral infections Caffeine is a central nervous system and to support those that are weak and stimulant, enhancing alertness and immunocompromised. Studies show it overcoming fatigue. High doses lead is likely all the plants’ constituents have to insomnia and tremors. It stimulates synergistic actions as whole extracts are cardiac output and heart rate and acts as a as effective as alkaloid constituents alone mild diuretic. Caffeine raises metabolism, (Fougere & Wynn, p. 176). influences blood sugar and is habit forming. It is sometimes used in formulations for The final group is the indole alkaloids. These treating migraine. Theophylline is a purine typically involve multiple, often complex, alkaloid in the tea plant and is structurally carbon-ring structures and form the basis and pharmacologically similar to caffeine. of several pharmaceutical drugs as well as The main medical use for theophylline is some of the most potent hallucinogenic as a bronchial smooth muscle relaxant drugs. The indole alkaloids include for the treatment of bronchial asthma catharanthine, vinblastine and vincristine and emphysema. (from Madagascar periwinkle), ergotamine (from rye ergot), reserpine, yohimbine, The next group to consider is the strychnine and the hallucinogen, harmaline isoquinoline alkaloids, most frequently (found in Passiflora incarnata and tobacco). found in the Papaveraceae (eg papaverine), Serotonin is another indole alkaloid and is Berberidaceae and Ranunculaceae families. found in bananas, tomatoes and hairs of the This is a very large class of medicinally stinging nettle. active alkaloids and includes curare, morphine and codeine from the opium Herbal Toxicity and Cautions poppy, berberine (in Barberry, Coptis and All alkaloid-containing plants are Goldenseal – pictured), canadine and potentially toxic substances and should be hydrastine (from Goldenseal), emetine treated with care at all times. As alkaloids (from Ipecac) and sanguinarine (from are extremely reactive, even at small doses, Bloodroot). Properties of isoquinoline most alkaloid-rich plants are used sparingly alkaloids are extremely variable. as medicines. Indeed, use of many of the Reported pharmacological properties alkaloidal species is restricted by law, include antispasmodic, antimicrobial, or listed on poison schedules in certain antitumour, antifungal, anti-inflammatory, countries. cholagogue and hepatoprotective, antiviral, amoebicidal and antioxidant actions. It has An important group of alkaloids are been shown these alkaloids act to inhibit potentially highly toxic to the body, these oxidation and the activity of pathogenic are the pyrrolizidine alkaloids (PA) that can bacteria (reducing their ability to adhere to cause hepatotoxicity. Plant families known cell surfaces), as well as stimulating bone to contain PAs include the Asteraceae and marrow leukocyte production. Hence they the Boraginaceae (plus a few members civtedu.org JIVT 2(1) March, 2012 37 of other plant families). However, toxicity the leaf used in teas. It is a perennial that is mainly found in unsaturated PAs. This may grow to 12 inches and usually blooms occurs when hepatic cytochrome P450 after its third year to produce a single converts them to a toxic N-oxide. white-green flower with no petals. The flower becomes a single raspberry-like fruit Hepatic damage by PAs is due to veno- in summer. occlusive disease, cirrhosis and cancer. The degree of susceptibility varies amongst Chemical composition: isoquinolone alkaloids (hydrastine), protoberberine species. Although horses and cows are alkaloids (berberine, berberastine, believed to be the most susceptible species, canadine), phenolic acids and resin. Symphytim officinale (Comfrey) has been traditionally used as part of their feed, Energetics: bitter, cold, clears heat and likely due to low levels of unsaturated toxins and dries damp. King’s American PAs it contains. Comfrey and other plants Dispensatory notes it is useful for containing PAs, such as borage (Borago improving blood circulation in cases where officinalis), coltsfoot (Tussilago farfara) and there is stasis. liferoot (Senecio) are restricted to use by Traditional use: the Cherokee were said to herbalists in many countries, (eg the UK) have used Goldenseal for treating cancer, and are banned in others. as a wash for localized inflammation, for dyspepsia, as a tonic and a dye. A principal In addition, steroidal alkaloids (found in indication was for inflammation and the Liliaceae and Solanaceae families) ulceration of mucus membranes in the contain potentially toxic glycoalkaloids. gastrointestinal or reproductive tracts. It These substances are mainly concentrated was used in treating liver disease, to help in unripe fruits and green potatoes and stop bleeding after parturition and in disappear during ripening. Steroidal sinusitis. Goldenseal was also indicated for alkaloids are toxic so avoiding sprouting treating diarrhoea, presumably due to its potatoes and unripe tomatoes is antimicrobial and antigiardia actions. Titus recommended. As there is evidence of (1865) recommended Goldenseal as being teratogenicity, this recommendation is very important for farm animals as a tonic particularly pertinent to pregnant women. and alterative. Selected alkaloid monograghs: Veterinary uses: Goldenseal can be Goldenseal used in the treatment of gastrointestinal Source: Hydrastis canadensis, native to North America; traditional names are Indian complaints such as stomatitis, gastritis Tumeric and Ground Raspberry. It is now an and colitis. It can be used to treat enteric endangered species and highly threatened pathogens, such as giardia, and bacterial in the wild, therefore it is important to buy overgrowth. In addition, Goldenseal may Goldenseal from sustainable sources only be used as an eyewash for bacterial or and not buy wildcrafted products. It is in other infectious conjunctivitis cases and the family Ranunculaceae and the yellow topically to treat bacterial and fungal coloured roots and rhizome are used, with skin complaints.

civtedu.org JIVT 2(1) March, 2012 38 Potential interactions and cautions: in rheumatism and circulatory disorders, not to be used in very young animals or to help bring blood flow to the periphery. those with high blood pressure. There Prickly Ash may be indicated, for example, are theoretical concerns about using in conditions where there is coldness and Goldenseal for patients with liver and cramping in peripheral muscles. cardiovascular disease. Safety in pregnancy Potential interactions and cautions: it and lactation has not been established. should not be used in pregnancy, lactation

or for patients with gastric ulcers. Nausea is possible in clinical patients. No interactions with drugs have been noted. References Bone, K, A Clinical Guide to Blending Liquid Herbs Carter, AJ 1996, ‘Narcosis and Nightshade’, British Medical Journal, vol. 313, p. 7072 College of Integrative Veterinary Therapies, 2011, Course Notes Fougere, B & Wynn, S 2007, Veterinary Herbal Medicine, Mosby Elsevier Prickly Ash Source: Zanthozylum clava-herculis Pengelly, A 1996, The Constituents of medical (common names Toothache bark and plants, Sunflower Herbals n Hercules club). This plant is found all over the United States with different species in the north and south. It is in the Rutaceae family and the bark (sometimes berries) is vbma used medicinally. Energetics: pungent, warm and bitter. graduate Chemical composition: amides (herclavin and others), lignans and program in benzophenathridrine alkaloids (chelerythrine, nitidine and others). of western Traditional use: native North Americans veterinary bioregulatory veterinary used the bark topically for toothache and medicine course skin problems. herbal Veterinary use: Its actions are a topical now available on demand! anodyne, anti-inflammatory, antirheumatic, see the website for details: medicine bitter tonic, diaphoretic and circulatory stimulant. Hence it has indications for use www.civtedu.org/courses start now or join the next “I am still loving this course”. Dr Kris August, USA civtedu.org JIVT 2(1) March, 2012 39 group in 2012! “I cannot praise this Do chronic cases frustrate you? Don’t you wish there was stimulating, exciting and something more you could offer? Then learn how to expand your fascinating course treatment options with Western Herbal Medicine. Developed in highly enough!” collaboration with VBMA, Drs Susan Wynn and Barbara Fougere Dr Holly Mash, UK (authors of the textbook Veterinary Herbal Medicine) are your “I am enjoying this teachers on this course. This comprehensive program bridges course enormously.” tradition and science and will develop your expertise to safely Dr Astri Hagenlord, Norway and effectively integrate herbal medicine into your practice.

n Online learning – study when it suits you n Case support throughout n Recognition of prior learning available n VBMA members receive a 5% discount n Free VBMA & CIVT membership if enrolling in whole course

For more information, or to enroll online, visit: civtedu.org [email protected] evidence based natural medicine Monograph: Radix Astragali for muscle numbness secondary to Blood/ Mary Ellen Sayre DVM Qi Deficiency (Chen & Chen 2004). Modern research/TCM use The root of Astragalus membranaceous contains flavonoids, saponins and polysaccharides (Dharmananda 2006).

Flavonoids (formonenonetin, ononin, calycosin and calycosin-7-0-β-d-glucoside) have been shown to enhance glucose consumption in adipocytes, improve insulin sensitivity and lower lipids (Zhao et al. 2011), as well as stimulate erythropoietin (Zheng et al. 2011), protect the myocardium against infarction injury (Zhang S et al. 2011) and prevent tumor growth of human breast cancer cells (Chen et al. 2011). This Astragalus membranaceous, Astragalus group of chemicals would appear to Tonify root, Huang Qi Qi (particularly Wei Qi) and to Tonify Blood. Description and classification The Astragalus saponin Astragaloside IV This is the dried root of Astragalus has been shown to suppress the growth membranaceous, a perennial herb from of human colon cancer cells (Auyeung Inner Mongolia, and the Shanxi, Gansu and et al. 2010), induce apoptosis of gastric Heilongjiang provinces of northern China. adenocarcinoma cells (Auyeung et al. 2011), It is used in Traditional Chinese Medicine reduce blood pressure and triglyceride and, within this realm, it is classified as a Qi- levels in induced metabolic syndrome Tonifying Herb (Chen & Chen 2004). in rats (Zhang N et al. 2011), and reduce cochlear damage in guinea pigs via the TCM properties ability to prevent the formation of reactive Radix Astragali is considered sweet and nitrogen species (Xiong et al. 2012). This slightly warm and it enters the body saponin has strong anti-inflammatory through the spleen and lung channels properties helpful in preventing asthma (Chen & Chen 2004). attacks (Yuan et al. 2011). This group of TCM indications chemicals supports Lung Qi and appears to This herb is used primarily as a Qi Tonic and regulate the Triple Burner. Yang supporter. It is useful for Spleen Qi Astragalus polysaccharide (APS) can Deficiency, internal organ prolapse, Lung Qi improve energy, nausea, pain and appetite Deficiency, Blood Deficiency secondary to during chemotherapy (Guo et al. 2011). Qi Deficiency and Qi Deficiency caused by Additionally, APS stimulates the production chemotherapy and radiation. It is also used of GM-CSF, TNF-α and NO through to Tonify Wei Qi, induce diuresis (in cases of increased binding with macrophages (Zhao edema due to Yang or Qi Deficiency) and al. 2011) and has been shown at doses of civtedu.org JIVT 2(1) March, 2012 40 200mg/kg in dogs to significantly increase CD4+ cells, CD8+ cells, INF-γ and IL-2 (Qiu et al. 2010). Through their documented effects, these polysaccharides could be said to treat Qi Deficiency secondary to chemotherapy, Tonify Wei Qi, and act as a general Qi Tonic. Potential veterinary uses l Chemotherapy adjuvant, both for preventing side effects and suppressing cancer cell growth of some cell lines Auyeung, KK, Woo, PK, Law, PC & Ko, JK l Asthma-anti-inflammatory 2011, ’Astragalus saponins modulate l Diabetes mellitus cell invasiveness and angiogenesis in l Bone marrow disorders such as human gastric adenocarcinoma cells’, J. myelodysplasia, anemia, bone marrow Ethnopharmacol, Aug 12 (Epub ahead of toxicity print). l Infectious disease Chen, John K & Chen, Tina T 2004 Chinese l Congestive heart failure Medical Herbology and Pharmacology, Dosage in animals City of Industry: Art of Medicine Press, Dried herb: 60mg/lb tid Inc, pp. 847-852. Tincture: 1.0-2.0 mL per 10kg (20lb) Chen, J, Zeng, J, Xin, M, Huang, W & Chen, divided daily (optimally TID) and diluted or X 2011, ‘Formononetin induces cell cycle combined with other herbs. Higher doses arrest of human breast cancer cells via IGF1/ may be appropriate if the herb is used by PI3K/Akt pathways in vitro and in vivo’, itself and not combined in a formula (Wynn Horm Metab Res, vol. 43, no. 10, pp. 681-6. & Marsden 2003). The safety dose in dogs has been shown to be up to 2.85-19.95 g/kg Dharmananda, Subhuti 2006, ‘Astragalus: (Yu et al. 2007). Practical Aspects of Administering the Herb’, http://www.itmonline.org/herbs.htm. Precautions/Drug interactions Guo, L, Bai, SP, Zhao, L & Wang, XH 2011, Due to its ability to stimulate the immune ’Astragalus polysaccharide injection system, Astragalus should not be used in integrated with vinorelvine and cisplatin for combination with immunosuppressive patients with advanced non-small cell lung medications such as cyclophosphamide cancer: effects on quality of life and survival’ and corticosteroids. Med Oncol, Sep 18 (Epub ahead of print).

References Qiu, H, Cheng, G, Xu, J, Zhang, N, Liu, F, Auyeung KK, Mok NL, Wong CM, Cho CH, Ko JK Zhu, X, Zhao, J & Zhang Y 2010, ‘Effects 2010. ‘Astragalus saponins modulate mTOR and of Astragalus Polysaccharides on ERK signaling to promote apoptosis through Associated Immune Cells and Cytokines in the extrinsic pathway in HT-29 colon cancer Immunosuppresive Dogs’, Proced Vaccin, cells’, Int J Mol Med, vol. 26, no. 3, pp. 341-9. Vol. 2, no. 1, pp. 26-33. civtedu.org JIVT 2(1) March, 2012 41 Wynn, Susan & Marsden, Steve 2003, fatty acid esters with anti-adipogenic Manual of Natural Veterinary Medicine, and enhancing glucose consumption Science and Tradition, St. Louis, MO, activities’, Bioorg Med Chem, vol. 19, no. Mosby, p. 626. 10, pp. 3192-203. Xiong, M, He, Q, Lai, H & Wang J 2012, Zheng, KY, Choi, RC, Cheung, AW, Guo, AJ, ’Astragalus IV inhibits apoptotic cell death Bi, CW, Zhu, KY, Fu, Q, Du, Y, Zhang, WL, in the guinea pig cochlea exposed to Zhan, JY, Duan, R, Lau, DT, Dong, TT & Tsim impulse noise’, Acta Otolaryngol, Jan 4 KW 2011, ’Flavonoids from Radix Astragali (Epub ahead of print). induce the expression of erythropoietin in cultured cells: a signaling mediated via the Yu, SY, Ouyang, HT, Yang, JY, Huang, XL, accumulation of hypoxia-inducible factor- Yang, T, Duan, JP, Cheng, JP, Chen, YX, Yang, 1α’, J. Agric Food Chem, vol. 59, no. 5, pp. YJ & Qiong P 2007, ’Subchronic toxicity 1697-704. n studies of Radix Astragali extract in Rats and Dogs’, J Ethnopharmacol, vol. 110, no. 2, pp. 352-5. Yuan, X, Sun, S, Wang, S & Sun Y 2011, vbma ’Effects of astragaloside IV on IFN-gamma level and prolonged airway dysfunction in graduate a murine model of chronic asthma’, Planta Med, vol. 77, no. 4, pp. 328-33. program in Zhang, S, Tang, X, Tian, J, Li, C, Zhang, G, Jiang, W & Zhang Z 2011, of western .’Cardioprotective effect of sulphonated formononetin on acute myocardial veterinary infarction in rats’, Basic Clin Pharmacol Toxicol, vol. 108, no. 6, pp. 390-5. herbal Zhang, N, Wang, XH, Mao, SL & Zhao F 2011, ’Astragalus IV improves metabolic medicine syndrome and endothelium dysfunction in fructose-fed rats’, Molecules, vol. 16, no. 5, graduatestart now programor join the in next “I am still loving this course”. pp. 3896-907. Dr Kris August, USA westerngroup veterinary in 2012! Zhao, LH, Ma, ZX, Zhu, J, Yu, XH & Weng DP “I cannot praise this 2011, ’Characterization of polysaccharide Do chronicherbal cases frustrate medicine you? Don’t you wish there was stimulating, exciting and something more you could offer? Then learn how to expand your fascinating course from Astragalus radix as the macrophage treatmentEnroll now! options Begin with Western studying Herbal immediately Medicine. Developed in highly enough!” stimulator’, Cell Immunol, vol. 271, no. 2, pp. collaborationand get with a head VBMA, Drsstart, Susan or Wynnbegin and with Barbara Fougere Dr Holly Mash, UK 329-34. (authorsthe of nextthe textbook intake Veterinary in January Herbal 2012. Medicine) are your “I am enjoying this teachers on this course. This comprehensive program bridges course enormously.” Zhao, W, Sun, J, Xiang, H, Zeng, YY, Li, XB, tradition and science and will develop your expertise to safely www.civtedu.org/courses Dr Astri Hagenlord, Norway Xiao, H, Chen, DY & Ma RL 2011, ’Synthesis and effectively integrate herbal medicine into your practice. and biological evaluation of new flavonoid n Online learning – study when it suits you n Case support throughout civtedu.org JIVT 2(1) March, 2012 42 n Recognition of prior learning available n VBMA members receive a 5% discount n Free VBMA & CIVT membership if enrolling in whole course

For more information, or to enroll online, visit: civtedu.org [email protected] evidence based natural medicine Holly’s Herb Walk l Use the crushed or chewed fresh leaf as a Holly Mash BVSc IVAS MRCVS vulnerary on wounds to speed healing. l Recent studies show Vervain helps British veterinarian and CIVT student, (along with Self-Heal) to normalize thyroid Holly Mash takes a stroll around her hormones – therefore, it may be useful in Bristol home, identifying the local herbs. conditions of the thyroid gland.

Vervain (Verbena Officinalis) Tansy (Tanacetum Vulgare) Family: Verbenaceae Family: Asteraceae Genus: Verbena Genus: Tanacetum Parts used: leaves Identification and flowering heads l Tansy is not native to the United Kingdom, it comes from Europe and is cultivated for Identification medicinal use. l There are no other l In midsummer, Tansy produces a flat wild members of bunch of yellow, button-like flower heads. the Verbena family These consist of disc florets that look like a found in the United daisy without petals. Kingdom. (NB: l Tansy is in the Asteraceae family, so has Lemon Verbena is characteristics of a flower made up of many often called Vervain). smaller inflorescences. l It is a slender l It has bracts outside the lower head. perennial, to 60cm, with square stalks and l It is pungently aromatic when crushed. spikes of small white, or pale lilac, flowers in late summer. Materia medica l Leaves are opposite and cut into For many years, toothed lobes. Tansy was used as a l Flowers have no perfume. medicinal herb and Materia medica before its toxicity This herb has a reputation for magic as well was discovered. It as medicine. It was a sacred plant of the was an important Druids, used as an alter plant in ancient women’s herb in Rome. (Until recent times picking Vervain traditional was always accompanied by a prayer). medicine. Its use l Vervain is used as a tea or tincture. was advised for l It restores and calms the nervous system – preventing used for insomnia, anxiety, stress and tension miscarriages, as a l Has a reputation as a ‘cure all’. digestive and for gout. l Is a digestive tonic. l Alleviates headaches. NB: recent studies have found that l Restorative after a long illness and during the whole plant is toxic, especially the convalescence – especially indicated for essential oil (Thujone). Therefore, internal nervous exhaustion. use is contraindicated.

civtedu.org JIVT 2(1) March, 2012 43 Yarrow (Achillea Millefolium) Identification Family: Asteraceae l Mid-sized perennials that grow commonly Genus: Achillea on road verges and rough grassland. Parts used: flowers l The leaves have small oil glands that look and leaves like perforations (this is the reason it has Identification the name ‘perfoliatum’). They are opposing, oblong leaves without stalks. l Identifying features of the Asteraceae l The flowers are yellow and have five petals family include a with black dots. The common name comes flower made up from its traditional flowering and harvesting of many smaller on, or around, St John’s day (24 June). inflorescences. l The leaves are Materia Medica dark green, feathery St John’s Wort is and look like veins. mostly known as l Yarrow is part of the Doctrine of a treatment for Signatures, as it is a key herb for stemming depression (for bleeding. example peripheral neuropathy, NB: do not confuse with the Umbrellifeae anxiety, depression family. Yarrow’s flower stems are staggered and obsessive- off the main stalk and not from one central compulsive point. disorders in animals). It Materia Medica strengthens the l A leading hedgerow medicine, Yarrow nervous system is a first aid treatment for wounds and (the main active constituent, hypericin, is nosebleeds. It is also used as a fever herb. a monoamine oxidase inhibitor). St John’s l It is a circulatory system remedy, helps Wort is also an antiseptic wound herb. It staunch bleeding and moves stagnant reduces pain, is used in liver disease and blood and prevents blood clots (in bruises has antiviral properties. and blood blisters, for example aural hematomas in dogs). It tones blood vessels NB: may cause photosensitization of the (especially small ones) and lowers high skin in some patients. blood pressure. Red Clover (Trifolium Pratense) l Yarrow is a key fever herb, acting as a Family: Fabacea relaxing diaphoretic when taken at the Genus: Trifolium beginning of a fever. Parts used: flower heads and leaves St John’s Wort (Hypericum Perforatum) Family: Hypericaceae Identification Genus: Hypericum l Red Clover has characteristics of the Parts used: flowering tops (picked on a Fabaceae family. The pink to purple flowers sunny day) have a ‘banner, wings and keel’ appearance. civtedu.org JIVT 2(1) March, 2012 44 l The leaves are three parted (trifolium). silver underneath. It is closely related to A. l This family (pea and bean) is nourishing absinthinum, Wormwood. to both people and soil. It is an important l It is an ancient herb of healing, magic and nitrogen-fixing forage crop and is often divination. Before hops, Mugwort was used used for food. in Europe to make ale. l Red Clover’s medicinally active Materia Medica constituents are steroidal analogues l Calms the nervous system – relieves stress (including phytoestrogens). and nervous tension. Can be useful in mild depression as it lifts the spirits. Materia Medica l Mugwort is traditionally a women’s herb, l Blood cleanser – used for regulating menstruation and an alterative. Helps aiding childbirth. Nowadays it is not used the eliminatory for these purposes. and detoxification l It has the capacity to influence dreams organs to rid the – Mugwort tea before bed can ward off body of toxins. It nightmares, or it can cause lucid dreams. is good for chronic diseases, especially NB: pregnant women should not take skin complaints. Mugwort as it is known to contain Thujone, l Red Clover contains a toxic oil. phytoestrogens and is used to Hedge Woundwort (Stachys Sylvatica) treat menopausal Family: Lamiaceae symptoms, such as hot flushes. Genus: Stachys l It has an anti-inflammatory action and is used to treat bronchitis and coughs. Identification l Nutritive – as it contains many beneficial l Found in vitamins and minerals. woodlands, l Red Clover has been used in the hedgerows and treatment of cancer and is one of the main shady places. herbs in the Hoxsey formula. l A perennial that grows to 1 meter NB: do not use in patients using blood- and flowers in thinning medications. July and August Mugwort (Artemisia Vulgaris) (summer). Family: Asteraceae l The flower is a Genus: Artemisia purple, two-lipped trumpet. Parts used: flowering tops and leaves l Leaves are toothed and opposite and the Identification stalks are square. l Often found growing at road junctions Materia Medica and crossings. Its traditional name was ‘traveller’s herb’ . l The entire herb is styptic, therefore it can be l Mugwort is a tall plant, up to 2-3 meters applied externally to wounds to stop blood flow. high, with tiny silvery flower spikes. l Hedge Woundwort is said to be diuretic, l Leaves are pinnate, dark green above and emmenagogic and tonic. civtedu.org JIVT 2(1) March, 2012 45 Self-Heal (Prunella Vulgaris) l In Traditional Chinese Medicine, Self- Family: Lamiaceae Heal is used for ascending Liver fire and Genus: Prunella Liver Qi Deficiency. Parts used: flowers Canadian Golden Rod (Solidago Canadensis) and leaves Family: Asteraceae Identification Genus: Solidago l Self-Heal is a Parts used: flowering tops and leaves common, creeping Identification lawn weed. l Canadian Goldenrod is an erect perennial l It has a square plant with small yellow flowers. stem and opposite, l It is an invasive weed in the United Kingdom. downy leaves. l This is a similar species to Solidago l It has the common virgaurea, which is commonly used as features of the Mint a medicinal herb to treat catarrh and family and is aromatic. kidney stones. l The corolla of the delicate violet flowers are said to look like an open mouth and Materia Medica swollen glands when viewed close up l Canadian (according to the Doctrine of Signatures). Goldenrod was l Self-heal is used in Traditional Chinese used by a number Medicine and was popular for centuries of North American in Europe as a wound herb and for tribes to treat throat problems. children’s disorders, such as fevers that Materia Medica start during sleep, as l As the name Self-Heal indicates, it has a wide range of medicinal actions. It has a well as the inability long history of western folk use. One name to speak or laugh. it acquired was ‘touch and heal’, indicating l It was also used its value as a first aid for cuts and wounds. for influenza, l It was found to staunch bleeding and to fever, diarrhoea, help knit wounds together. Taken internally sleeplessness and excessive crying. as a tea, it treated fevers, diarrhoea and l A decoction of Canadian Goldenrod and internal bleeding. wild tarragon was used by the Thompson l A Self-Heal tea was used as a mouthwash Indians as a wash for sores and cuts in horses. and gargle to treat sore throats and a wide range of mouth problems. Recent studies Plantain (Plantago Major) have shown it to be effective for herpes. Family: Plantaginaceae l Antiseptic, anti-inflammatory and Genus: Plantago antibacterial properties. Parts used: leaves l Self-Heal has marked antioxidant activity – it is said to have strong immune Identification stimulating effects, to calm inflammation l Plantain is regarded principally as a weed. and allergic responses. l It is a perennial plant with a rosette of civtedu.org JIVT 2(1) March, 2012 46 ribbed leaves and wind-pollinated flowers Study shows how Primates learn on erect stalks. about Herbal Self-Medication Materia Medica l The plantains, A 2012 study reveals how information now considered about therapeutic plants spreads within just weeds, were primate communities – it’s much the celebrated as same way traditional herbal information magical herbs in is disseminated among humans. pre-Christian times and were one of the Primates’ use of therapeutic plants nine sacred herbs of has been studied since the 1980s. It the Anglo-Saxons. was inspired by a field researcher’s l They have followed observation in Gombe National Park European settlers in Tanzania. This was in 1972, when a around the world and chimpanzee named Hugo was seen were called ‘white picking Aspilia rudis leaves. They’re not a man’s footprint’. part of chimpanzees’ regular diet as the l Plantain has anti-inflammatory, leaves are rough and sharp. However, astringent, emollient, demulcent and Hugo not only deliberately selected vulnerary actions. Aspilia rudis, but carefully folded the l It is a very good first aid remedy for leaves concertina style, held them in his insect stings and quickly relieves pain and mouth momentarily before swallowing, inflammation in bites, cuts and ulcers (as then grimaced. a vulnerary). l A leaf can be chewed and then applied Further research showed Aspilia rudis as a poultice directly to the wounded area. leaves were used by local herbalists Ribwort plantain is preferred for this use for stomach complaints and had both as its leaves are smoother than greater antibacterial and antiparasitic qualities. plantain (P. major). Ribwort plantain is Back in 1972, it was not accepted by the identified in the same way, however, the mainstream scientific community that leaves are thin and ribbed. animals could self-medicate. Various l Plantain has a soothing effect on the studies and observations have since mucus membranes of the digestive tract proven this to be wrong. and can be used for stomach ulcers and Latest findings irritable bowel disorders. n African and French zoologists and ethnobotanists studied a group of 41-44 wild chimps in Uganda and 11-13 wild western gorillas in the Central African Republic. natural recipes for healthy dogs The researchers identified the ‘unusual and bioactive foods’ (UBF) located in the download your exclusive free e-book! areas surrounding the primates’ habitats. civtedu.org/membership UBF are defined as foods with biological civtedu.org JIVT 2(1) March, 2012 47 or medicinal properties that, although led to the proposition that chimps are infrequently consumed, are eaten by mainly motivated to seek UBF for self- more than one animal in a group. medicating. By learning from the most successful and healthiest adults, risks The researchers listed 36 UBF for the are decreased. chimps and 24 for the gorillas. The UBF species sought by chimpanzees were The researchers conclude their “results plentiful in their surroundings but, at show that differences in sociality and the gorillas’ site, some UBF were rare. physiology between the two species may This finding led researchers to propose influence mechanisms that discriminate gorillas were searching further for these between plants for nutrition and plants plant species for possible self-medication, with potential therapeutic dietary and not for nutritional, purposes. components… Self-medication may have appeared in our ancestors in association It was observed that the highly social with high social tolerance and lack of chimps took cues from the fittest adults, herbivorous gut specialization.” learning about UBF species by watching their older, successful counterparts. For References gorillas however, knowledge is acquired Masi, S, Gustafsson, E Saint Jalme, M et al. by observing related, immature gorillas. 2012, Physiol Behav, vol. 105, no. 2, pp. The researchers suggest that, as it’s 337-349. harder for chimpanzee to detoxify MediHerb e-Monitor 2012, no. 40, March, harmful compounds than it is for gorillas, pp. 4-5. ingestion of UBF species is likely to be a riskier proposition for chimps. This The Guardian, 17 January 2002. n civtedu.org JIVT 2(1) March, 2012 48 Research Updates in sick dogs, as commonly believed. It was found that only 9% of the plant-eating Saliva as a topical ointment and plant dogs regularly appeared ill prior to eating eating in young dogs plants and only 22% of dogsregularly vomited afterwards and the great majority From: Hart, B 2011, ‘Behavioural defences in appeared normal. An important finding animals against pathogens and parasites: was that dogs under one year of age ate parallels with the pillars of medicine in plants much more frequently than the older humans’, Philos Trans R SocLondBiolSci, vol. dogs and were even less likely to appear ill 36, no. 1583, pp. 3406-3417. beforehand or vomit afterwards. In nature,

the young are most vulnerable to intestinal Licking: use of the medicine cabinet in the mouth parasites, having not developed a more As an adaptation to the potential risk mature immunity to the parasites and of infection, animals of several species being more vulnerable to the loss of blood readily lick their wounds. The coating of they can cause. saliva contains a number of antibacterial and wound-healing substances including lysozyme, lactoferrin, leucocytes, lactoperoxidase and immunoglobins, along with epidermal growth factors. Saliva is a readily available, all-purpose medicinal ointment. As an indication of the effectiveness of this treatment, dogs’ saliva was found to be bactericidal to both Escherichia coli and Streptococcus canis, common wound contaminants. Sows are observed to generously lick the nipples just before piglets start to suckle, applying a salivary wash that is bactericidal for common disease-causing pathogens. Plant eating by dogs Plant material has been found in 2–4% of scats and stomach content samples of wolves and cougars, revealing that they regularly consume non-digestible plants.A broad ranging web-based survey of thousands of dog owners was posted to A comparison of plant eating by dogs up to look for evidence that plant eating in dogs one and 3–13 years of age. evolved as a means of intestinal parasite (a) The younger dogs eat plants more control, rather than reflecting a dietary frequently. deficiency or a way of inducing vomiting (b) Not only do younger dogs appear civtedu.org JIVT 2(1) March, 2012 49 ill beforehand less frequently, but they A study in chicks infected with the rarely vomit afterwards. These differences protozoan parasite Coccidia concluded that reflect an apparent innate developmental dietary supplementation with E. pupurea adaptation to the young being more root extract significantly decreased lesion vulnerable to intestinal parasites by eating scores and improved the health of the parasite-purging plants more frequently animals, in comparison with animals raised (Sueda, K, Hart, B & Cliff, K 2008). on a normal diet. As immune parameters were not measured, it is not clear whether Veterinary Applications of Echinacea the effect of E.pupurea was directed against From: Hudson, J 2012, ‘Applications of the the parasite itself or on the immune system. Phytomedicine Echinacea pupurea (purple Nevertheless, an effective treatment for coneflower) in Infectious diseases’, J Biomed coccidiosis would be welcome in the Biotechnol, vol. 2012, no. 769896. poultry industry. Most domestic animals, including pets, In a study in young pigs, dietary E. livestock and fish, require treatment for pupurea was found to offer no protection viral and microbial diseases at some point against the porcine reproductive and in their lives. The causative organisms are, respiratory syndrome virus (PRRS virus). for example, avian influenza viruses, animal It is a member of the arterivirus family herpes viruses, various respiratory viruses, bacteria and many fungal and parasitic (related to coronaviruses) and possesses a infections. Some should be responsive membrane, therefore would be expected to Echinacea treatment, either as a direct to be susceptible to direct contact with E. antiviral, antimicrobial, or as an anti- pupurea. However, the systemic nature of inflammatory agent. Some organisms, the infection could render it inaccessible especially bacteria such as Salmonella and to dietary Echinacea components. Campylobacter species, are important Alternatively, the treatment protocol may sources of contaminated foods. There is have been inadequate. a need to evaluate herbal preparations as replacements for at least some of the In addition to controlling infections in antibiotics that farmed animals often receive. domestic animals, herbal preparations have been advocated for immune stimulation, Certain herbs, including Echinacea, growth promotion and performance have a modern tradition of veterinary enhancement. Studies in uninfected horses applications in North America and Europe. and fish (Tilapia,) suggest possibilities for The treatments were concluded to be Echinacea preparations and, again, safety safe and free of significant side effects, although there are relatively few reports was not considered a problem for the of basic studies analogous to those for animals. Fish, like other farmed animals, are human diseases, or even controlled trials potentially vulnerable to viral and microbial in animals. The conclusion is supported infections, especially under conditions of by studies in mice and rats in which toxic stress, so alternative treatments to synthetic effects were not observed. antimicrobials could be useful. civtedu.org JIVT 2(1) March, 2012 50 Du HuoJi Sheng Tang for Osteoarthritis Bees Update From: Chao-Wei, Chen, Jian, Sun, Yu Mei, Li From: Dainat, B, Evans, J, Yan, Ping, Chen et et al.2012, ‘Action Mechanisms of Du HuoJi al. 2012, ‘Predictive Markers of Honey Bee Sheng tang on Cartilage Degradation in a Colony Collapse’, PLos One,vol. 7, no. 2, e Rabbit model of Osteoarthritis’, Evid Based 32151. Complement Alternat Med, vol. 2011, no. Across the Northern hemisphere, managed 571479. honey bee, Apis mellifera, colonies are Currently, there is not a cure for currently affected by abrupt depopulation osteoarthritis (OA) and available treatments during winter and many factors are only slow the progression of disease. For the suspected to be involved, either alone or last 20 years, Traditional Chinese Medicine in combination. Parasites and pathogens (TCM) has seen significant advancement are considered suspects, in particular against OA, such as in improving patients’ the ectoparasitic mite Varroa destructor, clinical findings by inhibiting inflammatory associated viruses, plus the microsporidian reaction and cartilage degeneration. In vivo Nosema ceranae. Long term monitoring and in vitro studies showed Chinese herbs of colonies and screening for 11 disease provide multiple comprehensive actions agents and genes involved in bee against OA. immunity and physiology were used to identify predictive markers of honeybee Du Huo Ji Sheng Tang (DHJST) has been colony losses during winter. It was shown widely used for treating OA. It is composed that Deformed Wing Virus, N. ceranae, of Radix Angelicae pubescentis, Herba V. destructor and Vitellogenin can be taxilli, Radix Acanthopana cisbidentatae, predictive markers for winter colony losses, Herba asari, Radix Gentianaemacrophyllae, but their predictive power depends on the Cortex cinnamomi and poria. DHJST can season. In particular, the data support that improve patients’ clinical symptoms, knee V. destructor is a key player, in line with its function and quality of life. Researchers specific impact on the health of individual investigated its effect on preventing bees and colonies. It has been shown that cartilage degeneration from OA in rabbits V. destructor, or its associated microbes, can with anterior cruciate ligament injury affect the immune system of parasitized and observed its mechanisms. There was bees. In addition, viral infections linked significant histological degeneration in the with V. destructor are generally considered control group compared with the treatment a major cause of bee losses and plays a group and normal controls. The study central role as a mechanical and biological indicated that DHJST exerts a significant vector of several viruses. n therapeutic effect on OA by inhibiting chondrocyte apoptosis and regulating the expression of VEGF and HIF-1a expression We’d love to hear from you! in chondrocytes. VEGF contributes to pain We welcome and encourage your feedback, and swelling and HIF-1a increases apoptosis letters and contributions to JIVT. in chondrocytes. Email your missives to [email protected] civtedu.org JIVT 2(1) March, 2012 51 About the Journal of Integrative Published articles receive $50.00 CIVT voucher. Veterinary Therapies Commentary: The Journal of Integrative Veterinary Issues of significant interest to practitioners. Therapies (JIVT) is the first international Book reviews: veterinary publication addressing evidence New books of interest. based natural medicine for animals. Clinical Pearls: This is a modern, clinically relevant and Pearls of wisdom from experienced peer reviewed journal. JIVT is issued practitioners. quarterly. 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