IMeG Health Clinical Report, 2009, No.
- Traditional Chinese Medicine Clinic
Suite 300 – 1177 West Broadway, Vancouver, BC V6H 1G3 • 604-736-8928 • info@imeghealth.com
Traditional Chinese Medicine Treatment of
Rheumatoid Arthritis (RA)
Keywords: arthritis, OA, osteoarthritis, RA, rheumatoid arthritis, Traditional Chinese Medicine, TCM,
Acupuncture, Herbal medicine, IMeG HealthTM Clinic, Vancouver, Canada, joint pain, inflammatory
pain, CAM, phlegm, blood stasis, herb-drug interactions
Introduction
There are more than 100 kinds of arthritis, the
most common of which are osteoarthritis (OA) and
rheumatoid arthritis (RA). Of the two, osteoarthritis is
the most common form, affecting approximately three
million Canadians, mostly over the age of 45. While
both forms involve the typical joint pain associated
with arthritis, they are in fact completely different
diseases.
Osteoarthritis is commonly caused by hard
repetitive activity, and joint injury. The condition is
normally limited to the joint capsule, and is the result
of the gradual deterioration of the cartilage that lines
the bone surfaces. As it wears away, the synovial
lining in the joint capsule becomes inflamed. When
severe, the bone ends will touch, and begin to wear
away, resulting in joint deformity.
On the other hand, in rheumatoid arthritis, the
inflammation is the result of an autoimmune illness.
Autoimmune conditions result when the body
recognizes some of its own cells as being harmful and
Clinical practice at the IMeG Health™ TCM
Clinic is supported by research at some of the finest
universities in the world. This platform enables
practitioners to achieve the mission of “patient-
focus” health care delivery. IMeG Health™ Clinical
Report is a community service provided by IMeG
Health™. For all enquiries on this report, please
contact the editor: Professor Steve C. F. Au-Yeung,
email: s.auyeung@imeghealth.com. Other clinical
resource materials are available on the IMeG
Health™’s website at www.imeghealth.com.
© Platinum Link Health Management Inc. 2009 All Rights Reserved.
in turn begins to attack itself.
Like OA, RA affects the joints, but in addition it can
also result in inflammation of the tendons, lungs, and
blood vessels. Over the years, there has been
speculation as to its causes, but as yet its cause
remains unknown.
Conventional treatment for rheumatoid arthritis
employs the use of pain killers, anti-inflammatory
medications (which includes the COX-2 inhibitors
such as Vioxx and Celebrex), and a category of
medications known as disease modifying anti-
rheumatic drugs, or DMARDS (which includes
medications such as methotrexate). Reports over the
last year have resulted in several of the commonly-
used COX-2 inhibitors being pulled off the market.
In addition to these conventional treatments,
more and more patients are seeking out different
treatment options, and in many cases seeing multiple
practitioners for the same condition. One of the most
highly sought treatment options is traditional Chinese
medicine (TCM).
TCM Treatment of Rheumatoid
Arthritis
Traditional Chinese medicine classifies all
arthritis as a syndrome called “Bi”, or “Painful
Obstruction Syndrome”. This syndrome is further
differentiated on the basis of the presenting signs and
symptoms, resulting in names such as “Wind Bi”, Pain
Bi”, Hot Bi”, “Damp Bi”, “Bone Bi”, and others. Many
studies have been conducted over the years as to the
efficacy of TCM in the treatment of this disease, many
reporting success rates of over 80%. However, in

many of those studies very little information is
i
provided regarding outcome measures. Still, there
are many studies that are noteworthy, and they do
point to the efficacy of TCM in arthritis.
In their paper “Arthritis and Acupuncture: The
Evidence for Effectiveness”, which was published by
the British Acupuncture Council in October 1998,
authors Saunders, Gould, and MacPherson reviewed
a total of 18 papers, and regarding rheumatoid
arthritis, they reached this conclusion:
“Acupuncture has been shown to give some pain relief
in rheumatoid arthritis and an anti-inflammatory
response may also be present. Treatment early in the
disease is preferable but age and duration of the
disease should not be seen as barriers to treatment.”
There are also countless studies regarding the
efficacy of Chinese herbal medicines. Some of these
studies examined the effects of a single herb, while
others examined the effects of herbal formulas. In one
such study, a team of researchers from the University
of Texas and the National Institutes of Health
analyzed the effect of the herb Tripterygium wilfordii
Hook F, or lei gong teng as it is known in Chinese.
Thirteen patients with long-standing rheumatoid
Table 1. Acupuncture: General Treatment Protocol for RA
Treatment Duration (# of Treatment Frequency
Phase weeks) (times/week)
I 2-4 2 -3
II 4-8 1-2
III 8 - 20 1 Good
IV 20 - 30 1 per 2 weeks
V 30 - 40 1 per 3 weeks
Maintenance Continuous 1 per month
Like the above acupuncture protocol, herbal
therapy is also of longer duration, and patients can
expect approximately one month of herbal therapy for
© Platinum Link Health Management Inc. 2009 All Rights Reserved.
IMeG Health Clinical Report, 2009, No.5
arthritis participated in the trial over a 12-18 month
period. Nine of the patients went through the whole
program, all experienced marked improvement and
one went into complete remission on a dose of 390
mg/day. ESR (erythrocyte sedimentation rate) went
from 55 mm/hour to 22 mm/hour on a dose of 480
ii
mg/day. Fuelled by the results of this small trial,
researchers are currently conducting a much larger,
double- blind, controlled study to confirm the benefits
of lei gong teng extracts.
Clinical Experience
In my own experience, I have found arthritis to be
one of the most commonly-encountered clinical
conditions, and one that responds very favourably to
treatment. Based upon my own clinical experience
using acupuncture, I have devised a treatment
protocol that divides the treatment into different
phases (Table 1). I recommend treatment initially at 2-
3 times per week for several weeks. Depending on a
patient’s reaction to treatment, this will be reduced to
1-2 treatments per week (perhaps for several weeks
or more), then 1 per week, then every 2 weeks, then
3, and eventually tapering to a maintenance schedule
of one treatment per month (plus or minus).
Receptivity to Total Treatments
Treatment
Good 4-12
Good 4-16
8-20
Good 10-15
Good 10-13
Good 10-12 per year
every year they have had the condition. Therefore, if a
patient has had RA for 10 years, they can reasonably
2
 IMeG Health Clinical Report, 2009, No.5

expect to be taking herbal medicines for at least 10 diagnosed several years earlier, and was prescribed
months. methotrexate, (a disease modifying anti-rheumatic
drug “DMARD”). Her pain was considerable and joint
deformity in the metacarpophalangeal (MCP) joints as
Case Example: Rheumatoid Arthritis
well as the thumbs of both her hands was evident.
(62-year-old Female Accountant) Her right hand was somewhat more painful, but both
were at times “intolerable”. Her hands were especially
The case history of a 62-year-old female stiff in the morning, and could remain so for several
accountant is summarized in Table 2. hours or more. She was an accountant, and the pain
made doing her job “impossible at times”.
Table 2. Case History - Rheumatoid Arthritis of the
Hands The TCM diagnosis confirmed that she was
suffering from “Bi Zheng” due to “Wind-Cold-Damp”
(considered to be the main etiological factors in
Chief Complaint Joint pain of hands arthritic conditions). In accordance with the
discussion presented above, the recommendation for
MD Diagnosis Rheumatoid arthritis this patient was a comprehensive treatment of
acupuncture and herbal medicine (Table 3). The
Treatment anti-inflammatory medication - acupuncture treatment focussed on invigorating
Methotrexate (DMARD) circulation and stopping the pain, while the herbal
medicine treatment focussed on resolving the Wind-
Cold-Damp condition, clearing the stagnation of
Phlegm and blood, tonifying the Kidneys,
A 62-year-old female sought help for her joint strengthening qi, and clearing heat-toxins.
pain due to rheumatoid arthritis. She had been

Table 3. TCM Diagnosis and Recommended Concomitant Treatment Modalities

Diagnosis:
TCM Disease: Bi Zheng
TCM Pattern: Wind-Cold-Damp Bone Bi
Acupuncture: Initial treatment frequency of weekly acupuncture, gradually decreased over
the course of one year
Herbal Medicine: Herbal formula was modified periodically, with focus on

 Clearing Wind-Cold-Damp
 Clearing stagnation of Phlegm
 Invigorating Blood
 Strengthening Kidneys
 Boosting Qi
 Clearing Heat-Toxins
Other Recommendations: The patient was also encouraged to participate in stress-reducing
activities such as meditation, and to ensure she was getting adequate rest.

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 IMeG Health Clinical Report, 2009, No.5

In autoimmune conditions such as RA, one has to
be careful not to stimulate the immune system too
much, but the main concern in the case of this patient
was her use of methotrexate. This drug has some
hepatotoxic effects (toxic for the liver), and some
studies suggest that the use of certain herbal
medicinals can add to the hepatotoxic effects. For
example, echinacea (not a TCM herb) is commonly
used to boost the immune system during bouts of
common cold. Studies have also shown that using it
with methotrexate can add to hepatotoxicity if used for
more than 8 weeks. Dang gui (Angelica) is a
commonly used TCM herb to invigorate circulation,
but it also can increase the hepatotoxic effects of
methotrexate. Understanding the possible herb-drug
interactions, an herbal formula was utilized, the main
focus of which was to address the phlegm and blood
stagnation.
The patient reported noticeable decrease in pain
after every acupuncture treatment. Sometimes it
would last for a few days, sometimes longer. She
found that the stress of caring for her ailing husband
directly influenced her level of pain, as well as too
much use of her hands (in the course of doing her
job).
She was treated weekly for 3 months, and then
bi-weekly for 3 months, then she began coming less
regularly because she moved. The patient was
treated for about a year, after which the pain, redness,
and swelling of her joints was significantly reduced.
Her treatment frequency and progress is summarized
in Table 4.

Table 4. Treatment Progress: Rheumatoid Arthritis of the Hands

Week # Treatment Frequency Treatment Response Practitioner Evaluation

1 - 12 Weekly Decrease in pain after every Joints red and swollen, pain
treatment. reduced on palpation.

12 - 26 Bi-weekly Good pain management, able to Reduced redness and swelling.

perform daily activities without pain.

26 - 52 Irregular Significant overall reduction in pain. Redness and swelling decreased.

At the last examination, she was more able to
carry out her daily activities, but was still taking the
methotrexate, as she felt “afraid to stop”. She has
since moved again, and it is not known how her
condition is now.
Interdisciplinary Communication – varied. Many (61%) thought it was not important for
the only way forward
Complementary and Alternative (CAM) therapies
are more popular than ever. A 2006 study conducted
by the Fraser Institute showed that more than 80% of
British Columbians have used at least one alternative
therapy at sometime in their lives, and of the therapies
most commonly utilized, almost one in five had used
iii
acupuncture. Unfortunately, despite the fact that the
majority of respondents had expressed “total”, or “a
lot” of confidence in their CAM provider, more than
half of those who had used CAM in 2006 did so
without discussing their use with their doctor. The
reasons for patients not having a discussion with their
doctor about their use of complementary therapies
their doctor to know about it, while 56% of
respondents said that their doctor had never asked
about these therapies. Thirty-one percent of
respondents felt that it was none of their doctor’s
business, and 11 percent were concerned that the
iv
doctor would disapprove or not understand.
Studies like the Fraser Institute Study illustrate
the reality of practicing medicine in modern times:
patients are commonly seeing multiple practitioners

© Platinum Link Health Management Inc. 2009 All Rights Reserved. 4


for the same condition, and often not informing their
practitioners of other treatments they might be
receiving. This is especially true for chronic and
enduring conditions like arthritis, and represents a
potentially hazardous situation. As the above Case
Example illustrated, some understanding of potential
herb-drug interactions is imperative in order to
mediate the risks of herb-drug complications. This fact
requires and demands more open communication
between different disciplines of heath service
providers (interdisciplinary communication).
In modern clinical practice, the prudent
practitioner will make himself aware of the potential
risks and benefits of such therapies as herbal
medicine. As an example, certain herbs have shown
an effect in enhancing the circulating levels of
corticosteroids by slowing their metabolism. This
action will not only increase the amount of natural
corticosteroids (hormones produced by the adrenal
cortex), but also any steroids administered as drugs.
Table 5. Summary of some Drug-Herb Interactions
Latin Name Chinese Name
Glycyrrhizin - a compound in licorice gan cao
Radix Ligustici Wallichii chuan xiong
Radix Saviae Miltiorrhizae dan shen
Radix Angelicae Sinensis dang gui
Magnoliae Officinalis hou po
Ligustri Lucidi nu zhen zi
Ginseng ren shen
Anemarrhenae Asphodeloidis zhi mu
Finally, immunostimulants such as echinacea and
zinc should not be given with immunosuppressants
© Platinum Link Health Management Inc. 2009 All Rights Reserved.
IMeG Health Clinical Report, 2009, No.5
When the steroid levels administered for treating
inflammation are high enough to cause some side
effects, elevation of the drug level by herb action
v
could increase the side effects. At the same time,
due to this very interaction, conventional steroid
therapy could be reduced. This has been exactly the
case in Japan, where an herbal formula called Chai
Ling Tang (Bupleurum and Hoelen Combination) has
been used in cases of rheumatoid arthritis and found
that the result is a reduction in the dose of steroids by
up to two-thirds. It was also shown to be helpful in
vi
reducing arthritic inflammation.
Studies such as this would indicate that there can
be a positive effect for the use of herbs in combination
with corticosteroids, but it also presents a potential
problem: if a medical doctor is administering high
(rather than low) doses of steroids to a patient who is
also taking herbal medicine, the effects can be
vii
adverse . Other examples of potentially negative
drug-herb interactions are summarized in Table 5.
Drug–Herb Interaction
may prolong the biological half-life of the systemic
corticosteroids
may interfere with Anti-Coagulating drugs
may interfere with Anti-Coagulating drugs
may interfere with Anti-Coagulating drugs
contains magnolol, a mild anticoagulant. Caution should be
used in patients taking antiplatelets or anticoagulants
including; aspirin, dipyridamole, clopidogrel(plavix), heparin,
warfarin, and enoxaparin(Lovenox)
lowers plasma glucose levels. Combining this herb with anti-
diabetic medication such as insulin or sulfonylureas may result
in hypoglycaemia
may reduce fasting blood glucose levels. Hypoglycemia may
occur when this herb is combined with drugs for diabetes
mellitus.
may interfere with Anti-Diabetic drugs
such as corticosteroids (prednisone, etc.) and
cyclosporine, and are contraindicated in patients
5
 IMeG Health Clinical Report, 2009, No.5

suffering from rheumatoid arthritis and systemic lupus

erythematosus.This list is far from exhaustive, and i
Saunders, Gould, MacPherson. “Arthritis and Acupuncture:
while it remains true that we still do not know all The Evidence for Effectiveness”. Edited and produced by the
possible interactions, steps can be taken to ensure Acupuncture Research Resource Centre. Published by the
that those situations that could be problematic are British Acupuncture Council, October 1998.
understood. Inherent in this understanding is the very ii
Xuelian Tao, Jean Younger, Fred Z. Fan, Betty Wang,
real need for open communication amongst the
Peter Lipsky. “Benefit of an extract of Tripterygium Wilfordii
practitioners, and between practitioners and patients. Hook F in patients with rheumatoid arthritis: A double-blind,
Statistics point to the fact that patients will explore placebo-controlled study”.
other treatment options, and only by encouraging
iii
open dialogue will practitioners be armed with all of Esmail, Nadeem. The Fraser Institute, “Complementary
the information necessary to the formulation of and Alternative Medicine in Canada: Trends in Use and
Public Attitudes, 1997-2006”.
effective, safe treatment.
iv
Ibid.
SUMMARY v
Subhuti Dhamananda. “The Interactions of Drugs and
Herbs”. Institute for Traditional Chinese Medicine, Portland,
Acupuncture and traditional Chinese medicine (TCM) Oregon.
have been safely used for thousands of years. My
vi
clinical experiences would corroborate with many Ibid.
studies that point to the benefits of acupuncture and vii
Ibid.
herbal medicine in the treatment of arthritis. In some
cases treatment might only involve acupuncture, and
other times a comprehensive therapy of acupuncture
and herbal medicine is employed. In almost all cases,
patients will also be taking conventional medications
for their condition. Those medications typically include
NSAIDS, DMARDS, COX-2 inhibitors, and
corticosteroids. Statistics show that when properly
prescribed, herbal medications and conventional
medications can work well together. Unfortunately,
statistics also show that many patients are not
informing their doctors of the other therapies they are
using. This fact is disturbing at best and potentially
hazardous at worst. Medical doctors, rheumatologists,
and doctors of traditional Chinese medicine must
begin open and clear dialogue and communication in
order to ensure our patients are receiving the highest-
possible level of care, in order to most effectively treat
these very common conditions.
TM
At the IMeG Health Clinic, traditional Chinese
medicine doctors are supported by up-to-date
knowledge of herb-drug interactions, and current
research studies in the field of TCM by some of the
finest TCM universities in the world. These materials
are available on our website at www.imeghealth.com.

contributed by Bradley Matthews, Dr. TCM

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