Sample proposed intervention for a Nonspecific Autoimmune Condition

Five years ago client suddenly presented with acute high fever and severe pain leading to hospitalization and severe intervention of high dose steroids. After almost 3 weeks in the hospital and investigation of various diseases she was diagnosed with a non-specific autoimmune condition. She remained on high dose steroids for almost two years, each time she lowered her dose the inflammation increased and she was hospitalized.
After almost two years, she became pregnant at which time she ceased the steroids and had no recurrence of the autoimmune disease while pregnant and 6 months later. After 6 months, she recently had a full recurrence with hospitalization and life threatening inflammation and fever.
Sleeps poorly, 4-5 hours per night and then can’t sleep anymore. Bloodwork reveals elevated liver enzymes. Also concerned about cold hands and feet even when in warm places.

Body Type: Client is observed as fairly deficient woman of average height and weight with typical steroid side effects in her appearance. She appears pale and fatigued, with dark circles under her eyes.
Tongue: pale, glistening with little coat, puffy with scallops. Exercise: no formal exercise, has 2 small children
CV: Hypertension as a medication side effect.
Skin/joints: Joints are painful and stiff at times.
Digestion: Client reports limited digestive tolerance for foods. Reports raw foods, lots of vegetables and o most fruits cause her to have gas, distension, bloating and loose stools. Cannot tolerate fried or oily foods.
Urinary and Respiratory: Nothing notable
Pshyc / Social: Supportive family and colleagues. She is frustrated with her health and lack of
medical care to support her condition.
Medications: methotrexate 2.5mg, prednisone 40mg / day, beta-blocker Herbs and Supplements: none

Client is frustrated with her current health state. Despite getting the best care she can find because of her location and connections within the medical community, she has never gotten better. Life “looks grim” and she can’t imagine how long she can “ live this way”.


Gently incorporating walks  is a great first step.  Another idea might be to engage in a class at the Y or Curves or the local gym.  Once recent review proposed a hypothesis that exercise as an intervention could inhibit TNF-α production and increasing anti-inflammatory cytokines.  The mechanism they proposed involved recent recognition of skeletal muscle as an “endocrine organ” which expresses and secretes cytokines which exert endocrine/paracrine effects (Perandini et al., 2012). If she uses the Y she can most likely enjoy use of a sauna which could also prove helpful (Crinnion, 2011). In my limited experience,  people with cold and damp energetics tend to enjoy saunas.

From a dietary standpoint I initially thought that probiotics could be considered a good first choice for a dietary intervention but then I read a 2013 review of the recent literature at that time, and realized that this is actually a controversial subject. The author argued that there was enough evidence of probiotics such as  Lactobacillus casei actually stimulating of T helper mediated immune responses, to warrant caution.  The author did identify studies that showed an anti-inflammatory effect from increased production if interleukin-10 (Özdemir, 2013).

In clients who present with complex conditions like this are probiotics are a good choice to address the food sensitivities and poor digestion the client is experiencing or is the auto-immune imbalance severe enough to warrant caution?

Another dietary change the client could make would be to explore alternatives to soda such as La croix or pelegrino.  To go even further the client might consider exploring alternatives to cold drinks altogether.  Cold drinks suck up stomach chi to keep the “oven” at operating temperature and cause stagnation in the periphery.     Quick prepackaged teas such as morning thunder (caffine), hibiscus, orange zinger, rasberry zinger etc are varied enough in flavor to remain interesting.  I would point out to the client that diet and digestive health are going to play a significant role as allies in her return to balance, she may want to consider a referral to a nutrition specialist for an advanced consultation.


4g Cordyceps sinensis cordyceps dried mycelia powder 2:1

4g Curcuma Longa Turmeric dried rhizome powder

Yogurt with live active cultures

Powders are compounded for client.  Client mixes 4 grams of powder into a serving of the yogurt and eats this B.I.D.  Turmeric is kind of intense this way but this seems more convenient than pills and the powders are ideal for these plants.


6ml Apium gravolens dried seed ethanolic extract 1:2

2ml Smilax spp dried root ethanolic extract 1:2

1ml Zanthoxylum clava-herculis prickly ash fresh bark ethanolic extract 1:2

Formula is compounded for client.  Client takes 3ml of tincture T.I.D. Directly on the tounge or with a small amount of water or juice.

Monthly Cost:

38.40 for the powder

82.20 for the tincture

120.60 Total.

Smilax spp. is a building anti-inflammatory alterative that has exhibited hepaprotective effects in (ethically flawed) animal models.  Flavonoids isolated from Sasparailla have also demonstrated selective suppression of lymphocyte function. Curcuma Longa turmeric, is a pungent drying herb that down-regulates the constitutive activity of NF-kB, decreases expression of NF-kB target genes COX-2 and cyclin D1 and significantly inhibits cellular production of pro-inflammatory mediators TNF-a and NO.  Turmeric also inhibits release of MCP-1 from adipocytes. Apium graveolens is a warming seed that can serve a dual purpose of helping to bring balance to the inflammatory response as well as the digestive process.  Cordyceps sinensis, Dong Chong Xia Cao is a warm cardiotonic adaptogen that is useful as an immunomodulator.  Cordyceps has been shown to modulate cytokyne levels.     Zanthoxylum clava-herculis, prickly ash is a warming and diffusive herb that Traditionally was used for  Chronic rheumtism, deficient digestion and circulation, and pertinent to this client, cold hands and feet (Grieve, 1971) and (Priest & Priest, 1983).

Rehmmmania glutinosa is recommended by Kerry Bone for clients to prevent the suppressive effect of steroid use on endogenous steroids, but it’s contraindicated in excessively damp clients so while it was initially in the formula but I left it out.  I would be interested to know if anyone considers this a mistake, and that it would have been useful for this clien (Bone & Mills, 2013).

Turmeric potentially interacts with the P-glycoprotien substrates and same the CYP450 substrate as prednisone.  Natural Standards lists interactions between immunosuppressants and cordyceps as a moderate risk level but all of the studies are in vitro.   The botanical safety handbook lists cordyceps as interaction class “A” and actually discusses another in-vitro study which explores aqueous extractions of  cordyceps  combined with methotrexate (Nakamura et al., 2003).  Other studies have discussed immune suppressing effects of cordyceps (Chen, Shiao, Lee, & Wang, 1997).   Based on what I know now it seems like cordyceps is appropriate for use in auto-immune conditions.  But then again, this could be a totally aggressive and irresponsible formula for a deep and serious imbalance like this and the equivalent of running around squirting pokeroot 1:1 into the mouths of random neighborhood children.   I have marked cordyceps for further research but it won’t occur in time to be relevant to this weeks discussion so this is the formula I am going with based on the limited materia medica I have internalized so far.   


Bone, K., & Mills, S. (2013). Principles and practice of phytotherapy: modern herbal medicine (2nd ed). Edinburgh: Churchill Livingstone, Elsevier.

Chen, Y. J., Shiao, M. S., Lee, S. S., & Wang, S. Y. (1997). Effect of Cordyceps sinensis on the proliferation and differentiation of human leukemic U937 cells. Life Sciences, 60(25), 2349–2359.

Crinnion, W. J. (2011). Sauna as a valuable clinical tool for cardiovascular, autoimmune, toxicant- induced and other chronic health problems. Alternative Medicine Review: A Journal of Clinical Therapeutic, 16(3), 215–225.

Grieve, M. (1971). A modern herbal; the medicinal, culinary, cosmetic and economic properties, cultivation and folk-lore of herbs, grasses, fungi, shrubs, & trees with all their modern scientific uses. New York: Dover Publications.

Nakamura, K., Konoha, K., Yamaguchi, Y., Kagota, S., Shinozuka, K., & Kunitomo, M. (2003a). Combined effects of Cordyceps sinensis and methotrexate on hematogenic lung metastasis in mice. Receptors & Channels, 9(5), 329–334.

Nakamura, K., Konoha, K., Yamaguchi, Y., Kagota, S., Shinozuka, K., & Kunitomo, M. (2003b). Combined effects of Cordyceps sinensis and methotrexate on hematogenic lung metastasis in mice. Receptors & Channels, 9(5), 329–334.

Özdemir, Ö. (2013). Any role for probiotics in the therapy or prevention of autoimmune diseases? Up-to-date review. Journal of Complementary & Integrative Medicine, 10.

Perandini, L. A., de Sá-Pinto, A. L., Roschel, H., Benatti, F. B., Lima, F. R., Bonfá, E., & Gualano, B. (2012). Exercise as a therapeutic tool to counteract inflammation and clinical symptoms in autoimmune rheumatic diseases. Autoimmunity Reviews, 12(2), 218–224.

Priest, A. W., & Priest, L. R. (1983). Herbal Medication: a clinical and dispensary handbook. London: Fowler.

Extraction technique effects on constituent profile: Turnera diffusa

Assume that we are dealing with T. diffusa and not T. umifolia which is a small but significant adulterant in commerce.  The constituent profile for these closely related plants is very distinct (Schäffer, Gröger, Pütz, & Zimmermann, 2013). Let’s also assume a holistic perspective as opposed to a reductionist one (i.e. Galen vs Paracelsus) and grant a-priori that extracting a full constituent profile of the whole plant is the optimal extraction goal for therapeutic use within the modality of modern Western Herbal Medicine (WHM). 

Obviously, the easiest way to get the whole plant is by consuming fresh powdered leaf.

For many people who seek the therapeutic benefits of damiana this is an impractical method.  Ethanolic extractions can extend the life of a product to bring it to a wider market out of season.

Damiana is not in E.S.C.O.P’s monographs or  Hoffman’s “Medical Herbalism”,  In Bone’s “Guide to Blending Liquid Herbs” no discussion of constituents occurs.  In the Commission E monographs it is listed as an “Unapproved Herb.”   It is listed in the 1983 “British Herbal Pharmacopoeia” which states that T. diffusa has 0.5-1% or green volatile oil (which is mirrored in Grieve’s “Modern Herbal”) , 5-7% of a bitter substance, “damianin”, and 3-4% if a mixture of resins, tannins, starch, gum and fixed oils (British Herbal Medicine Association, 1983).    The constituents listed for Damiana in “Herbs and Natural Supplements 4th Edition) are: Alkaloids, flavonoids, arbutin (glycosated hydroquinone), essential oils containing caryophylline, delta-cadinene, beta-elemene and 1,8-cineole,  0.26% tertraphylin and possibly caffine (Braun & Cohen, 2015).  Skinderi corroborates the above, but lists the volitale oil as containing: 1,8-cineole, pinenes, thymol, o-cadinene (Skenderi, 2003).  Potter’s description of the constituent profile is similar (Williamson, 2003).

So a polity of authoritative texts list the constituents of damiana as follows with parts per million (ppm) as referenced from Jim Duke’s ethnobotanical database (Duke, 2016):


  • Alkaloids
    • caffeine
  • Phenols
    • Flavonoids
      • arbutin – 7000ppm
      • tannins – 75,000 ppm
    • Glycosides (cyanogenic)
      • tertraphylin B (barterin)
    • Bitter substance
      • damianin – 70,000ppm
    • Terpenes
      • resins (note: resins are composed of more than just terpenes) – 65,000 ppm
      • volatile oil
        • caryophylline
        • delta-cadinene
        • beta-elemene
        • 1,8-cineole – 1100ppm
        • pinenes
          • alpha pinine – 100ppm
          • beta pinine – 100ppm
        • thymol
        • o-cadinene
      • polysaccharides
        • starch
        • mucilage (actually an exopolysaccharide)
        • gum 150,000 ppm
      • protein
        • albuminoids 150,000 ppm


The main concern with extraction is ensure that the polarity of the solution is effective to fully extract the constituents. The because of the presence of oils and resins, a supercritical C02 (SCE) extraction stands a chance of getting a fuller constituent profile of these constituents (Ganora, 2009).  An ethanolic concentration of 20% is considered the lowest for shelf stability (Ganora, 2009).   The polysaccharides are typically water soluble.  The glycosides are soluble in water or ethanol, ideally hot.  The terpenes will require a high percentage ethanol solution. The flavinoids are all over the map but glycerin is a useful method for preventing the tannins from precipitating (Ganora, 2009). 

With damiana, as with many plants, any single extraction method is going to come with some compromises.   Lisa Ganora recommends using a medium ethanolic extraction method of 55-65% ethanol (Ganora, 2009).  The BHP calls for 60% ethanol. 

Based on my research and a full constituent assessment, an extraction of 30:10:60 (H20, Glycerite, Ethanol) will create a high polarity solution without being high enough to cause the tannins to precipitate out and take other important constituents with them. This may provide a fuller extraction even if many of the constituents facilitated by the addition of glycerin are not “active”.

So in conclusion:  Whole plant, hot tea, SCE, or a combination of ethanol/glycerin are effective ways of extracting damiana.



Bone, K. (1996). Clinical applications of Ayurvedic and Chinese herbs: monographs for the Western herbal practitioner. Warwick, Qld.: Phytotherapy Press.

Bone, K. (2003). A clinical guide to blending liquid herbs: herbal formulations for the individual patient. St. Louis, Mo: Churchill Livingstone.

Braun, L., & Cohen, M. (2010). Herbs & natural supplements: an evidence-based guide (3rd ed.). Sydney; New York.: Elsevier Australia.

Braun, L., & Cohen, M. (2015). Herbs and natural supplements an evidence-based guide. (4th ed., Vol. 1). Edinburgh: Churchill Livingstone.

British Herbal Medicine Association (Ed.). (1983). British Herbal Pharmacopoeia. Bournemouth: British Herbal Medicine Association.

Duke, J. A. (2016). Dr. Duke’s Phytochemical and Ethnobotanical Databases. Ag Data Commons. Retrieved from

European Scientific Cooperative on Phytotherapy (Ed.). (2003). ESCOP monographs. [Hauptbd.]: […] (2. ed., completely rev. and expanded). Exeter: ESCOP [u.a.].

Ganora, L. (2009). Herbal constituents: foundations of phytochemistry: a holistic approach for students and practitioners of botanical medicine. Louisville, Colo.: Herbalchem Press.

Hoffmann, D. (2003). Medical herbalism: the science and practice of herbal medicine. Rochester, Vt: Healing Arts Press.

Schäffer, M., Gröger, T., Pütz, M., & Zimmermann, R. (2013). Assessment of the presence of damiana in herbal blends of forensic interest based on comprehensive two-dimensional gas chromatography. Forensic Toxicology, 31(2), 251–262.

Skenderi, G. (2003). Herbal vade mecum: 800 herbs, spices, essential oils, lipids, etc., constituents, properties, uses, and caution. Rutherford, N.J: Herbacy Press.

Williamson, E. M. (2003). Potter’s herbal cyclopedia: the most modern and practical book for all those interested in the scientific as well as the traditional use of herbs in medicine. Saffron Walden: C.W. Daniel.

FORMULA All Purpose skin support salve With Calendula Comfrey Chamomile and Plantain

Calendula, comfrey, plantain and chamomile all have a long history of traditional use as skin supporting herbs.  They also share many of the same actions (Wichtl and Bisset, 1994).  The Commission E expanded monograph indicates the use of calendula for poorly healing wounds, bruises, boils and rashes.  Similarly, comfrey is indicated for pain, inflammation contusions and injuries although it is contraindicated for deep puncture wounds.  Plantain is a vulnerary and  anti-microbial and anti-inflammatory.   

The components of the salve are 90.8% Infused oils and ethyl-oil extractions, 9% beeswax and  0.2% Lavandula angustifolia essential oil.  The infused oil formula consists of: 7 parts Calendula officinalis infused olive oil, 6 parts Plantago major infused olive oil,  5 parts Symphytum officinalis sweet almond oil  and 2 parts of Matricaria recutita ethyl-oil extract comprised of M. recutita infused apricot kernel oil with an  of  M. recutita 1:5 60%.

The calendula and chamomile were harvested from my garden in late summer of 2015, dried on racks and stored in amber bottles in a climate controlled room.  The dried organic c/s plantain leaf which originated in Bulgaria, was purchased from Mountain Rose Herbs Lot 22223.  The beeswax is also from mountain rose, Lot# B8589.  The dried organic c/s comfrey leaf which originated in Croatia, was purchased from Starwest Botanicals Lot# 62288.  The M. recutita tincture was produced in January 2016 using the scientific maceration method. The olive and sweet almond oils of unknown origin were purchased from Essential Depot. Their 25 digit batch numbers are available upon request.  The Turkish apricot kernel oil is beauty aura brand with no batch number but an expiration date of 12/1/2017.   The oils were all infused using the “warm digestion method” (Green, 2002, p. 194.)

The ethyl-oil extraction was chosen for chamomile as a method of increasing the quantity of terpenes such as alpha-Bisabolol, matricarin and matricin, the distinctive chamazulene and phenolic coumarins relative to volume of chamomile infused oil in the final product.  These constituents are considered to be anti-inflammatory (Hoffman, 2003) and contribute to chamomile’s vulnerary properties (Braun & Cohen, 2010).   All of these constituents are well extracted in hydroethanolic solutions. The ethanol and water can then be evaporated increasing the levels of constituent in the oil solution.

Organoleptically all of the infused oils embody the energetics of the infused herbs.  The calendula oil is an orange yellow in color indicating a good extraction of the carotenoids and has the aromatic qualities of the flower. The comfrey oil and was an opaque dark green in color  and had the grassy sweet smell of steroidal saponins.  The plantain oil was also an opaque dark green in color and had the distinctive pepper scent of plantain tea.  The chamomile oil was a rich translucent and had the characteristic aromatic and bitter scent of the therapeutic volatile oils and coumarins as well a yellow color tint.  The chamomile oil was translucent.  None of the infused oils had the scent of fixed carrier oil.

To create the salve all glassware and containers were sterilized.  150ml of chamomile was combined with 100ml of M. recutita  1:5 60% in a boiling flask and heated to 130F until the ethanol and h20 have evaporated.  The ethanol was vented during this process.  This yielded 150ml of chamomile ethyl-oil extract.  This was combined with 550ml of the calendula oil, 475ml of plantain oil, 325ml of the comfrey oil and 165g of beeswax shavings.   The mixture was covered, heated to 150F until the beeswax was melted.  The mixture was blended with a stick blender until uniform consistency was reached.  A small sample was frozen to check viscosity of the final mixture.  3ml of lavandula angustifolia essential oil was added and the mixture was stick-blended again.   The  mixture was poured off into containers capped and allowed to dry. After wastage, the yield was approx. 1600ml  13  four oz jars and 2 1oz tins were filled.

The salve is a yellow in color with a slight front scent of lavender and a sweet scent of the combined aromatics of the infused oils. It is initially greasy but ultimately is absorbed leaving a slight sheen on the skin.  I was aiming for a salve without overpowering scent that was on the softer side so it cold be spread on wounds.

Next time I make it I would source higher quality oils, use exclusively almond and apricot oil instead of olive oil. I would also source better jars because some of the blue chipped off during boiling.


Braun, L., & Cohen, M. (2010). Herbs & natural supplements: An evidence-based guide. Sydney: Elsevier Australia

Green, J. (2000). The herbal medicine-makers’ handbook: A home manual. Freedom, CA: The Crossing Press.

Hoffmann, D. (2003). Medical herbalism: The science and practice of herbal medicine. Rochester, VT: Healing Arts Press.

Wichtl, M. and N.G. Bisset (eds.). 1994. Herbal Drugs and Phytopharmaceuticals. Stuttgart: Medpharm Scientific Publishers.