Course:

Course: Diabetes SeminarDr. Zheng ZengDate: October 3, 2009

IntroductionThis is the #3 killer in the US at this point.

Diabetes is a disease in which blood glucose levels are above normal. WE mostly see type 1 and 2 diabetes though there is a 3rd. Type 1 insulin resistant diabetes. Dependent upon insulin administration as they cannot make enough or any. Herbs to lower blood sugar dont work for these types. You can use herbs to mitigate circumstances however. Type II make insulin, but dont use it well. Insulin resistance is first. This is a condition in which muscle, liver and fat cells dont use it properly. At first the pancreas keeps up with demand by producing more, but over time lose ability to secrete enough in rsvp to meals. Herbs work better if never had insulin tx. Helps with complications of diabetes (diarrhea and incontinence for instance).

Gestational Diabetes develop in late states of pregnancy. Generally around 28 weeks. Usually resolves after delivery of child, but higher risk of diabetes in later life. Mostly dont need herbs though many are safe more on that later. Change in diet/exercise will manage. Often due to Spleen Qi xu, unable to convert food to glucose properly. Diagnosis of DiabetesFPG test (fasting plasma glucose) measures blood glucose after 8 hours w/o eating. In the diagram to the right, the FPG numbers are indicated by the arrow on the left side. OGTT, the oral glucose tolerance test, mostly used for preggers testing. Measures blood glucose after 8 hours w/o eating then 2 hours after drinking glucose containing beverage.

Steps to delay/prevent Type 2?

Change diet to lo fat, lo cal and lose a modest amount of weight. Walking briskly for 30 minutes 5x per week will do the trick actually.

The most important thing for diabetics is exercise, followed by diet. And the thing about exercise is that Qigong and Yoga dont work. Gotta get physical. Points to Remember Check the blood glucose levels.This is key for diagnosis. You cant tell by symptoms alone.

Symptoms of DiabetesSome patients dont have the following symptoms since they appear after having diabetes a while. This exacerbates the symptoms.

Increased urination

Increased thirst

Increased hunger

Unexplained weight loss

TCM DiscussionEtiology

Heat in the body can be the problem, but mostly related to the diet. Greasy foods (especially greasy foods) and lots of sugars can create damp heat.

Emotionally it could be too much stress or emotional stimulation/shock which block the channel.

Overwork including mentally/physically. This can generate stress.

Inheritance

Differentiations

Etiological factors can lead to disorders of Zangfu lung, kidneys for instance. Xiao Ke indicates excessively thirsty/hungry but with weight loss (ke). Some people divide diabetes into upper, middle and lower xiao. This is similar to upper/middle/lower jiao problems. Upper jiao = lung or heart fire generating dryness which can increase thirst. Herbs will be more nourish yin.

Middle jiao/xiao = stomach fire (excess heat) or yin xu (deficient heat). This manifests as excessive hunger (or possibly thirst). Unexplained weight loss and fatigue can be attributed to Spleen and ST qi deficiencies. Even without other symptoms the fatigue is usually found. Spleen isnt digesting/converting properly, hence the high blood sugar levels. Spleen also ascends clear essence/yang with Sp qi xu cant ascend, so essence isnt ascending and blood sugar isnt working. This is why we use Huang Qi in many diabetic support formulas. This assists in fatigue, regulates blood sugar. Huang Qi makes the blood sugar normal with both hypo and hyperglycemia. Shan Yao is another good food/herb 100 200 Shan yao per day. Many practitioners will recommend the decoction because you dont get the carbs (and the resultant sugar conversion problems).

Many herbs for tonifying Qi and yin.

Lower jiao/xiao = Kidney and Liver yin xu, LV qi yu, and often/eventually KI yang xu. Increased urination results.

Blood Stasis, Phlegm or Damp and Heat

These are always found in diabetes! Blood Stasis. This is the most important of the three. When heat consumes the body yin/fluids the blood gets thicker circulation problems. Blood sugar raise also = circulation problems. Vascular disease such as retinopathy, macular degeneration/edema, TIAs, peripheral neuropathy, tingling, erectile dysfunction and more are common for this reason. Even if a patient doesnt have stasis symptoms you can add herbs for blood stasis. (Dan Shen for instance gentle and no bruising/bleeding)Early stages of neuropathy can be improved by blood sugar control. If the blood sugar levels are high the responses are poorer.

Damp/Phlegm

High cholesterol tends to follow damp retention/blood sugar problems. Incontinence not uncommon for insulin dependent/Type 1 diabetes. Blisters on the feet also common. Patients can have this even in the presence of yin xu. This is the only one that may not be present of this triumvirate. Heat

Skin infections that last for a long time. Toxic and damp heat. Excessive thirst and hunger are also heat related.

Notice in the table above how large the Tonify Qi and Tonify Yin herbs are. Helps blood sugar levels. Single herbs to lower blood sugar levelsThere are more than are listed here, but this is a good starter pack!

Clear Heat, Drain FireShi gao for instance. This is a big time clear heat, but it was noticed in context of the formula Ren Shen Bai Hu Tang. When Shi Gao was taken out of this formula using only ren shen and zhi mu the lower blood sugar effect seemed not so good. Shi Gai and Zhi Mu paired help lower heat and blood sugar. Zhi mu in tincture (true of other herbs too) works well. Shi gao, zhi mu and tian hua fen good effect for the excessive thirst too. Bai Hu Tang formula has these. Tian Hua Fen has a side effect to create a lot of saliva thats why it helps with thirst. If you dont have the dryness or thirst, thats really annoying however! Like Huang Qi it will 2-way regulate blood sugar. Tian Hua Fen tincture doesnt lower blood sugar, but decoction does. ZZ: theoretically tincture not so good for diabetesjust her opinion. Tian hua fen extract with abdominal injection can cause uterine contractions which terminates preggersbut there are some proteins in this herb that can cause allergic reaction. Some reactions were quite severe. Clear heat and cool blood category

Sheng di and xuan shen commonly used. On the handout, page 11, look at the bottom. Add Sheng di to the middle line. These are paired herbs. In the case of the middle line, its a trinity.

Sheng di can stimulate the production of insulin and make the body more sensitive to insulin. Overdose of sheng di can make the bowel movement loose. ZZ gives about 15g of sheng di. Can also cause gas and bloating because its cloying, though Shu di is worse. Xuan Shen can lower blood sugar, but when comparing singles, sheng di is stronger. Can also lower high bp, which is handy since a lot of diabetics have high bp. Xuan Shen doesnt increase/decrease insulin receptor binding rate, however.

Clear heat and dry dampnessHuang qin and huang lian. Some research says huang bai also.

Huang qin lowers blood sugar after eating, so not just for empty stomach. Also prevents complications of diabetes, esp cataracts, kidney problems.

Huang lian also lowers blood sugar for high blood sugar patients, but not if blood sugar is normal. Also decreases cholesterol levelof course this is only in rats, so if you have a rodent with this problem, now you know what to give them. Huang lian clears MJ and heart heat as well. For MJ problems, use small doses and stomach muscles will become more active and digestion is better. The formula Jian Pi Wan has a chief of bai zhu, but 6 grams of huang lian. Large doses (10g or higher) will reduce contractions in the GI tract, which is how it is used for dysenteric diarrhea. Huang qin/lian often used together for excess cases.

Clear heat and relieve toxicityMa chi xian (purslane or portulaca) doesnt get a lot of press here. In china its both a veg and an herb. Used to treat diarrhea in china. Has good result for eczema, esp fresh version. From sacredlotus.com:

Relieves Fire Toxins and Cools the BloodFor dysentery from Damp-Heat or Fire Toxins, urinary tract infections with Blood, red and white vaginal discharge, and post partum bleeding.

Reduces Sores from Damp-HeatCan be used both topically or internally.

Used to reduce the swelling and pain from snake bite or wasp stings.

Clear deficiency heatDi gu pi and gou ji zi come from the same plant. Di gu pi is the root bulb. Both lower blood sugar, bp and cholesterol. In tincture or decoction form lowers bp. Di gu pi 50g per day cooked with 500mg of water is used as a common tea in parts of China. Can help drop blood sugar to normal level. Cool herbs that release exterior

Niu bang zi lowers bp and blood sugar levels. Actually helps keep it even. Not a lot of clinical reporting about this though. Ge gen lowers blood sugar and secondarily treats and prevents diabetes complications including cataract, nerve, kidney etc. Also lowers bp and chol. Sang ye (leaves), sang zhi (twigs expel w/d and clr heat category), sang bai pi (root bark), and sang shen zi (fruit), all mulberry tree components, lower blood sugar. Even the silk worms and silk worm poop do this. Basically, eat the whole tree, bugs and all. Stabilize and bindShan zhu yu lowers blood sugar and also increases insulin secretion. Helps body use blood sugar more efficiently. Mostly for xu cases yin xu for instance. Transform phlegm coldJie geng is actually neutral despite the category. Has a lower blood sugar level in both decoction and tincture form. Cholesterol level related to phlegm can also be treated with this herb. Aromatic herbs that tx damp

Cang zhu is fabulous. Wont raise/lower if blood sugar normal, but if low will slightly raise not so strong. Diabetes can be related to spleen/stomach abnormality and failure to use blood sugar correctly. This would be used for damp retention causing blood sugar problems. Historically upper xiao was treated with he ye, middle with pei lan, and lower with bi xie. All of them treat dampness/draining damp.

Drain dampFu ling is used as an insulin sensitizer, making the body more aware of it. Yi yi ren helps lower blood sugar and can be used in the diet rather than in herbal decoction form. Both drains damp and tonifies Spleen. Can induce ovulation. Dont use for preggers due to possibility of miscarriage. This herb is used in PCOS patientswhich is complex since many patients with PCOS are coming for infertility! PCOS patients are often insulin resistance often report excessive hair growth, acne, and weight gain despite small food intake. PCOS patients often have a lot of damp retention. Ze xie also lowers blood sugar levels. Move bloodMost cases for diabetics reflect blood stasis. Not that many herbs listed here, but you can use the others.

Niu xi seems to target lower extremity circulatory problems. Legs are far away from the heart due to the distant proximity to the heart. The first vascular complications typically show in the feet for this reason.

Xue jie heals wounds and prevents blood clots. Also lowers cholesterol. Not used much in the clinic.

Dan sen

Stop bleedingSan qi also promotes blood circulation. Stops bleeding through moving blood! Huh? Bleeding due to clots for instance. This is not uncommon for abnormal gynecological bleeding lots of blood with huge clots. (Dont use for small clots this is a different situation.) Only use for a couple of days and will usually do the trick. The heavy bleeding occurs because the clots break loose usually comes along with cramps. You can also use san qi for problems of the eyes due to diabetes. Dosages should be small. Large doses will cause too much bleeding because the blood would be strongly encouraged to flow. Choose the raw San Qi (which you can get in powder form/capsule form), not the steamed. (Steamed nourishes, not stops.) Start at 1.5 grams, up to 2-3 times. Same for lowering blood sugar go small, like 1-3g per days. San qi is effective for about 24 hours, then the blood sugar goes back up. Taking san qi long term can reduce platelets. This is the chief herb in yunan biayao. Only use as needed. Downward drainingDa huang not often used in clinic. Poop-a-pa-looza. Can be used for insulin resistance. High insulin blood level will breed high cholesterol/bp. Several formulas for high chol/bp have da huang in them. Good herb for pts with history of intestinal infection. We study da huang as a purgative, but its also cooling and moving. To mitigate the purgative, cook longer and helps cool/move blood. More excess cases tend to have insulin resistance. Use da huang in these cases.

Subdue LV yangMu li (sheng version). Supplies calcium, improves insulin saturation. Patients with heat and lots of sweating LV qi stagnation with heat responds well to mu li. Also controls blood sugar. Diabetes patients can take this long term.which is a good thing because diabetic patients take herbs long term and take a lot of em. Tonify QiThis is the big category. Commonly and often used. Ren Shen

Xi yang shen and dang shen work too, but the research is about ren shen. Lowers blood sugars. Xi yang shen is more often used in Texas. Ren shen has a 2 way regulation on blood sugar. Hypoglycemics with light-headedness and such have qi and blood xu. Works for them too.

Strongly tonifies qi. Lowers sugar in the urine and in the blood if used singly can mean that the patient doesnt have to take as much insulin.

Caution: Then again, if you take a bunch, can raise bp.

Bai Zhu

Regulates intestinal functions. Dries dampness so could cause constipationthen again, helps with diarrhea!

Huang qi

Lowers blood sugar, but also for complications related to diabetes. Huang Qi Tang is a Sun Si-miao formula, used for Xiao Ke: huang qi (chief), fu shen, gua lou, zhi gan cao, mai dong, sheng di, all at 9 grams but for sheng di at 15 grams. All of these herbs lower blood sugar. Interesting that gan cao, though sweet, lowers blood sugar. Formula also raises blood sugar for hypoglycemic patients.

Huang qi is also very good to help protect the KI functions. Can lower the protein spillage to the urine. Huang qi in larger doses (20-60g) helps reduce proteins in urine. Tonifies qi, promotes urination/drain dampness to get out excessive water.

If someone already has this and gets to the dialysis stage, use da huang rather than huang qi.Diabetics can have long term ulcers if due to qi xu, use huang qi, dang gui, zao jiao ci.

Shan YaoUsed as a food in China. Dont use the chao form as it does not lower the blood sugar. Only the raw works steam cooked works ok. 150g/daily and blood sugar will drop within 10 days. Since it is expensive here usually only dosed at 50g daily. Bai Bian Dou

Tonifies spleen qi, is used as a food in China. Lowers blood sugar and cholesterol. Tonify Blood

Bai Shao Nourishes blood and treats Liver problems. Combine with da huang and sheng di. Both decoction and tincture will work.

Nourish Yin

Mai dong

Sang shen zi

Gou qi zi

Nu zhen zi nourishes yin and is less cloying than something like shu di huang. No gas/bloat side fx. Also lowers cholesterol as well as the eye pressure (glaucoma). Yu zhu nourishes yin especially for stomach problems, treating excessive stomach fire/hunger. Combine with shu di. Tonify YangYin yang huo helps blood sugar levels and blood cholesterol levels. If patient has water retention, combine with other herbs. Because it is warm, can help blood circulation in certain tissues/organs.

Yang xu can result in blood yu as can yin xu. Sha yuan ji li

Diabetic complications, mostly urinary.

Warm interior herbs

Fu zi. Not used often and if so, in small doses. Helps body use glucose instead of raising insulin level.

Rou gui. Some studies are using rou gui/cinnamon to lower cholesterol and blood sugarsbetween 1 and 6 grams per day. Even 1 gram works. Beware of heat and/or yin xu with xu fire with use of this herb, however. Use these herbs choose by differentiation.

Pairing Herbs

Shi Jinmai promoted the concept of pairing herbs. He was famous for this from 50s thru 70s.

Spleen def can result in too much sugar in the blood, then in the urine. Fatigur, catch bugs easily, sugar in urine. Change in diet is very helpful. To treat this Shi Jinmai used these pairs:

Huang qi + shan yao

Ton sp qi, lowers blood sugar levels. Yin component is shan yao while huang qi is more yang, thus the pair is balanced.

Cang zhu + xuan shen +

Similar. Thi is more for spleen and kidney.

Ge gen and dan shen

This pair is actually from Shi Jinmais student and s about assisting the blood.

Dosages were traditionally large. Now they are less since our requirements are less. Also, they are gentle and they are food.

Huang qi = 30-50g + Shan yao = 30gSpleen Qi xu Cang zhu = 15g + Xuan shen = 30 gYin xu, damp ret, stagnant heat, blood heat Ge gen = 15g + Dan shen = 30gBlood stasisCan use all pairs if they have all of the above. You can also use sheng di huang, cang zhu sheng. FormulasLung and heart symptoms. Benefits liquids. Thirsty symptoms mostly, caused by lung heat/dry and heart heat.

Xiao ke fang/dan xi xin faMost important formula for upper jiao xiao ke. Tian hua fen has that drool side fx. Huang lian is about fire/heat clearing. Sheng di nourishes yin/cool blood. Ou zhi isnt often used thats the lotus root juice. Cow milk was rare in China long ago now its not so common since there are lactose intolerance and allergies. You could also add mai dong to nourish the yin.

Excessive thirst and drinking will cause excessive urine since the water metabolism is so far off basically goes right through. You cd also add ge gen or lu gen or mai dong.

Bai hua jia ren shen tang used for diabetes with excessive thirst, hunger and constipation. You can swap ren shen for xi yang shen and save some $. Er dong tang also used for excessive thirst and dryness mouth, nose, dry cough.

If you look at the top 3 formulas you see they help benefit the liquid, good for excessive thirst.

Sheng mai san often used for diabetics. Qi and yin xu in diabetics often seen as well. This is a commonly used formula for this pattern with diabetes. You can add the three pairs of herbs above plus this combination. Jia jian yi yin jian also nourishes yin. Useful for when patients have metal and water or Lung/KI yin xu diagnosis. Excessive thirst, weak lower back/knee, night sweating, hot flashes, dryness, thirst in evening/afternoon, qi xu sx. Can add qi tonifying herbs huang qi + shan yao. Again, tonify the Sp qi! unless you see strong wiry/slippery pulses which are excess sx. Huang qi tang here is different than found in the book mentioned earlier. This one is huang qi, ren shen, mai dong, wu wei zi; add sang bai pi, gou qi zi and shu di.

Mai dong yin zi shares 3 herbs (ren shen, mai dong, wu wei zi) with huang qi tang above. Lots of calm shen herbs herein. Nourishes heart and lung yin . Traditionally used for overthinking + diabetes + irritable and thin/rapid pulse.

Middle jiao symptoms include SP and ST problems such as ST fire, ST yin xu with xu fire, constipation, excessive weight loss, strong/powerful/slippery/wiry pulse.

Bai hu tangAdd herbs inside such as ren shen or xi yang shen. Except about that add some clr heat herbs such as huang lian, clr ht/drain fire such as tian hua fen or ge gen for excess types. For yin xu with xu heat you add shu di and other things to tonify yin.

Da huang gan cao yin ziDa huang is the chief. Also gan cao and hei dou (black beans). Helps reduce cholesterol level, but no research says that it directly reduces blood sugar. Traditionally cooked 3-5 hours so black beans are all mushy like kanji. Cooking da huang and gan cao together for a long time will reduce purgative functions so is more clr ht/move blood. Zhu ye shi gao tangUsed for ST yin xu. (Excess fire long term damages the yin.) Clear heat herbs and nourish yin herbs in this formula. Ban xia is in this formula even though this wasnt one of the single herbs discussed previously. Youll see this in the Lan Xiang Yin Zi formula below also. Some historic practitioners disagree with this thinking it was too dry. Cang zu and pei lan are more gentle to clear the damp than ban xia. Yu quan wanThere is a patent for this. Very good formula to nourish qi and yin. Not many side fx and can take long term. Formula may differ from what is listed above in the table.

Another formula you can use for MJ problems to benefit body liquid is Zeng Ye Tang.

Sidebar: how long does a patient need to take herbs? Years? Not always. Depends on length of time patient has had diabetes, severity of situation, patient response. If patient is already on drugs, probably more long term. If your patient takes herbs as well, encourage them to check blood sugar levels 3 times daily.

Use the pairs for Sp Qi xu.

Exercise and diet change are more important than herbs!

Sheng di ba wu yinST heat w/excess hunger and Ki yin xu. Rarely usedLan xiang yin ziST heat with damp rt. Excessive hunger, appetite might not be excessive. Thirsty, low energy, constip, sweating. Bai zhu sanSp qi xu, esp in early stage. Originally created for pediatric practitioner for childrens food stagnation. Yu ye tangMore frequent use than previous 2. Strong Sp qi tonification for Sp qi xu type diabetes. Good formula. Contains a couple of the pairs. Ji nei jin within this formula this is the chicken gizzard from the food stagnation category. With neuropathy, move blood!! for Mrs. Barnes.

Mostly kidney problems, often excess urination difficult and/or cold urine. Early stage diabetes is often Sp qi xu, but when that lasts a long time without good blood sugar control patient can long termly has Kidney yin xu. Later stages with poor blood sugar control KI yin xu will then transform to Ki yang xu. Zuo gui yinUsed for long term diabetes. Youll see Ki yin xu. Liu wei di huang wanTon Qi, enriches and nourishes KI yin and Lv yin. Mai wei di huang wanTon Ki essence. Yu nu jian This is the formula used for ST heat and KI yin xu.

Da Bu yuan jianTonifies KI qi. Patients with long term diabetes or pt blood sugar uncontrolled long term ( ki qi xu. Will have ki xu sx or ki yang xu sx: weak lower back/knee. Also night urination, sexual problems like impotence/premature ejaculation. Can treat those by tonifying ki yang, but not all pts have good results. Jin gui shen qi wanBoth this and the next are for ki yang xu. Zhen wu tangYang xu with water retention. Reduces edema from this complication swollen feet/lower legs plus proteins spilling in the urine. One other formula is Ji sheng shen qi wan, based on jin gui shen qi wan and adds promote urination, move blood herbs good for protein in the urine too. You can add huang qi to formulas to help with this too. NOTE: when a patient cant get rid of toxins and need dialysis. In ancient times used da huang to clear it out through the GI tract. We often dont give these patients herbs now because of the toxin buildup. Commonly used modifications

Thirst. Wu mei might help w/thirst due to the uber-sour taste! In the MJ formulas above, yu quan wan (jade spring), can use for excessive thirst.,

Hot flashes. Dont have to use these 2 herbs. Could use yin nourishing herbs and clear deficient heat/clear heat/cool blood. Could also use sheng di, mu dan pi, di gu pi, zhi mu. Differentiate between full and deficient heat! Excessive hunger. ST excess heat = shi gao, zhi mu.

Freq p.m. urination. Ask whether it is scanty or profuse. If scanty, dh in the lower jiao. Profuse is ki xu. Sang piao xiao to stabilize the bladder will help too. Gou qi zi and xu duan will help lower blood sugar.

Urine incontinence. Bai guo is astringent. Sang piao xioa too. Zhi ki helps make muscle stronger to help control the bladder.

Constipation treatment depends on type/differentiation. Dang gui and bai shao nourish and moisten. He shou wu and nu zhen zi also moisten. He shou wu however should not be used with liver problems like elevated liver enzymes, other liver dysfunction, especially with long term liver dysfunction. Itching skin. Bai ji li and di fu zi are listed, commonly used for lots of different skin itching, but there are others. This is more to take internally to take with itching skin.

Edema on the lower extremities. Theres a difference between edema lower and edema upper/face. Edema on the upper/face is due to lung. If on the lower body, use urination/drain damp herbs. If on the upper, use expel wind and induce sweating herbs. Diabetic complications are mostly lower extremity version. Bie xie separates and clearsand I didnt catch the other. Whatever. Look it up. Zhen wu tang can be used for lower body edema. Lower back pain. Lots more than listed here. Xu duan and sang ji sheng are mentioned here and are gentle. Use strengthen tendons/bones herbs.

Weakness of knees. Often with lower back pain. Qian nian jian in strengthen tendons/bones mostly for arthritis type cases with knee painoverdose can = toxicity, so use less than 12 g. Gou ji, xu duan, du zhong all tonify ki, str tendons/bones. Numbness on extremities. Xi xian cao is expel wind/damp herb. Ji xue teng is a blood mover to help extremity numbness. Gou teng toonote that both this and the previous are vines the extremities of the plants. Both treat numbness. MOVE BLOOD!! For numbness/tingling. Acupuncture is the 1st choice and works better than the herbs. The earlier the tx, the better. Several yearsless response.

Try heat lamp, zheng gu shui when there is tingling. Encourage daily self-massage, heating pad. Complications of Diabetes and TreatmentEyes, feet, cerebral/brain and kidneys are commonly affected as is nervous tissue. Many of these are related to blood circulation problems. Many practitioners will add move blood herbs into a formula even if there are no complications evident when the patient is treated. This has excellent effect to delay complications. Can even lower necessary insulin doses. Eyes

Fluctuating blood sugar causes the lenses of the eye to swell and shrink, resulting in fluctuating vision. When sugars are high, damage is underway. Once damage begins, its hard to stop. Loss of vision in diabetes is due largely to blood vessel damage. Blood vessels leak causing blood on the retina. Blood vessels also become blocked and then new vessels are formed. Abnormal growths cn press on the retina, even cause the retina detach. Abnormal pressure changes occur as well. There can be damage even before the patient notices problems.

Retinopathy.

There are two kinds nonproliferative and proliferative. Nonproliferative is common for Type 1 patients. In proliferative the blood vessels close off, there is vitreous hemorrhage, and retinal detachment. Retinopathy is often treated through laser surgery or traditional surgery. Earlier diagnosis yields better results. TCM treatment depends upon differentiation. 1. LV/KI yin xu. Early stage is more likely to be yin xu.Blurry vision, dry eyes/skin, weak lower back and knee, etc. Qi du di huang wan, ming mu di huang wan (better taken long term), shi hu ye guang wan, and bu zhong yi qi tang.

2. Qi/yin xu - Early stage is more likely to be yin xu. sheng mai san plus qi ju di huang wan. Both are good. Qi ju di huang wan also helps for dry eyes.

3. Yin/Yang xuMostly later stages of diabetes with eye problems. Jin gui shen qi wan + huang qi, dan shen, che qian zi, kun bu. Kun bu helps resolve nodules and abnormal growths, used since long term retina problems include scarring.

Zhu jing wan is a classic formula for clearing the vision, eye problems with ki xu and water retention: shu di, che qian zi, shan yao, shi chang pu. Also used directly after eye surgeries in China. Short term formula 1 to 4 weeks. Modifications for these formulas

1. Bleeding in the vitreous hemorrhage. Bleeding in the bottom of eyes.

a. Huai hua -- stop bleeding, lower bp, helps upper part of the body, makes blood vessels more flexible thus less bleeding

b. sheng pu huang non-dry fried is better to stop bleeding (dry fried moves blood stasis).

You could also use san qi in small doses to emphasize stoppage (1-2 g per day). Too much will make bleeding worse. Dont use raw, use powdered instead. If you are giving a raw formula, include san qi powder separately and have patient mix it in to the cooked decoction.

2. History of vitreous hemorrhage (bottom of eyes), blood stasis not absorbed

a. San qi

b. Dan shen gentle, low dose (10-15g raw is enough).

c. Sheng pu huang

3. Macular edema

a. Che qian zi excellent for herbs

b. Dan shen

4. Scar tissue growthHerbs are about resolving phlegm nodules

a. Kun bu kind of food in china. Prescribed as food. Eat 1ce to 2ce a day. Works for enlarged tonsils and such too.

b. Hai zao - foodc. Sheng shan zha also foodd. Bei mu

5. ConstipationPushing required to get fecal matter out can cause pressure in the eye and cause bleeding in the eye. Heart attack and stroke not that uncommon either. a. Huo ma ren moistens the intestines. b. Da huang purgative. Helps intestines move better. c. Zhi shi different opinions about this herb. Some practitioners wont use it because theres a possibility of raising the blood pressure. Studies about injectable forms have found this to be true. d. Gua lou ren

6. Excessively thirstyDiscussed previously. a. Tian hua fen

b. Shi hu

c. Ge gen

d. Shi gao

e. Zhi muTeas

In China the tea lasts longer when they drink it put the herb in the water, drink. Refill with hot water when the previous is almost gone dont drink it totally down though or its not as active on successive refills.

1. Ju hua, huai hua, green tea 3g each and drink daily. This benefits the eyes, lowers blood pressure.

2. Ju hua 3 6 g, jue ming zi 15g, and shan zha 15g. Careful with jue ming zi 5-6 g the first go round and increase slowly. Helps lower cholesterol. 3. Huai hua 3g, gou qi zi 10g, jasmine tea 3g. Benefit eyes.

Acupuncture treatment

Puncture or massage the points around the eyes.

BL 1 and 2, Qiu huo are all inside the eye socket. Slight danger depending upon your technique

ST 3, BL 2, GB 1, SJ 23, tai yang around the eyeBL 20, BL 17, ST 36 general points around the body. Flower bone one 55.02

Bottom of foot directly opposite the LV channel on the dorsum. This is a 4 point unit that isnt in a straight line so much, but follows the bone anatomy of the foot. You have to feel it with your fingers. Retain the needles for an hour. You can do one or both feet. Easiest if the patient is lying face down. First one is about cun from the webbing between the 1st and 2nd toes. Theyre all about cun apart, with the most proximal one being at about the level of the knuckle of the big toe.

This is indicated for eye problems, red eyes, night blindness, vision problems, glaucoma, cataracts, macular degeneration, detached retina with severe floaters, lens implants and herpes in the eye.

Cataracts

60% of diabetic patients get em. This is a cloud over the lens of the eye. Surgery is the common treatment. The lens is removed and it is replaced with plastic so it doesnt cloud over again. Glaucoma can occur afterwards. Retinopathy also gets worse after the removal of the lens.

Herbal treatment is for LV/KI xu and is the same as previously mentioned for retinopathy. Qi ju di huang wan, ming mu di huang wan, shi hu ye guang wan (which may no longer be available), and bu zhong yi qi tang.

Think about lack of clear essence ascending to the head thats what bu zhong is about.

GlaucomaCommon condition for diabetics 40% more so thn for non-diabetics. This is where the internal eye pressure gets higher putting pressure on the retina and blood vessels carrying the blood to retina/optic nerve. Resulting reduced blood flow in these vessels decreases circulation in the retina and optic nerve, damaging them in the long run. TCM treatment is broken into 3 differentiations:

1. Liver and GB fire with internal windLing jiao gou teng tang is the formula for this problem, especially glaucoma and headache/pain around the eyes. Higher pressure can also cause nausea and vomiting. This formula quickly descends the heat.

2. Yin xu with hyperactivity of LV yangZhi bai du huang wan

E jiao ji zi huang tang to expel any internal wind

3. LV Qi yu w/ stagnant heatJia wei xiao yao san + zuo jin wan

Ju hua, jue ming zi, and nu zhen zi. Small doses of chuang xiong with zhu hua and perhaps bai zhi to guide herbs upward. Gu jing cao and mi meng hua for retina problems or cataracts.

Dont use a lot of astringent herbs to stop bleeding. San qi and pu huang are better to move/stop bleeding. Foot ComplicationsMost important thing is to move blood! Skin changes

Skin becomes dry, peels, and cracks. Diabetic dermopathy, roundish slightly indented patches of skin that are brown/purplish, and calluses which occur more quickly than normal are all common skin changes around the feet. As a word of warning, dont cut calluses or corns nor remove them with chemical applications. This can result in ulcers and infections. Remember diabetic patients have vascular degeneration and reduced blood flow. Use lotion immediately after using a pumice stone to remove calluses.

Poor circulation, ulcers, and infections

Poor circulation causes blood vessels of the foot and leg to harden and narrow. The result can be foot ulcers that wont heal. Amputation may be necessary. For blood circulation, niu xi is the common herb to use and add into formulas. You can also add jie xue teng, dan(g?) shen, tao ren, hong hua. Short term skin infections can be helped with wu wei xiao du yin (toxic heat) or xian fang huo ming yin (phlegm damp resolution herbs also toxic heat, drain out pus). Components of these formulas can also be used for chronic infections which can be another complication of poor circulation. One Chinese hospital study used insulin dissolved together with huang qi and used externally resulted in quicker healing of these kind of infections. Another treatment is huang qi injection which increases circulation and results in fewer amputations.

Diabetic neuropathy

Diabetic neuropathy is nerve damage in the feet. This causes lack of sensation which can lead to unnoticed injuries. Can also manifest as changes in the shape of the feet and toes. Moxa and body work on KI 1 can be beneficial. Increases circulation and blood flow. Check diabetics toes and feet for damage. Be careful about body work and make sure your hands are clean as the feet can crack when you do the body work. If there is any cracking or bleeding, refer to an MD or minor emergency clinic for wound care. Zheng gu shui is good to promote circulation. Unless theres an open wound! Then do something else. More on that later.

The Patho 1 class covered the difference between dry and wet gangrene (start at slide 61).

Dry gangrene when due to deficiency: Can be qi and yin xuShen ling bai zhu san + hau niu xi and ji xue teng

Dry gangrene due to excess:Like toxic and damp heatXue fu zhu yu tang + chuan shan jia and di bie chong.

Wet gangrene with deficiency in bodyLiu wei di huang want + dang gui, huai niu xi

Wet gangrene with excesssi miao yong an tang

Skin complicationsThis also applies to the foot complicatons and fits together with it. Many of these can be avoided with proper sugar control. Possibilities include

diabetic dermopathy

necrobiosis lipoidica diabeticorum

Atherosclerosis

Allergic reactions

Diabetic blisters (bullosis diabeticorum)

Digital sclerosis

Disseminated granuloma annulare

Acanthosis nigricans darkened skin on the hand.

Eruptive xanthomatosis

Wu wei xiao du yin tackles infections as previously noted. For skin itching you can add bia ji li 10g, di fu zi 15g, bian xian pi, tu fu long. For upper body, add chan tui and jiang chan. For lower add mu gua and bai xian pi.

Vaginal itching responds to zhi mu 10g, huang bai 10g.

Externally you can use ku shen 30g, she chuang zi 15g, huang bai 15-20, bai xian pi 15, sheng di yu 15, di fu zi15, mang xiao 15. Works for yeast and bacterial infections too. Make a decoction with small amount of water, no soak necessary, cook for hour. Wash the vaginal area with water, no soap. Then apply the herbs externally. If there is itching inside, either get the applicator for Yin Care or soak a tamponuse the kind with the plastic tubes!! Dont use with swelling or burning. Internally, for dry eczema, use wen qing yin or dang gui yin zi. You can also use xiao feng san. If there is damp heat, use that external formula for vaginal itching above. Wei qing yin is for nourishing and clearing heat. Contains dang gui, bai shao, shu di, chuan xiong (all 4 = skin problems due to damp and xu), huang lian, huang qin, huang bai, and zhi zi (for damp heat). All herbs are at 4.5g. Water decoction, 1 bag per day taken on an empty stomach. Originally to regulate menstruation with cramps and damp heat. Dang gui yin zi is for blood xu causing dry skin. When they scratch gets bloody. No blisters, no discharges. Can also be used for hives (look for pale tongue)dang gui, bai shao, jing jie, he shoul wu, chuan xiong, gan cao, huang qi, sheng di fang feng, bai ji li, and sheng jiang.

Xiao feng san

The Yin Care formula, while a closely guarded secret, does contain jin yin hua and other clear toxic heat herbs. Some people say it doesnt help much, probably because concentration is not strong and because it sits on the shelf for a while and suffers from factory-ness! The raw formula above is better.

Ku shen is a single herb thats good to add for damp heat/skin problems.

Lu rong is a unique thing in this respect. Older patients with SP/KI yang xu, if internally taking damp/toxic heat herbs might not have good result. Try lu rong for skin infections with this differentiation at 1.5gBID. Zheng gu shui with no open wounds. Soak feet in warm water first. Open wounds, use that external use soak for vaginal itching. Youve boiled the bejesus out of it so the bacteria should be dead.

Kidney Disease/NephropathyKidney damage can occur without symptoms. By the time the patient has sx, the organ is majorly damaged. If there are sx, they will likely be: Fluid buildup/edema moxa at Ren 9 is excellent for this. So it ST 28, KI7, SJ 5 Loss of sleep

Poor appetite, upset stomach

Weakness

Difficulty concentrating

High blood sugars make for vascular problems and nerve injury. Applies to the kidney organ also. If a patient has high blood pressure the risk for kidney disease is higher. Patients should be checked regularly for blood pressure, urine for protein, blood for waste products, and other organs for complications. Biomed Treatment for Ki disease: Control of blood glucose

Control of blood pressureWeight loss, lower salt intake, get regular exercise. Medicines may be necessary if all else fails. Low protein diet with macroalbuminuria never do this without doctors supervision and advice.

Dialysis when kidneys fail

TCM Treatment

Qi/yin xu, LV/KI xu

Shang mai san + liu wei di huang tang (modified). Add huang qi.

SP/KI xu with blood stasis

Si jun zi tang + liu wei di huang wan modified. Add gentle moving blood herbs dan shen for instance.

Yang xu w/blood yu, water retentionWe wont see these KI complications but we can help prevent them.

Zhen wu tang + ling gui zhu gan tangFullness in the stomach, swollen/wont descend

Jin gui shen qi wan + fang ji fu ling tangFang ji 9g, huang qi 9g, gui zhi 9g, fu ling 18g, and gan cao 6g

Yi mu cao and ze lan single herbs will move blood but will also treat edema

Damp retention and disturbance of ST

Da huang fu zi xi xin tang

DepressionDepression is common in diabetes, more so than in populations without it. Some phys causes of depression are drugs/alcohol, thyroid problems and side fx from medications. Symptoms look for 3 +

Loss of pleasure loss of interest in things used to enjoy

Change in sleep patterns

Early rising, cant get back to sleep

Change in appetite

Trouble concentrating even watching TV or reading

Loss of energy fatigue

Nervousness/anxiety

Guilt

Morning sadness worse than other times of day

Suicidal thoughts

Treatments

LV qi yu chai hu su gan san

Ht/LU yin xuBi he di huang tang + gan mai da zao tang Gan mai da zao tang can also used around menopause/pms crying without reason. Dont have to take forever take 2 months often and then reduce dosage

Phlegm and Qi stagnationBan xia hou po tang (huang liang wen dan tang)Mostly about plum pit qi. If no plum pit, but psycho-emo sx then take huang lian wen dan tang or just wen dan tang.

Qi/blood stagnationXue fu zhu yu tang (dan shen yin)

HT yin xuTian wang bu xin dan

Ht/SP xu qi/blood xuGui pi tang

LV/KI yin xu often manifests with anxiety, sensitivity. Red tongue, less coating or tongue is reddish, edge is peeled. Pulse is thin/wiry. Yi guan jian

NeuropathyUsually the earlier you start, the better result. Use acupuncture in addition to herbs. Acupuncture better for nerve injury/damage.

Neuropathy is most often seen in diabetes. High blood pressure can also cause it as there is damage to the blood vessels carrying oxygen and nutritents to the nerves. Autoimmune problems causing inflammation in nerves are an other cause. If there is mechanical damage such as carpal tunnel, the nerve can be damaged. Inherited traits and lifestyle factors (smoking/alcohol) can also cause it.

Neuropathy, again, is most often due to blood stasis.

1. Peripheral neuropathy

Affects the nerves in the toes, feet, legs, hands, arms. Sx include:

Tingling and numbness, insensitivity to pain/temperature; tingling, burning, prickling sensation; sharp pain,cramps; extreme sensitivity to touch; loss of balance/coordination

Symptoms are worse at nightbecause this is blood stasis!

There are 5 differentiations. Note that all have blood stasis components. Qi and blood xu is best response, followed by SP/KI yang xu and finally Yin xu.

a. LV/KI yin xu with blood stasis

i. Hu qian wan + shao yao gan cao tang

b. Qi/blood xu with blood stasis

i. Huang qi gui zhi wu wu tangSee the handout, pg 46 for the formulary information.

c. SP/KI yang xu with blood stasis

d. Qi yu with blood stasis

e. Damp heat with blood stasisGinko products are also used

Si teng yi xian tang: ji xue teng 30, gou teng 15, luo shi teng 15, hai feng teng 16g, wei ling xian 15. Foot soaks like hai tong pi tang are good treatments for diabetic neuropathy. Hai tong pi 6, tou gu cao 6, ru xiang 6, mo yao 6, dang gui 4.5, hua jiao 9, chuan xiong 3, hong hua 3, wei ling xiang 2.4, bai zhi 2.4, gan cao 2.4, fang fen 2.4 grams.Another foot soak is da huang, hong hua, bai zhi, chuan xiong, zhi mo yao, huang lian all at 10g each, di gu pi 15g, ge gen 30g. You can also do points on the legs and use e-stim. Good for nerve recovery. If you dont use electricity, you then have to manually manipulate.

2. Autonomic neuropathyThis is more related to internal organ sx. Trtd according to organ fxd. Nerves fxd include ht/blood vessels, ST and intestines, urinary tract/bladder, sex organs, sweat glands, eyes. This form of neuropathy can cause low blood sugar

3. Proximal neuropathy

4. Focal neuropathy

Idiopathic diarrheaOften in type 1 diabetes. Common complication of diabetes mellitus. Mostly for acute stage, some tx for chronic. See pg 50 of handout.

Ge gen huang qin huang liang tang is good for diarrhea, burning sensation. If they have watery diarrhea, use huo xiang zheng qi san. You can also add the singles listed on pg 50. Huang lian su is used for diarrhea. Originally used for bacterial causes, but today seems to be more heat related. Pay attention on this slide to the chronic versus the actue.

Gastroparesis and Diabetes pg 52After eating patient feels blocked - hard to descend the Qi. Delayed digestion.

Very important to control blood glucose level. Pg 54 for treatment.

Coexisting excess and xu, cold and heat accumulation

Ban xia xie xin tang. Ban xia is the chief herb.

St yin xu

SP/ST qi xu Qi wei bai zhu san: 1st 4 are from si jun zi tang.

Qi stagnation.

Si ni san

Overactive bladder pg 59Control blood sugar, then not as thirsty, dont have to pee as much. TCM treatments and acupuncture. Baliao points in the lower back area. Lower ab point, like Ren 3 be careful with full bladders. Very superficial, transverse puncture downward. Spleen qi xu note ren shen is in both formulas, also chai hu and fu ling. If you modify, you dont need to double up on these herbs! use for frq urination, incontinence.

Ki yang xu

Formula promotes urination.

Damp heat in lower jiao.

Ba zheng san promotes urination. Dao chi san not as strong for this.

Add pelvic floor muscle rehabilitation. Can help with urinary incont, sexual function in both men and women, pelvic prolapse in women. Consult website for how to: http://www.seekwellness.com/incontinence/how_to_do_pelvic_muscle_exercise.htmSexual problems pg 62Mostly due to nerve damage. Can give tonify ki herbs, but probably not the best long term.

KI yang xu: jin gui shen qi wan has 3 drain herbs. You gui wan is more tonifying. Wu zi yan zhong wan is for fertility problems, esp male with low motility/sperm count. Dont have to use wu zi yan zhong wan more for tonifying kidney.

Other warm yang herbs / fortify yang herbs can be used too such as xian mao, yin yang huo, etc. to help sexual drive. The problem for diabetics isnt usually drive, but ejaculation/erection and dryness problems.

Ki yin xu use move blood herbs. Zhi bai di huang wan (nourishes yin) or er zhi wan. Vaginal dryness might be a sx here. LV qi yu. Some pts have sexual problems due to liver qi rather than due to kidney.

Chai hu su gan san and add tu si zi, gou qi zi, zhi yan zhi, shi chuang pu

Damp heat in lower jiao

Long dan xie gan tang for impotence with thick yellow tongue coating. May also have pain in the genitals. Si miao san is another. Proximal Neuropathy pg 65

Constant pain in side, hip area rather than on distal areas. Lumbosacral, femoral areas. Also diabetic amyotrophy. Acupuncture is more important than herbs. Du huo ji sheng tang or sheng tong zhu yu tang is commonly used herbal tx.

Focal Neuropathy pg 66Again, move blood! Some tonification. For all nerve damage, acu is better than herbs alone.

More complications followalmost all of them are about blood stasis. Can be combined with other diagnoses, but qi/yin xu and blood stasis ae the common ones.

Heart problems p 691. Dont have to choose both chest tightness formulas, choose one. Dan shen yin is more gentle. Adding dan shen to either and they become similar. 2. Shortness of breath - sheng mai san more for qi/yin xu. Good for sob, fatigue, palpitation, irregular pulse, even if its just anxiety. Zhi gan cao tang is used for all kinds of deficiency.

4. Gua lou xie bai ban xia tang more for phlegm retention type heart problems. Look for the greasy coating on the tongue. Hypertension p70Can progress to stroke. Can blood let on the ear to help lower in the short term. Post stroke (p 71) herbs are classic bu yang huan wu tang. Huang qi dose is high because supposition is that insufficient qi to move blood. Now go with 20g and increase slowly.

Acupuncture is an important treatment post stroke. Use scalp points and others. Periperal vascular disease p 72 (last one!!!)Blood vessel problems = (guess what) blood stasis.

Diet and Supplements see supplemental handout Jiao gu lan Gynostemmae HerbaLow energy. Tastes like hell. Also called Panta Tea and sold as Jiao gu lan in pills.

Bitter Melon Fructus Balsampear

Food to balance the sugars. Cool natured, so clears heat in summer. Also comes in a patent. Bitter Melon Sugar Balance Plus. Shan Yao Rhizoma Doscoreae

Once 150g each daybut expensive now! Use pills/herbs.

Stima Maydis corn silk

Reduces proteins in urine, helps KI fnx recov. NOT the corn though.

Buckwheat Semen fagopyri cymosi

Lowers sugars. Eat bookwheat noodles

Semen Litchi li zhi he

You use the seed, not the yummy fruit part. Dang! Very bitter tasting. Also works for hernia, guides to Liver

Pericarpium Granati shi liu pi

Peel only

Yi yi ren

Use as a food. Congee recipe from http://herbal.recipes.webs-sg.com. Lowers blood sugar levels. Not specifically mentioned for diabetesleave out the sugar in any recipe.

Garlic and onions

Lowers blood sugar. Theoretically if pt has yin xu could be too warm for these patients.

Cordyceps (dong chong xia cao)

Can cook with itseems pretty freakin icky thoughalso its expensive. Lowers blood sugar

Ling zhi

See the aforementioned website. Cook with it and lower blood sugars. Not specifically mentioned for diabetesleave out the sugar in any recipe.

Bai mu er - Tremellae

Lowers blood sugars. Lots of water, add gou gi zi and cook overnight on low. Liquid will be thick. Can add da zao and gou gi zi. Tastes too weird per ZZs daughter.

Yam ganoderma lucidum seu japonicum

In China made into a yam cake or yam noodles. Shirataki makes a yam noodle you can get in the Asian markets. Helps with detoxifying the body. Dont use if you have skin rashes. Lowers blood sugar levels. Pumpkin asian kind though

This is a softer version, available in asian markets. Will also lower blood sugars. Sweet taste. Can help with sweet cravings. Diabetes Seminar Fall 2007

Zheng Zengwww.CatsTCMNotes.comPage 1 of 29