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June 18, 2020

Part I: TCM and COVID-19, What Every Practitioner Should Know

The content of this article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your acupuncturist, physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 or local emergency number immediately.

A Two Part Interview with Dr. Michael McCulloch, LAc, MPH, PhD.

“Predict, prepare, be ready” is the mantra of Dr. Michael McCulloch in the midst of the coronavirus pandemic. A licensed acupuncturist who holds a master’s degree in public health and a doctorate in epidemiology, Dr. McCulloch is uniquely positioned to provide our profession some much needed guidance as we continue to forge ahead into unknown territory. After watching his March and April COVID-19 webinars, he kindly agreed to give me an hour of his undivided attention to address some of my burning questions. Here is what he had to say.


E: Worldwide, nations scramble for a vaccine and antiviral therapies to treat COVID-19. In your April webinar, you present evidence demonstrating the effectiveness of Chinese herbs in treating corona viruses. A meta analysis conducted during the 2003 SARS outbreak revealed a two-thirds reduction in the death rate for patients treated with Chinese herbs in addition to Western supportive care.1 How does this research translate to the current pandemic and potential for using Chinese herbs to treat COVID-19?

M: This paper 1 is really worth reading. It’s a very thorough review of all the evidence published following the [2003] SARS outbreak. It’s worth students and acupuncturists getting a copy of that paper. It was published by the Cochrane collaboration, a highly credible and mostly volunteer research group with high standards in critically assessing research topics.

The way that research translates to the current pandemic is there is around an 80% overlap between SARS COVID-1 and SARS COVID-2 virus or COVID-19. The two strains tend to be similar but it’s not really known yet the differences between the two. It’s worth looking at and researching Chinese herbal medicine specific to COVID-19, although very little of it has been done.

There are just over a dozen peer-reviewed papers, which consist of a handful of case reports and a handful of theoretical papers interpreting COVID-19 treatment with herbs, drawing from the experience with SARS in 2003. There are also a few reports from Chinese clinical trial registries that list titles of clinical trials in progress. There is also one other peer-reviewed paper written by a group in Korea, that presents, all in one efficient PDF, all of the known national guidelines for treatment of COVID-19 with TCM: 26 from China and two from Korea. I’d like all practitioners to know these guidelines 2 and have access to them. The guidelines include all the stages of disease and which herbs to use at each stage.

But what we haven’t seen yet, are the peer-reviewed results of any of the trials that have been done specific to TCM treatment of COVID-19, and so a lot is still unknown. This is a big problem because of the severity symptoms that can happen with COVID-19. What that means is the practitioner really has to educate themselves about which of their patients are in the high risk groups and the study reports coming out on new signs and symptoms, as well as pay close attention to the individual patient and use their judgement in interpreting signs that would say the patient should go to the hospital.

E: Absolutely. I appreciate you sharing these [guidelines]. Is there anything else we should know?

M: To close on that question, the potential for successfully treating SARS COVID-2 with Chinese herbs is high,

but one of the important new developments is to pay attention to the reported evidence that the virus is behaving somewhat differently in the US population than it has in China. Perhaps these differences are due to higher rates in the US of overweight, diabetes and heart disease. Those three factors put patients at a substantially higher risk for a very catastrophic sounding term called hemostatic derangement.

E: I’m not familiar with that term – can you elaborate?

M: Yes, it’s a blood clotting disorder following the now well known cytokine storm that affects people with severe COVID-19, causing inflammatory damage to the capillaries and small blood vessels in the lungs, heart, liver, kidneys and spleen. So COVID-19 is an illness that is affecting all the five organs and elements. It’s no longer enough to assume that tonifying the spleen and clearing heat and transforming toxic phlegm in the lungs is sufficient treatment.

The body-wide consequences of a cytokine storm has a central mechanism driving them, which is a slippery slope that precedes with immune overreaction by the virus. The virus tricks the immune system and the body into letting itself replicate into millions of copies, flooding the system, and it travels through the blood and causes inflammation in the lining of the blood vessels.

E: Is this similar to something we see with disseminated intravascular coagulation (DIC)? Or is this a separate phenomenon?

M: DIC is the crescendo of the cytokine storm that’s usually quickly fatal. We know Chinese herbs can be used for blood moving, but at that point when it [DIC] takes hold it may well be too late for herbs; and, you won’t be able to access your patient there in the ICU. There are currently promising clinical trials evaluating tPA (Tissue Plasminogen Activator), the drug used for acute occlusive stroke and heart attack, happening in Denver and France. It’s promising they’re testing a widely available pharmaceutical drug in critical care for this problem.

However, in Chinese medicine we should be thinking: What could I do earlier in the process? In the course of a person’s illness and even before they get ill. What we can be doing is using exercise and diet to lower inflammation levels, lowering the propensity for blood clotting disorders, which is a multifactorial process.

How diligently can we predict phenomena and prepare the patient if they are to be infected? That’s the real and unique role of Chinese Medicine.

Of course in Asia they are using Chinese herbs quite a bit in the hospital setting given the medical legal landscape. However Chinese medicine is much more powerful when used earlier on as prevention.

E: Absolutely, your point of staying within our scope of practice is very valid.

M: In addition to scope of practice, it’s really a function of what are the strengths of Chinese medicine. Prevention is its very powerful core. Skillfully using the language and the strategies of the Five Elements helps a person work through meridian stagnations and obstructions that keep them from taking preventative actions. Let’s take for example a patient who feels like they’re too busy with too many things to do. That may be the pattern of kidneys not nourishing the liver adequately, could be others. Help them to slow the pace down and do acupuncture to calm the liver and maybe they won’t be as persistently and fearfully overworking.

Another scenario, say a person with the diagnostic pattern of the heart and kidneys not connecting. They might fundamentally fail to recognize the realities of their health and not take adequate care of their health. There’s a lot within the Five Element framework that can help a person work through their energetic obstructions in the channels that prevent them from doing the more pragmatic, more grossly preventive steps like exercising more and eating better.

E: I love that you brought that up because I feel it addresses an important psychological component to our health that often goes overlooked or isn’t factored into recognizing why someone gets sick.

M: Yes. There is a widespread fear gripping the nation, which is a sign pointing to kidneys. They could be considered the origin of a person’s susceptibility to infection or [serve as a] risk factor for a severe version of the disease. In this case, ear acupuncture, Hua Tou points along the spine and scalp points could be helpful. You’re plugging directly into the central nervous system. This is helpful to a patient, to help that fear cycle settle down a little and help them to be more able to hear. This enables a practitioner to use their words like needles, to help a patient’s understanding of the importance of taking active steps toward prevention. And one of the essential steps the practitioner or student can take is to use TCM diagnostic skills and common sense to identify what part of the person’s physiology and energetic network puts them at higher risk for severe COVID-19, and begin vigorously taking concrete steps to improve their health.

Primary prevention is preventing infection with good hygiene and social distancing. Secondary prevention is getting stronger and calmer and healing the blood level.

E: Speaking of prevention, due to its antiviral effects3,4 Yu Ping Feng San has emerged as the arguably the gold standard Chinese herbal formula for coronavirus protection. You’ve taken this a step further by creating herbal “prevention sets” that combine components of Yu Ping Feng San with herbs that support either a yin or a yang deficient constitution. Can you share your thought process behind these formulations?

M: Yu Ping Feng San was used during the 2003 SARS COVID-1 epidemic for prevention, apparently fairly successfully in the Hong Kong hospitals that reported its use among frontline medical staff, direct patient contact staff and general hospital staff. That’s present in several different papers. Unfortunately the quality of the reporting is quite poor on those papers, there are a lot of details that could’ve been reported that weren’t.

Because of that we can’t really say Yu Ping Feng San is the gold standard herbal formula because the level of the quality of evidence hasn’t reached the level of quality that justifies using the term “gold standard” to describe the formula. This puts the responsibility back on us as practitioners to pay close attention to the individual patient. To really make sure that things keep moving in a favorable direction over the evolution of the case. That said I’m going to send you the details of the prevention sets*.

*Dr. McCullough’s prevention sets, including composition and dosing, have been provided at the end of the article. Additionally, he has shared his intervention set, which has been formulated based on the emerging research from peer-review medical journals for treating acute cases.

E: Fantastic.

M: We had two versions of the prevention formula based on either kidney yin or kidney yang deficiency. Do all the patients have that as an origin of their etiology and risk factors? That goes back to our earlier conversation about the involvement of the kidneys in the current pandemic. Also, I believe, fundamentally, all cases have some level of kidney yin or yang deficiency, since in Chinese cosmology, these are the origin of everything. I believe almost everyone, at some point back in their past, has had some sort of kidney yin or yang deficiency that in some way played a role in the patterns and the imbalance that they show up with at your office.

E: Definitely, it’s back to the basics. Looking at predominant patterns of deficiency of yin or yang without looking into the nitty gritty of qi, blood, body fluids.

M: That’s right. By nourishing kidney yin, we nourish the whole body’s yin. From kidney to liver, liver to heart, heart to spleen and spleen to lung. We’ve combined that with the essential three part core herbs of Yu Ping Feng San, then adding to that lung yin nourishing Pi Pa Ye and Bei
Sha Shen and blood cooling Ban Lan Gen and Yu Xing Cao [to the yin prevention set].

E: Thank you for sharing that list. They’re definitely some herbs in there I learned about in herbs class I didn’t think I’d ever have to use. It’s informative to see them coming alive.

To Be Continued

In the next article Dr. McCulloch will share how he treated a patient with a probable case of moderately severe COVID-19 and how he’s partnering with Bay Area hospitals during the pandemic. Watch this space for the next article!

Dr. McCulloh’s Prevention Sets

Yin Prevention set formulated by Dr. McCulloch

Figure 1: Yin Prevention set formulated by Dr. McCulloch. Disclaimer: Consult a licensed acupuncturist and herbalist before starting any Chinese herbal formula.

Table of herbs & dosages for Yang Prevention Set

Figure 2: Yang Prevention set formulated by Dr. McCulloch. Disclaimer: Consult a licensed acupuncturist and herbalist before starting any Chinese herbal formula.

Table of herbs & dosages for Dr. McCulloh's Intevention Set

Figure 3: Intervention set formulated by Dr. McCulloch. Disclaimer: Consult a licensed acupuncturist and herbalist before starting any Chinese herbal formula.

References

  1. Liu X, Zhang M, He L, Li Y. Chinese herbs combined with Western medicine for severe acute respiratory syndrome (SARS). The Cochrane database of systematic reviews. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993561/. Published October 17, 2012. Accessed May 15, 2020.
  2. Ang L, Lee HW, Choi JY, Zhang J, Lee MS. Herbal medicine and pattern identification for treating COVID-19: a rapid review of guidelines. Integrative Medicine Research. 2020;9(2):100407. doi:10.1016/j.imr.2020.100407.
  3. Choi RCY, Zheng KYZ, Dong TTX, Lau DTW, Tsim KWK. Yu Ping Feng San, an Ancient Chinese Herbal Decoction Containing Astragali Radix, Atractylodis Macrocephalae Rhizoma and Saposhnikoviae Radix, Regulates the Release of Cytokines in Murine Macrophages. PLOS ONE. https://doi.org/10.1371/journal.pone.0078622. Published November 11, 2013. Accessed May 15, 2020.
  4. Zheng KYZ, Bi CWC, Dong TTX, Lin H, Tsim KWK. Yu Ping Feng San, an Ancient Chinese Herbal Decoction, Induces Gene Expression of Anti‐viral Proteins and Inhibits Neuraminidase Activity. https://www.onlinelibrary.wiley.com/doi/full/10.1002/ptr.5290. Published January 14, 2015. Accessed May 15, 2020.

About the interviewer

Erin is currently a candidate for a Master’s in Oriental Medicine at the Acupuncture and Integrative Medicine College, Berkeley. When she’s not studying acupuncture she finds great joy in hiking, coastal camping and getting lost in a good book.

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