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.

Herbs:

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.

Tincture:

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.   

References:

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. https://doi.org/10.1515/jcim-2012-0054

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. https://doi.org/10.1016/j.autrev.2012.06.007

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