MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

At present, we see a wave of promotion of Traditional Chinese Medicine (TCM) as a treatment of corona-virus infections. In this context, we should perhaps bear in mind that much of the Chinese data seem to be less than reliable. Moreover, I find it important to alert people to a stern warning recently published by two Australian experts. Here is the crucial passage from their paper:

We wish to highlight significant concerns regarding the association between traditional herbal medicines and severe, non-infective interstitial pneumonitis and other aggressive pulmonary syndromes, such as diffuse alveolar haemorrhage and ARDS which have emerged from Chinese and Japanese studies particularly during the period 2017−2019. Initially the association between traditional herbal therapies and pneumonitis was based on isolated case reports. These included hypersensitivity pneumonitis associated with the use of traditional Chinese or Japanese medicines such as Sai-rei-to, Oren-gedoku-to, Seisin-renshi-in and Otsu-ji-to (9 references in supplemental file). Larger cohorts and greater numbers now support this crucial relationship. In a Japanese cohort of 73 patients, pneumonitis development occurred within 3 months of commencing traditional medicine in the majority of patients [], while a large report from the Japanese Ministry of Health, Labor and Welfare, described more than 1000 cases of lung injury secondary to traditional medications, the overwhelming majority of which (852 reports) were described as ‘interstitial lung disease [].

Currently the constituent of traditional herbal medicines which is considered most likely to underlie causation of lung disease is Scutellariae Radix also known as Skullcap or ou-gon, which has been implicated through immunological evidence of hypersensitivity as well as circumstantial evidence, being present in all of those medicines outlined above []. Notably, skullcap is a constituent of QPD as used and described in the paper by Ren et al. relating to COVID-19 []. Scutellariae Radix-induced ARDS and COVID-19 disease share the same characteristic chest CT changes such as ground-glass opacities and airspace consolidation, therefore distinguishing between lung injury due to SARS-CoV-2 and that secondary to TCM may be very challenging. The potential for iatrogenic lung injury with TCM needs to be acknowledged []…

Morbidity and mortality from COVID-19 are almost entirely related to lung pathology []. Factors which impose a burden on lung function such as chronic lung disease and smoking are associated with increased risk for a poor outcome. Severe COVID-19 may be associated with a hypersensitivity pneumonitis component responsive to corticosteroid therapy []. Against this background the use of agents with little or no evidence of clinical efficacy and which have been significantly implicated in causing interstitial pneumonitis that could complicate SARS-CoV-2 infection, should be considered with extreme caution.

In conclusion, the benefits of TCM in the treatment of COVID-19 remain unproven and may be potentially deleterious. We recognise that there is currently insufficient evidence to prove the role of TCM in the causation of interstitial pneumonitis, however the circumstantial data is powerful and it would seem prudent to avoid these therapies in patients with known or suspected SARS-CoV-2 infection, until the evidence supports their use.

Declaration of Competing Interest: There are no conflicts to declare.

18 Responses to The use of Traditional Chinese Medicines to treat SARS-CoV-2 may cause more harm than good

  • Chinese herb shops (TCM Practices, if you want to call them that) have spread through Britain like ringworm; an active front leaving less inflamed areas behind, as they move on from less profitable locations to try new areas. There was fairly briefly one in my town some years ago.

    The dried sliced herbs and roots on display in jars have a very strong visual appeal. As others have pointed out, we might make a mental picture of a sylvan meadow, with industrious country folks gathering dew-speckled herbs at dawn. But the herbs might very well come from beside a busy road with diesel lorries thundering past all day spewing toxic heavy metal particulates all over the plants. We don’t KNOW, that’s the thing.

    We take the quality of the herbs, and the results of mixing and stewing them together – interactions etc – and possible toxicity, all on trust. What quality control is there? One field might have twice the amount of a pharmacologically active substance in the plants, as is found in another field. (That happened years ago with the foxgloves used to make Digoxin, didn’t it? It led to improved production methods).

    Years ago dermatologist Dr David Atherton investigated the use of Chinese herbal preparations for atopic eczema, and a freeze-dried granule preparation was produced, called Zemaphyte. But it couldn’t get approval, because the ‘active ingredient’ could not be specified.

    It’s horrible to think, in the light of the study quoted, of people trying TCM in good faith, with vague ideas of herbalism, and ending up with damaged lungs.

    • While you all are throwing stones at TCM, save a few in your hand to aim at EBM.

      https://covid19data.com/2020/04/12/are-ventilators-doing-more-harm-than-good-to-covid-19-patients/

      • That’s an invalid comparison. The link you pasted is to an article from April 12th, when Covid-19 was still relatively new and treatment modalities still being investigated and developed.

        It was EBM, not TCM, which discovered that the use of ventilators might not be optimal.

        What has TCM discovered about Covid-19?

        • @David B

          David, that is laughable. So EVM is to be commended for discovering that they were killing patients ? Keep it up, a good laugh is healthy for me.

          https://www.wpr.org/almost-death-sentence-how-wisconsin-doctors-peers-are-rethinking-ventilators-coronavirus

          • That is an inaccurate and emotive use of language. I am sorry that you are laughing in connection with thoughts of patients dying.

            In hospitals, in doing their very best to stop patients from dying of a new disease whose properties were still largely unknown, doctors rapidly noted which treatment approaches were more, or less, useful and/or dangerous, and they modified treatments accordingly.

            What has TCM done for Covid-19?

          • @David B

            I’m not laughing at patients dying, I’m laughing at YOU, are you daft ?
            You can’t seem to see the forest because of the trees.

            Hospitals were quick to use them because they could charge a hefty price for the machines, similar to much Western medicine.

            First rule of medicine…. “do no harm”

          • I write from a UK perspective, in which health provision is “free at the point of need”, provided by the National Health Service.

            People were in hospital in the first place because they were very ill with Covid-19, likely to die, and desperately needing treatment.

            Doctors quite quickly began to realise that the use of ventilators wasn’t necessarily turning out to be the best treatment method. Doctors discovered that, because they are schooled in observing and recording clinical outcomes, as part of EBM. Practitioners of TCM didn’t tell them about ventilators. (The link you provided, to an article from early May, discusses this realisation by doctors doing their best to find the best way to treat Covid-19)

            What have practitioners of TCM done for Covid-19?

            Tell everyone that you are laughing at me if you like, but I don’t think you sound like a nice person when you talk like that.

          • And I did not say that you were “laughing at patients dying” – don’t put words in my typing fingers. I wrote “I am sorry that you are laughing in connection with thoughts of patients dying”.

            There is a difference.

          • David B

            I’m not going to trash talk TCM, nor do I make a case for it. For those that choose to use it, I support their right to choose for themselves what therapies that want to use on themselves. Who am I to decide what works for them ?

          • You have no qualms about trashing EBM, however.

  • Good points.. The ‘strolling to the market’ anecdotes are hard to counter, what with professionals also jumping into the fray to support their use..

  • Chinese Medicine(CM) belongs to Medicine by law in China. Covid-19 patients have been treated by CM or integrated medicine (CM and BIomedicine)by the doctors, registras and consultans in ChineseMedicine at the hospitals. The Covid-19 patients include, mild , moderate, severe and critical levels. The clinic effectiveness have proved by the researches of clinic and lab. Please read the evidences as below

    1. China National Knowledge Network (CNKI), the largest database in China, has published thousands of articles on the treatment of covid-19 with CM.

    2. Auggust 14, 2020 news
    Facebook
    Twitter
    “US Health Agency Says Traditional Chinese Medicine Can Help COVID-19 Patients Recover Faster ”

    3.Comparing the covid-19 mortality rate and recover rate of different countries, China is the best one to control. Chinese medicine plays an extremely important role in it.

    Anyone’s evaluation of things should be based on scientific evidence.

    • As you said: “Chinese Medicine(CM) belongs to Medicine by law in China.”

      LAW dictates, that TCM is medicine in China by ignoring scientific and medical evidence. So your argument is not valid and worthless.

      • Thank you for your reply.

        There’s a lot of scientific evidence, and I’ve given you access to it. Please take your time and make a comprehensive literature search before you express your views and comments.

        • “[TCM] is largely just pseudoscience, with no rational mechanism of action for most of its therapies.”

          https://www.nature.com/articles/448106a

          “Traditional Chinese medicine has a long history as propaganda. The modern concept of it originated in the 1950s under Mao Zedong, at a time when cultural pride and foreign-directed propaganda demanded the invention of a powerful Chinese tradition. The range of traditional Chinese healing practices was sold as “scientific” to gullible foreigners and the Chinese public alike. In a still desperately poor country, traditional medicine was better than nothing for the masses.”

          https://foreignpolicy.com/2018/02/28/is-china-the-world-leader-in-biomedical-fraud/

          Your “scientific” evidence is worthless as I said.

          “What counts is not what sounds plausible, not what we would like to believe, not what one or two witnesses claim, but only what is supported by hard evidence rigorously and skeptically examined. Extraordinary claims require extraordinary evidence.”

          Carl Sagan

          • In your article, with two articles, traditional medicine and non infectious interstitial pneumonia lung disease, and your inherent views on Chinese medicine, without a comprehensive literature search, it is too one-sided to say “Chinese medicine treatment of covid-19: disadvantages outweigh benefits”?
            Moreover, in your example, A(traditional HERBAL Medicine) = B (non infectious interstitial pneumonia), 然 C (covid-19) = B (infectious lung changes), rusult: A≠ C, this mathematical logic has no logical relationship in the treatment of covod-19 by ‘Chinese medicine in medicine, which does not exist in this problem and is unreasonable. B is a different concept here, and A is a different concept too. And there are too many variables, such as too many Chinese Herbal medicines.

            Have you read the guide of covid-19 in China? Do you know the prescriptions for covid-19? Do you know the clinic outcomes at hospitals?
            the USA RCT result is only one of the prescriptions of treatment ptescriptions in China. Do you compare the reports of world Covid-19?It is suggested that you do a literature search on covid-19.
            Thank you.

  • I totally understand the concern about the safety of herb usage. But I can hardly agree Mr Gary’s conclusion: The use of Traditional Chinese Medicines to treat SARS-CoV-2 may cause more harm than good. In fact, COVID-19 is controlled well in China after Chinese herb medicine involved in and systematic review and meta-analysis shows it is beneficial for the treatment (1). qingfei paidu decoction (QPD) is one of the formulas and there are other formulas available as well dependent on patient’s individual situation.

    Japanese herbal medicine (JHM), is originally came from China. Today, 148 herbal Kampo formulas can be prescribed under the national health insurance system of Japan, allowing physicians to integrate Kampo in their daily practice. A survey that was administered to physicians throughout Japan (n = 684) showed that 83.5% of physicians currently use Kampo in the clinics(2). Rather than modifying formulae as in Traditional Chinese Medicine, the Japanese Kampo tradition uses fixed combinations of herbs in standardized proportions (3). They are used in Japanese practice to treat a wide range of diseases or symptoms, such as allergies (4), infectious diseases (5)

    There are some facts suggest that Mr Gary’s conclusion needs to be deliberated. He cited a review from Enomoto YM et al stated that 73 patients in 59 articles, pneumonitis development occurred within 3 months of commencing traditional medicine in the majority of patients. The author suspected that Scutellariae Radix may be responsible for the pneumonitis because it was the most used herb in most of the formulas.

    The using Kampo patients were found some characteristics of pneumonia or interstitial pneumonia. However, there are limitations in this paper. As the author mentioned the main limitations were the retrospective nature of data collection and the limited information available in the published literature and their study design could not provide any evidence regarding the incidence and risk factors for JHM-induced pneumonitis. To evaluate such clinically valuable information, future prospective studies with a large number of consecutive patients receiving JHM are needed.

    These patients did not rule out pneumonia or interstitial pneumonia before receiving Kampo treatment. It is not clear what sort of other drugs they were using. There are different causes contribute to pneumonia or interstitial pneumonia such as bacteria and virus infection, autoimmune disease, some chemicals, unknown cause etc(6)(7). Actually the precise cause of most interstitial lung disease is unknown. If an elder lower immune functional patient had some disease need to be treat and took certain herb formula meanwhile infected with a virus in early stage. Some days later pneumonia symptoms developed. Some viral infection is a self-limiting disease to a certain extent, some patients will get better even if you do not give any treatment after stopping the herbs. Herbs should not be blamed lightly. In addition, in this paper, there is no further information about the died patients who may had server underlying diseases.

    Generally, good practice for TCM treatment requires 3 days prescription for acute disease under the Chinese medical diagnosis method and no more than 7 days for chronic disease given to patient then need to value and adjust the prescription according to patients situation. It is quite likely that the Japan physicians prescribed herb formulas but did not adjusted according to the changes in the condition which we believe is not good practice.

    Finally, Scutellaria baicalensis is a useful herb and there are specific
    indications for how to use it properly in Traditional Chinese Medicine. Actually Scutellaria baicalensis is effective in the treatment of respiratory tract infectious diseases and there are anti-inflammatory effects in clinic and in animal
    models (8)(9)(10).

    (1). Fan AY, Gu S, Alemi SF; Chinese herbal medicine for COVID-19: Current evidence with systematic reviews and meta-analysis. J Integr Med. 2020 Jul 31:S2095-4964(20)30078-9.
    (2) E.C . Moschik,  C. Mercado,  T. Yoshino, et al. Usage and Attitudes of Physicians in Japan Concerning Traditional Japanese Medicine (Kampo Medicine): A Descriptive Evaluation of a Representative Questionnaire-Based Survey. Evid Based Complement Alternat Med. 2012; 2012: 139818.
    (3) Kotoe Katayama; et al. (2013). “Prescription of Kampo Drugs in the Japanese Health Care Insurance Program” (PDF). Evidence-Based Complementary and Alternative Medicine  2013: 576973. 
    (4) Urata Y, Yoshida S, Irie Y, et al. Treatment of asthma patients
    with herbal medicine TJ-96: a randomized controlled trial.
    Respir Med 2002;96:469–74.
    (5) Mantani N, Kasahara Y, Kamata T, et al. Effect of Seihai-to, a Kampo medicine, in relapsing aspiration pneumonia—an open-label pilot study. Phytomedicine 2002;9:195–201.
    (6)Fabiola Atzeni , Maria Chiara Gerardi,  Giuseppe Barilaro  et al. lung disease in systemic autoimmune rheumatic diseases: a comprehensive review. Expert Rev Clin Immunol 2018 Jan;14(1):69-82.
    (7)Katerina M. Antoniou, George A. Margaritopoulos, Sara Tomassetti et al Interstitial lung disease. European Respiratory Review 2014 23: 40-54.
    (8) Ha-Young Jang,  Kyung-Seop Ahn, Mi-Jeong Park et al Skullcapflavone II inhibits ovalbumin-induced airway inflammation in a mouse model of asthma Int Immunopharmacol 2012 Apr;12 (4):666-74.
    (9) Seok-Bin Yoon,  Young-Jong Lee, Seong Kyu Park et al Anti-inflammatory effects of Scutellaria baicalensis water extract on LPS activated RAW 264.7 macrophages. Ethnopharmacol 2009 Sep 7;125(2):286-90. 
    (10) Shi H, Ren K, Lv B,  et al from Scutellaria baicalensis blocks respiratory syncytial virus (RSV) infection and reduces inflammatory cell infiltration and lung injury in mice. Sci Rep. 2016 Oct 21;6:35851

  • Here is another paper suggesting that Baicalin, a flavonoid compound isolated from Scutellaria baicalensis Georgi (Huang Qin), is able to protect mice from Staphylococcus aureus pneumonia.
    Acupuncture is also used for treating COCID-19. Evidence supports its anti-inflammation effect.

    Jiazhang Qiu et al, Baicalin Protects Mice From Staphylococcus aureus Pneumonia Via Inhibition of the Cytolytic Activity of α-Hemolysin. The Journal of Infectious Diseases, Volume 206, Issue 2, 15 July 2012, Pages 292–301
    Liu et al., Somatotopic Organization and Intensity Dependence in Driving Distinct NPY-Expressing
    Sympathetic Pathways by Electroacupuncture, Neuron 108, 1–15, November 11, 2020

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