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The Critical Issue of Dosage

by Todd Luger, L.Ac.
revised 9/23/02

A critical issue may jeopardize the future of Chinese herbal medicine.  That issue is dosage.  Correct dosage is the key to success in TCM.  Correct dosage is based on several factors.  There is historical precedent, for one thing.  Throughout Chinese history, the issue of dosage was paramount.  As far as I have been able to ascertain, traditional texts recommend fairly high dosages of herbs.  Bensky's formulary reflects this pattern with most formulae being used in dosages of 50-100 grams per day in decoction or about 18-27 grams per day in pill form.  In addition, modern Chinese clinical research has also emphasized high doses, so when claims are made about the efficacy of particular herbs or formulae, those claims are based on high dose research.  Finally, pharmacological research has revealed the active ingredients of many herbs and we know what amounts are necessary to achieve therapeutic effects.  Again, the doses necessary for pharmacological action are in line with high end Chinese dosing.  So several different avenues of inquiry support the concept of high dose prescribing.  Unless you believe herbs work by some other mechanism than pharmacology, there is a biochemical minimum necessary to achieve results.

Subhuti Dharmananda has written at length about this issue over the years and he has made a point of telling practitioners to prescribe very high dosages of his products.  However, it is unlikely that even high dose herbal pills can match the potency of a bulk herb tea.  The maximum dose for seven forest products results in the ingestion of no more than 15 grams of raw herbal material.  Subhuti claims that because there are no losses due to cooking, the dose requirement is much lower than with decoctions.  Assuming Subhuti is correct, what are we to make of products that provide patients with doses of herbs more in the 0.5 - 5 grams per day range.  I think we can safely say there is no evidence, either historical or pharmacological, that such products will be effective.  

Yet at least a significant minority, if not the majority, of acupuncturists around the country prescribe low dose products and claim success with their patients.  What is going on?  It is well known that in private practice, it is not possible to determine what variables have affected the patient's condition.  So you may assume it is your herbal formula, but you have no way of knowing in an uncontrolled environment.  You are able to determine your patient's level of satisfaction, but even many lab tests may fluctuate for reasons that have nothing to do with therapy.  In an uncontrolled environment, the placebo effect for taking a pill can rise to 90%.  That means 9 of 10 patients will report a positive response to a noniatrogenic treatment given by a caring doctor with whom they have a good rapport.  Placebos lower blood pressure, make pain go away, relieve depression and anxiety, improve sleep and digestion.  Sound familiar.  So be clear, whatever type of herbs you use, there is absolutely no way to truly gauge the herbs' effectiveness in the context of a private practice.

Because of this, I rely on tradition and science to guide me.  With no precedent in Chinese history for low dose prescribing, I must call into question this practice.  It is certainly more affordable for the patient or more profit making for all the sellers involved.  But it cannot be justified in any way.  Now since patients are satisfied, who cares?  If it's the placebo effect, great, more power to the placebo.  Well, there's a couple of problems with this rationale.  I think we all want to help as many people as possible with our methods.  In order to do this, we must achieve mainstream acceptability.

Right now, no one is really scrutinizing this aspect of the herb situation from outside the profession at this time.  But when mainstream sources begin to look at what we are doing, they will immediately suggest that most herbal prescribing must be due to placebo effects, according to modern pharmacology.  Insurance companies will not even consider covering a placebo, so it matters very much whether we give placebos or not.  In addition, we all should strive to create an ethical and cost effective healthcare system, part of which entails not charging patients for placebo treatments.

Personally, I think national and state professional associations should immediately consider the issue of standards of care in TCM as applied to herbal prescribing, particularly dosage.  Standards of care are standards we as a profession set internally.  If we cannot set them ourselves, they will be imposed.  If they are imposed by outsiders who do not understand our methodology, then our hands would really be tied.  I think that is an ominous scenario.  The solution is to develop an official pharmacopoeia similar to the German commission E monographs.  Among other things, this pharmacopoeia would address known issues of toxicity, drug/herb interaction and dosage equivalents for a wide range of products based upon their biochemical comparison to a standard decoction.  

 

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