TREATMENT OF ITP WITH CHINESE MEDICINE

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional

Medicine, Portland, Oregon
Idiopathic Thrombocytopenic Purpura (ITP) is a somewhat archaic term
for a condition of low platelets (thrombocytes). Idiopathic means that the
cause is unknown; with advances in modern technology, a substantial
amount has been learned about the causes. While one may not be able to
definitively point to all the causative factors and agents involved in any
one patient, as is the case with many diseases, now it is often possible to
describe much of the etiology and pathology of ITP quite
accurately. Purpura refers to the splotches seen on the skin where
capillaries have leaked blood to yield a bruise or many red or purple
petechia (flat, pin-head sized spots). However, with careful monitoring of
the platelet counts and appropriate treatment when the platelets
approach a low level, people with this disease may rarely show any such
symptom. Nonetheless the moniker ITP has stuck in the medical literature
and will, as a result, continue to be used here.
The deficiency of platelets has two basic origins: autoimmune attack
against platelets (primary ITP) and bone marrow disorder (usually:
secondary ITP). In primary ITP, the bone marrow produces platelets as
fast as usual (at least in the early stages of the disease), but even before
they have a chance to mature, they are taken out of circulation. An
antibody of the G series (the type involved in several autoimmune
diseases), IgG, attaches to the platelets and marks them to be removed
from circulation. It is likely that individuals who suffer this disease have a
genetic propensity to get it, and that a viral disease triggers it. Many
autoimmune disorders have this characteristic. In such cases, treatment
is often aimed at inhibiting the immune system with corticosteroids (e.g.,
prednisone). If necessary, the spleen is removed (splenectomy) in order
to both reduce the production of anti-platelet antibodies and to slow the
clearance of the platelets from the system (the spleen filters out the
platelet-immune complex). A suitable name for this disease is
autoimmune thrombocytopenia.
Autoimmune thrombocytopenia occurs mostly in children and young
adults (typically before age 30), though it can rarely occur later in
life. Many times, it manifests as an acute disease, lasting a few weeks and
then clearing up completely. It might recur again later after another viral
infection or with reactivation of a chronic virus, but eventually it ceases to
be a problem in the majority of children who experience it. The acute
manifestation can usually be controlled by a course of therapy using
steroids to inhibit the immune response for a period of several
weeks. Chronic autoimmune thrombocytopenia develops in a small
percentage of patients. In that case, steroid therapy eventually fails (due
to the side effects from prolonged administration). Until recently, the
main therapy for chronic autoimmune thrombocytopenia has been
splenectomy, which is sometimes curative, but at least reduces the
disease severity. More recently, intravenous (IV) infusion of normal IgG
(hence the treatment initials: IVIG) to replace the bodys anti-platelet IgG
has been tried with some success and may replace splenectomy for some
patients. IVIG has also been proposed as an alternative to the initial
therapy
with
prednisone. Other
therapies
are
also
being

developed. Medical opinion appears to be leaning towards finding an

alternative to splenectomy.
A defect in the production of platelets by the bone marrow, resulting in
ITP, can occur as part of a general bone marrow dysfunction, in which both
red and white blood cells are also produced insufficiently. Or, it can occur
secondary to leukemia, in which the stem cells that yield white blood cells
proliferate and crowd out the stem cells that produce platelets and red
blood cells (yielding high white cell count and low RBC and platelet
counts). Low platelets can also occur as the result of certain medical
treatments, such as chemotherapy for cancer. Some chronic diseases that
affect the immune system, such as HIV, hepatitis C, and systemic lupus,
may yield a combination of inhibited platelet production and shortened
time that platelets persist in the blood, with resulting ITP. For these
situations, the platelet deficiency is called secondary ITP, because there is
something else going on first or at the same time that yields the clinical
result. The platelet disorder that may be resolved if the other disease
process or medical treatment is removed.
CHINESE HERB THERAPY
In China, both primary and secondary ITP are noted in the medical
literature, though primary ITP is the main subject of the reports and is the
object of the current article. Treatment, other than Western medical
therapies, is based on using Chinese herbs: reports of acupuncture
therapy are rare or non-existent. The Chinese herbal therapies vary
markedly from one physician to the next and sometimes among different
patients, depending on the differential diagnosis.
The general theory of treating primary ITP, at least as it occurs in
children and young adults, is that there is a heat syndrome causing the
blood to escape the vessels. Therefore, clearing heat is the primary
concern. Also, since bleeding is the symptom, treatment with hemostatic
herbs, especially those which are also cooling, is standard
procedure. There are two major causes of the blood heat, one being an
excess heat syndrome that might be associated with a viral infection and
the other is a yin deficiency syndrome, which may arise from nutritional
deficits, prior diseases, or inherent factors. In the case of the yin
deficiency syndrome, nourishing yin (tonification) is deemed the most
important aspect of therapy.
Except in the cases of dominant excess syndrome, there are usually
some herbs included in the ITP treatment to tonify the spleen, owing to the
concept that the spleen restrains the blood within the vessels and the
spleen helps produce new blood and replenishes the yin. In patients who
show an evident spleen qi deficiency syndrome, the qi tonics may become
a major part of the therapy, with less emphasis on clearing heat or
nourishing yin. In cases where there is prolonged disease, the deficiency
of qi often extends to a deficiency of the kidney and additional tonic
therapies may be added. For most cases of secondary ITP, the theory is
that the bone marrow is inadequate to produce the cells and this is
addressed by tonifying the kidney (to invigorate marrow), nourish the liver
(to increase the blood storage), and tonify the qi to help produce blood
and essence.

Within the theoretical framework, a number of different herbs are

selected. Among the most commonly used herbs for primary ITP are the
ones listed in Table 1.
Table 1: Herbs Commonly Used in the Treatment of Primary ITP in Four
Categories.
Note that some of the herbs are classified differently than the standard
Materia Medica categories.

Heat Clearing

Hemostatic

Qi Tonifying

Liver Nourishing

rehmannia, raw

agrimony

astragalus

tang-kuei

gardenia

imperata

licorice

gelatin

moutan

eclipta

codonopsis

tortoise shell

red peony

rubia

hoelen

ho-shou-wu

salvia

san-chi

atractylodes

lycium

lithospermum

biota tops

jujube

millettia

isatis leaf

sanguisorba

dioscorea

cuscuta

Within these four groups are herbs that vitalize blood circulation (red
peony, moutan, salvia, san-chi, tang-kuei, millettia), which is another
method of therapy that has been proposed, to be described later in this
article.
According to the Chinese medical reports, administration of decoctions
made with the above-mentioned herbs in appropriate combinations will
raise the platelet levels in patients with persistent ITP, often to an
acceptable level, though only rarely will they return to the normal
range. Normal platelet levels are usually defined as 150 or above (billions
of platelets per liter of blood). According to the clinical reports, the use of
herbs will often raise the platelets from the unacceptable level (below 50,
at which bleeding that is difficult to stop may occur) to an average of
about 7585. Some patients described in the literature had their platelet
levels reach over 100 and very few attained a completely normal level.
Primary ITP spontaneously resolves at a rate that is better with younger
age; overall only about 20% of cases are persistent and refractory to
standard treatments. If the Chinese herb therapy can raise the platelets
to an acceptable level, the condition may stabilize for most individuals
within a few days or weeks; if there is a relapse, then the same kind of
treatment might be applied again.
For persisting ITP, which is a greater concern because of the difficulty
of finding suitable modern medical therapy, Chinese herbal treatment will
usually be administered for several weeks or months. In the Chinese
clinical evaluations, the success of the therapy for the chronic disease is
often monitored in terms of the relapse rate after the herbs have been
stopped. Herbal therapy is reported to be of some benefit to nearly all
patients, though the degree of improvement varies markedly and the
relapse rate (within a year, if monitored that long) is often high.
Virtually all studies of ITP treatment include a control group that
receives steroids, usually at high doses (about 45 mg/day). The Chinese
herbal therapies are claimed to be superior in their results and lacking in

the characteristic side effects of the drugs. Because the randomization

and matching of patients in the herb treatment and control groups is
usually not clear in the Chinese reports, the value of the comparisons can
be questioned. Further, it is unclear in the reports to what extent the
corticosteroid dosage is manipulated according to methods commonly
recommended in modern clinical practice. Therefore, in the summaries of
the medical journal articles presented here, the results for the control
group are usually not indicated. The main purpose of conveying the
information presented in the Chinese journal articles is to illustrate the
selection of herbs, the dosage (described in a separate section of this
article), duration of therapy, time to obtain changes in platelets, and the
claimed results of therapy.
Much of the work done on ITP in China has been carried out at the
Shanghai College of Traditional Chinese Medicine. This very large college
has a number of affiliated hospitals where studies can be carried
out. There are also other medical universities in Shanghai that cooperate
with the TCM College in conducting some of the studies.
CLINICAL REPORTS INVOLVING DIFFERENTIAL DIAGNOSIS
The majority of the recent Chinese clinical reports describe trials involving
a single herb formula that may be modified slightly according to
presenting conditions. However, outside of the trial setting, differential
diagnosis is the rule, so this aspect is presented first.
A study of patients with ITP according to their traditional Chinese
diagnostic category was carried out by the Shanghai College of Traditional
Chinese Medicine and published in 1991 (1). It involved 103 patients (75
female) with an age range of 1258 years. The differentiation went this
way:
Table 2: Division of 103 Patients with ITP into Four Diagnostic Categories
with Group Characteristics: Age, Disease Duration (years), IgG Levels, and
Platelet Counts.

Differentiation
Group

Number of
Patients

Mean Age
(Mean Duration
of Disease)

IgG
(Control:
18)

Platelets
(Control:
122)

Qi Deficiency

20

24 (3)

115

29

Blood heat

22

26 (4)

63

44

Yin deficiency

43

36 (7)

80

39

Yang deficiency

18

40 (12)

112

34

The qi-deficiency group was described as a spleen-deficiency type; the

blood-heat type was described as an excess syndrome, the yin-deficiency
type was described as a syndrome secondary to chronic spleen deficiency;
and the yang-deficiency type was said to be a deficiency of spleen and
kidney. The control group of non-ITP patients involved 20 individuals with
a similar ratio of the two sexes, mean age of 30, and similar range of ages
as the differentiation group. The control group was included for obtaining
relative blood values.

Looking at the mean values for patient age and disease duration only,
it can be seen that the disease generally started before age 30 and falls in
the category of chronic ITP. According to the analysis, the most common
type of the disease is a yin-deficiency syndrome. Both the blood-heat and
yin-deficiency syndromes can be described as being of the general heattype of ITP, accounting for 2/3 of the cases. The deficiency of qi and of
yang correlated with the most dramatic elevation of IgG. In the report,
there were also slight elevations noted in IgA and IgM for all the ITP
patients, but not sufficient to explain the disease manifestation. The
platelet numbers did not vary much from one group to the next (the
control group level is quite low to begin with, suggesting that these
numbers are not directly comparable to those from other
laboratories). The report also presented information on T-cell subsets, but
there were no significant differences in their numbers or ratios among the
different groups, including the controls.
In 1991, a research team at the Shanghai College of TCM presented a
formula for ITP (2) with the following ingredients: astragalus, codonopsis,
tang-kuei, moutan, agrimony, isatis leaf, perilla stem, licorice, raw
rehmannia, cooked rehmannia, and eclipta. The trial group of 36 patients
receiving this formula ranged in age from 1360 years. Treatment time
was at least three months (average 110 days) and it was reported that all
but 3 of the patients had improvement of symptoms. The average
increase of platelets was from 38 to 79, and the average decrease in IgG
was from 74 to 32. The formula included herbs for tonifying qi (astragalus,
codonopsis, licorice), nourishing yin (rehmannia and eclipta), clearing heat
(moutan, isatis leaf, raw rehmannia), and inhibiting bleeding (agrimony
and eclipta). The use of perilla stem (zisugeng) is unique; it is not found in
other formulations for ITP (see key herbs section, below).
This basic formula was later adopted by another group at the same
college using differential diagnosis and treatment (3). According to their
report, there were four categories of disorder and treatments, but the data
for all the patients were then pooled for analysis rather than divided by
group. The above-mentioned formula was adopted for the yin-deficiency
group and modifications of it were used for the other groups as shown in
Table 3.
Table 3: Differential Therapy for ITP at the Shanghai College of Traditional
Chinese Medicine.

Differentiation
Group
(Number of Patients)

Herb Formula

Qi Deficiency
(30)

astragalus, codonopsis, tang-kuei, moutan, agrimony, isatis

leaf, perilla stem, licorice, etc.

Blood heat
(24)

buffalo horn, raw rehmannia, red peony, moutan, eclipta,

trachycarpus, rubia, isatis leaf, perilla stem, licorice, etc.

Yin deficiency
(76)

astragalus, codonopsis, tang-kuei, moutan, agrimony, perilla

stem, licorice, raw rehmannia, cooked rehmannia, eclipta,
etc.

Yang deficiency
(24)

astragalus, codonopsis, tang-kuei, moutan, agrimony, perilla

stem, licorice, raw rehmannia, cooked rehmannia, eclipta,

epimedium, cuscuta seed, etc.

As in the previous report on differentiation of the syndrome, the most
common form was the yin deficiency type and the combined heat
syndromes (yin deficiency and excess heat as blood heat) comprised 2/3
of the cases. All of the formulas included moutan, perilla stem, and
licorice, and all but the qi-deficiency formula included raw rehmannia,
while all but the blood-heat formula included astragalus, codonopsis, tangkuei, and agrimony. For the kidney-deficiency cases, the formulas
included cooked rehmannia and eclipta. The herb formulas were prepared
as a liquid syrup and consumed three times per day. A control group was
given prednisone; treatment time was at least three months. Side effects
of the herb therapy were limited to a few cases of loss of appetite and thin
stools. The prednisone group presented side effects in half the patients
including the typical increase of body weight and upset stomach. Mean
values for platelets in the herb group rose from 38 before treatment to 68
after treatment. The control group had nearly identical mean
values. Some patients were treated for six months to a year, and the
platelet values continued to rise slowly in the herb treatment group,
reaching 75 at six months and 88 at one year. The IgG values in the herb
treatment group declined from 99 at the beginning of treament to 41 at
the end of treatment (three months); the values for the control group were
similar. The authors claimed that the best therapeutic responses were
among the patients suffering from qi deficiency and yin-deficiency
syndromes.
In a more recent study (4) conducted Shenyang (rather than Shanghai),
patients were simply divided into two groups, one being the common yindeficiency type with heat symptoms (30 patients), and a spleen-kidney
deficiency group, involving spleen qi deficiency and kidney/liver yin
deficiency (31 patients) with pallor signs The treatments were:

Yin deficiency type: codonopsis, cuttlebone, rehmannia, moutan,

artemisia, gelatin

Kidney/Spleen deficiency type:

astragalus, tang-kuei, san-chi.

ho-shou-wu,

lycium,

ginseng,

The herbs for the yin deficiency type were made as a decoction with
1015 grams of each herb (except cuttlebone at 25 grams). The herbs for
the kidney/spleen type were made into tablets, given 46 each time, three
times daily, with 380 mg/tablet. A control group was treated with
prednisone. At the end of four weeks, 35 of the herb treated patients had
some level of improvement; after one year, 56 of the 61 herb treated
patients had some degree of improvement.
According to the report, the time from starting herb therapy until the
platelet counts started to rise was, on average, 24 days (compared to 8
days for the prednisone group), and it took three months for the herb
treated group to reach its maximum level of platelets, compared to 22
days for the prednisone group. After one year of therapy, the herbs were
stopped. The relapse rate for the patients who did best in the herb
treatment group (in terms of platelet improvements and corresponding
improvements in symptoms), of which there were 24, was
examined. There were 11 patients that remained stable (no relapse),

while 13 patients had a relapse (between 3.5 and 11 months after

stopping the herbs).
A similar pair of differential groups was described in an earlier study
(1987) with the following formulas (5):

Yin-deficiency type: tortoise shell, oyster shell, phellodendron,

imperata, biota tops, sanguisorba, lycium, eucommia, scute, lycium
bark, gardenia, san-chi.

Kidney/Spleen-deficiency type: astragalus, imperata, schizandra,

codonopsis, hoelen, tang-kuei, atractylodes, lycium gelatin, san-chi.

These formulas were ground into powder, made into pills and taken in
the amount of 5 grams of herb powder twice per day. The patients had
been treated with Western medicine without success. The results from the
two groups were pooled, and it was claimed that all patients showed some
improvement.
These studies that involve differential diagnosis do not clearly
demonstrate that such differentiation is essential to the outcomes. All of
the formulas include herbs that clear heat, inhibit bleeding, and nourish
yin. While kidney deficiency is mentioned in the reports, there is very little
reliance on kidney-yang tonic herbs in the prescriptions. Even when
kidney-tonic herbs are included (such as the yin-nourishing rehmannia and
eclipta or the yang tonics eucommia, cuscuta, and epimedium), the ones
selected are also traditionally classified as nourishing the liver, so that a
liver-nourishing principle would describe the basis of treatment equally
well.
CHINESE CLINICAL REPORTS WITH BASE FORMULAS THAT MAY BE
MODIFIED
There are a substantial number of reports in the Chinese medical literature
published during the 1980s and early 1990s describing treatments for
ITP. They usually present a basic formula that can be modified slightly for
individual presentation of symptoms; the modifications may not be directly
relevant to the experience of ITP. Due to concerns about the quality of
clinical testing and reporting, and due to the fact that most of these
reports are available only in summary or abstract form, only the most
basic information is presented here in table format to illustrate the nature
of the prescriptions used.
Table 4: Clinical Reports on Herbal Therapy for ITP.
The majority of these reports were summarized in The Treatment of
Difficult and Recalcitrant Diseases with Chinese Herbs (5), translated
from Compendium of Secret Chinese TCM Formulas, a three-volume book of
medical report summaries first published in 1989. In a few cases, the
study reported here was available only as an abstract in Abstracts of
Chinese Medicine (a quarterly journal) or other source. A total of 600
patients were involved in the herbal treatments; most studies also had a
control group of about 20 patients using steroids.

Author
(Citation)
[No. Of
Patients]

Formula Ingredients;
Modifications

Comments

Sha Bingyi (5)

[22]

agrimony, jujube, oyster shell,

licorice, forsythia, salvia

Symptom improvement
reported after 5 days,
substantial platelet increase
after 10 days.

Yang Jin (5)

[50]

agrimony, sanguisorba,
codonopsis, atractylodes, cornus,
salvia, astragalus, shou-wu,
rehmannia, scrophularia, licorice,
phytolacca (this herb is boiled a
long time to reduce toxicity); for
yin deficiency, remove
codonopsis and atractylodes, add
phellodendron, anemarrhena,
moutan, tortoise shell; for qi
deficiency, add hoelen, jujube

All but 2 patients improved;

after treament was concluded
there was no relapse during a
six month follow-up.

Su Eryun (5)
[33]

millettia, agrimony, licorice,

tang-kuei, ixeris, biota tops,
astragalus, raw rehmannia; for
yin deficiency, increase
rehmannia, decrease astragalus;
for blood stasis, double the
millettia dose

Improvements claimed for 25

of the 33 patients.

Zhang Yisheng
(5)
[80]

gardenia, raw rehmannia, red

Bleeding brought under
peony, moutan, tang-kuei,
control in all cases.
astragalus; for heavy bleeding,
add lithospermum, rubia,
agrimony; for anemia, add
gelatin, millettia, ho-shou-wu; for
yin deficiency add yu-chu,
glehnia, ophiopogon, imperata;
for qi deficiency, add codonopsis,
atractylodes, hoelen, dioscorea

Deng Youan, et
al. (5) [31]

cnidium, salvia, tang-kuei,

carthamus, millettia, red peony,
leonurus; for qi deficiency add
codonopsis, astragalus,
dioscorea; for weak digestion,
add atractylodes, hoelen,
crataegus, malt, citrus, magnolia
bark; for kidney yang deficiency,
add morinda, cuscuta; for kidney
yin deficiency add ligustrum,
lycium

For treatment of chronic

platelet deficiency but not for
use when the platelets are
very low, causing
purpura. Average treatment
time was one month. IgG was
greatly decreased after
treatment. A few patients had
no relapse for at least 6
months.

Liu Shaoxiang

agrimony, rumex, millettia; for qi

Secondary ITP was mainly

Author
(Citation)
[No. Of
Patients]

Formula Ingredients;
Modifications

Comments

(5)
[62]

deficiency add astragalus and

codonopsis; for blood deficiency
add tang-kuei and gelatin; for
weak digestion, add atractylodes

treated, with chemotherapy

and radiation the
cause. Reported platelet
restoring effect took place in
5 days on average.

Han Weigang
and Qi
Rongfang (6)
[27]

buffalo horn, raw rehmannia,

24 of 27 patients reported to
moutan, red peony, isatis leaf,
respond well with 12 days
paris, agrimony, lithospermum;
treatment.
for blood heat, add fresh lotus
node; for qi deficiency, add
astragalus; for yin deficiency, add
ho-shou-wu

Gao Xiang, et al. astragalus, codonopsis, hoelen,

(7)
atractylodes, rehmannia, tang[35]
kuei, psoralea, drynaria, cuscuta;
for nose bleed add agrimony; for
purple petechia, add salvia; for
poor appetite, add red
atractylodes and citrus

30 day treatment course

(could be extended), 31 of 35
patients showed some
improvement. Platelet counts
increased from average of 52
to 79.

Cui Shuzhen, et
al. (8) [100]

cnidium, salvia, red peony,

millettia, leonurus; digestive
disturbance, add crataegus, malt,
citrus, atractylodes, malt; serious
bleeding, add raw rehmannia,
moutan, and cirsium

See Dong Youan study above,

with nearly identical in
treatment. This study
involved children 6 months to
13 years with persistent
ITP. One month treatment
course; platelet increased
from 26 to 109. All patients
improved.

Peng Xiang, et
al. (9)
[24]

astragalus, codonopsis,
Improvements noted in 20 of
atractylodes, licorice, rumex, scute, 24 patients.
coptis, frankincense, myrrh, tribulus

He Guoxing and
Wang Xiuhua
(10)
[52]

rehmannia, deer antler gelatin,

tortoise shell gelatin, ho-shouwu, codonopsis, tang-kuei,
astragalus, epimedium, salvia,
rubia, ligustrum, licorice

Improvements noted in 50 of
52 patients.

Zhang Gaochen
and Mao Yuwen
(11)
[55]

tang-kuei, agrimony, moutan,

gardenia, san-chi, biota tops

Treatment time was 936

days, and mean platelet count
rose from 58 to 78; 2/3 of
patients improved.

Li Zhiyuan (12)
[23]

astragalus, codonopsis, tang-kuei, 20 of 23 patients

nutmeg, rehmannia, cinnamon
improved. No relapse during
bark, aconite, dioscorea,
36 month follow-up.

Author
(Citation)
[No. Of
Patients]

Formula Ingredients;
Modifications

Comments

agrimony, gelatin
Duan Yu, et al.
(13)
[10]

bupleurum, codonopsis, scute,

licorice, jujube, equisetum,
pyrrosia, verbena, rehmannia

Average treatment time was 4

weeks; an IV drip of
hemostatic drugs and
vitamins was given for an
average of 3 day. Mean
platelets increased from 19 to
121.

Xiang Renpu
(14)
[26]

raw rehmannia, agrimony, hoshou-wu, lycium, psoralea,

cistanche, salvia, red peony,
rubia, tang-kuei, moutan, cornus

All but 1 patient has some

improvement, but relapse was
common. Platelet count
increased by an average of
32.

BLOOD STASIS HYPOTHESIS FOR CHRONIC AUTOIMMUNE

THROMBOCYTOPENIA
It has been proposed by some authors that the symptomatic manifestation
of purpura signifies a blood stasis syndrome and that the chronic disease,
in particular, should be treated mainly by vitalizing blood circulation. One
of the first descriptions of this approach was from the Heilongjiang College
of Traditional Chinese Medicine, published in 1981 and then republished in
English in 1983 (15). The authors reported that in a group of 200 ITP
patients, there were 46 who had chronic cases and, of these, 30 had
varying degrees of blood stasis. The remaining 16 chronic cases had
varying degrees of spleen qi deficiency with inability to restrain the blood
and yin deficiency with glowing fire.
The symptoms of blood stasis were: bruising and petechia; dry,
lusterless hair; dark facial color; purplish congestion in the eye vessels;
lower eyelid shows purplish dark case; pulse was thready and/or
astringent. Two or more of these signs were needed to place an ITP
patient in the diagnostic category of blood stasis. Since the purpura signs
are to be expected in chronic cases of ITP in those seeking treatment, only
one other sign would be necessary to yield the diagnosis. The proposed
formula was: millettia, red peony, san-chi flowers, rubia, tang-kuei, salvia,
codonopsis, jujube, eclipta, rehmannia. If there was a high level of
bleeding, the formula could be modified by temporarily removing red
peony and salvia and adding agrimony, lotus node, charred hair, and
trachycarpus. Additional anti-hemorrhage herbs might be added
according to their reputation for treating a specific site of bleeding. The
authors claimed that improvements occurred in all but 3 of the 30 cases of
blood stasis that were so treated. The average duration of therapy was 85
days (about three months) and the platelet levels increased from 41
before treatment to 85 after treatment.
The authors of this report quoted earlier physicians as stating that one
should not just attempt to stop bleeding, but should move or circulate the

blood. This should be done whether the blood is fresh or black, and
whether the condition is associated with cold or heat. The authors then
relayed their own experience:
In the beginning stage [of treatment] if we use the principle of
following the etiology (e.g., kidney yin deficiency with uprising
and flaming of deficiency fire; spleen deficiency with loss of
control and blood not returning to the vessels), we will have
some patients respond poorly to this treatment. These patients
will present the signs of blood stasis....Chinese researchers
using animal experiments found that the treament method of
vitalizing blood and dissolving blood stasis inhibit the formation
of IgG and regulates the T-cell balance....The treatment of
vitalizing blood and dissolving blood stasis lowers capillary
fragility and decreases the permeability of vessels and, in this
way, resistance to bleeding is increased.
In two of the studies cited in Table 4, the base formula that is applied
is: cnidium, salvia, tang-kuei, carthamus, millettia, red peony,
leonurus. The ingredients in common here are salvia, red peony, millettia,
and tang-kuei.
The principle of using a blood-vitalizing therapy for ITP, incorporating
many of the same herbs, was mentioned recently in a reported clinical
trial 16). The herb therapy was comprised of astragalus, atractylodes,
polygonatum, tang-kuei, millettia, red peony, moutan, carthamus.
According to the authors, 2/3 of the patients showed improvements, and
the average platelet count for the whole group increased from 34 to 57,
while the IgG level decreased from 195 to 122. In addition, the
researchers measured hepatoglobin, a substance produced by the liver
that is elevated in patients with ITP; this substance declined by 1/3
following the herb treatment. The authors expressed the view that ITP
had the characteristic of a dysfunctional immune system which could be
corrected by tonifying the qi (with astragalus, polygonatum, and
atractylodes; this method of therapy promotes the correct qi and reduces
the pathological qi) and invigorating blood circulation (which inhibits
autoimmune attacks).
A disorder similar in symptoms to primary ITP, idiopathic multifocal
bleeding and platelet aggregation defect (IMBPAC), was addressed with a
blood-vitalizing therapy by physicians working at the Tongji Medical
University in Wuhan (17). They used Xiaoyu Zhixue Pian (Reduce
Stagnation, Regulate Blood Tablets) made with astragalus, codonopsis,
licorice, peony, tang-kuei, and persica. The herbal material, corresponding
to 1.2 grams crude herb per tablet, was administered 58 tablets each
time, 23 times daily. They reported a hemostatic effect in most patients
in 57 days (total treatment time was four months). Instead of relying on
hemostatic herbs, the formula boosts the qi and vitalizes blood circulation
NORMALIZING PLATELET FUNCTIONS
There is considerable concern raised in modern medical practice about
altering platelet functions. During the 20th century, the primary cause of
premature death in the Western world was a blood clot that either caused
a heart attack or stroke. As a result, the stickiness of platelets, which
contributes to forming the blood clot, has been deemed one of the most

serious pathological problems. Patients who experienced a non-fatal blood

clot event would often be placed on life-long therapy to inhibit platelet
sticking, so as to avoid a second event.
The ease with which a clot could form in the population (especially
those past 45 years of age) appears to be due to several factors, including
excess blood sugars and lipids, high oxidation status (lipid peroxidation
products in the membranes), and the influence of smoking, excessive
alcohol consumption, use of exogenous estrogens (menopause treatment),
and the effects of sedentary lifestyle. These factors help explain why
there was such a dramatic increase in fatality due to blood clots during the
20th century compared to the 19th century, and also why there were
declines in incidence of these problems in the latter part of the 20th
century after recommendations were made for adjusting life style and
using drugs to inhibit clotting.
However, one effect of the high incidence of clotting and the
corresponding medical attention to the clotting problem is to generate an
image of platelets as being inherently harmful and to view substances that
alter bleeding and clotting to be something that must be strictly controlled
medically. In relation to herbal medicine, this has meant serious concerns
about using herbs that influence clotting (many of them do if the dosage is
high enough), and especially using these herbs along with medical
therapies that influence clotting.
Chinese physicians have emphasized the use of blood-vitalizing herbs
ever since Wang Qingren, in the first half of the 19th century, proposed
that blood stasis was a major factor in several serious diseases. His bloodvitalizing formulas had dramatic effects in many cases, and were widely
adopted for use during the 20th century when the cardiovascular diseases
became prominent.
One of the issues that was raised was whether or not blood-vitalizing
herbs might worsen, or even induce, bleeding; the other was whether or
not hemostatic herbs might worsen or induce undesired blood clotting. A
traditional theory, that some bleeding disorders are due to blood stasis,
meant that Chinese doctors would sometimes treat bleeding with herbs
that had a reputation for getting rid of clotted blood (e.g., bruising as
occurs with injuries). Those herbs were shown in some pharmacology
experiments to reduce platelet aggregation, which, one would think, would
worsen rather than aid bleeding. An explanation for the apparent
contradiction between clinical observations and the laboratory
experiments is that at low dosage the herbs can regulate platelet function
and stop bleeding when the function is deficient, while at very high doses
(as used in laboratory experiments and some decoctions), the herbs
specifically reduce platelet sticking.
One of the apparent paradoxes of modern Chinese herbal medicine is
the use of san-chi (Panax notoginseng) to treat bleeding and also to help
resolve blood clots and vitalize blood circulation. Other herbs that might
have this effect are agrimony, rubia, and leonurus. While this diversity of
actions may appear contradictory, it is not inherently so. For example, if
the dietary and other lifestyle factors yield platelets which function
abnormally, then lifestyle changes and herbs that help normalize their
functions can have several beneficial effects. Normal-acting platelets will
not be likely to spontaneously clot in the blood vessels, but they will clot

promptly when there is a damaged vessel causing leakage of blood. Herbs

that regulate blood circulation might normalize platelet functions and, at
the same time, influence blood vessel dilation, vessel wall integrity, and
other factors. The idea that the Chinese herbs will have a normalizing
function, rather than causing an adverse effect, is one which is difficult to
prove, leaving some question in the minds of concerned practitioners and
patients. Chinese physicians, for the most part, have adopted the view
that the use of the herbs to regulate blood conditions is safe.
KEY HERBS FOR REGULATING BLOOD
Table 5 presents hemostatic herbs that are included in several of the
formulas for treating ITP. There are a wide range of botanical sources
represented here (each herb being from a different plant family) and wide
range of active constituents that might ultimately contribute to hemostatic
action, including essential oils, flavonoids, saponins, and alkaloids. Other
herbs that are used to treat bleeding, such as fried schizonepeta, typha,
and the thistles (breea and cirsium), are not commonly used for ITP,
suggesting that the physicians have focused on a small group of herbs
that may be more suited to treating this particular disorder.
The possible mechanisms of action of the hemostatic herbs include:

increasing the production of platelets

promoting the ability of platelets to aggregate when there is blood
leakage

decreasing capillary permeability

contracting peripheral blood vessels

inhibiting autoimmune attack against platelets

These effects should be expected to be observed within a few days of
administering the herbs. In most of the Chinese medical reports,
improvement in symptoms (such as spontaneous bleeding and petechia)
were observed within about 10 days. Changes in bone-marrow functions
and autoimmune processes may require somewhat longer therapy, at
least several weeks (typically one to three months treatment time), with
increasing effect in responsive patients. The reported changes include
higher platelet counts and lower IgG levels. Three groups of active
constituents are known to have some hemostatic effects and may
influence autoimmune processes:

anthraquinones, found in rubia and rumex and also an ingredient of

rhubarb root (which has hemostatic effects, but is not included in the
ITP formulas)

flavonoids, found in eclipta and agrimony, and also in scute (used to

inhibit bleeding but rarely in the ITP formulas)

alkaloids, found in lotus (all plant parts), eclipta, and san-chi

The role of essential oils (which usually dilate vessels; some might
increase bleeding), triterpenes, and saponins found in several of the herbs
remains unknown. One of the most frequently-used herbs in the formulas,
raw rehmannia, contains iridoid glycosides that have hemostatic effects
(see: Rehmannia). The same active constituents are found in gardenia,
which is mentioned in a few of the ITP treatments, as well as in
scrophularia and cornus (only rarely mentioned in the ITP formulas).

Table 5: Hemostatic Herbs Used for ITP.

All of the herbs listed here are reported to shorten bleeding time in
laboratory testing.

Common Name
Pinyin

Botanical Name
Active Constituents

Comments

Agrimonyxianheca
o

Agrimonia pilosa;
agrimonin (essential
oil); agriminolide
(flavonoid)

Agrimonin has been developed into

a hemostatic drug in China, but
pharmacology studies give
conflicting results. The clinical
effectiveness is not confirmed.

Biota tops
ceboye

Biota orientalis
essential oils: juniperic
acid, thujone

Biota leaves are frequently used

(applied topically and taken
internally) to treat alopecia, which
is thought to involve an
autoimmune disorder.

Eclipta hanliancao

Eclipta prostrata
(ecliptine,
wedelolactone)

Though classified as a yin tonic, it

is often used to control
bleeding. The flavonoids may
reduce capillary permeability.

Imperata
maogen

Imperata cylindrica
triterpenes: simiarenol,
fernenol

The triterpenes reduce

inflammation; there may be
flavonoids in the flower that reduce
capillary permeability.

Lotus node
oujie

Nelumbo nucifera
alkaloids: nuciferine,
liriodenine

The alkaloids shorten bleeding

time.

Rubia
qiancaogen

Rubia cordifolia
alizarin, purpurin
anthraquinones

The herb extract dilates vessels and

shortens bleeding time.

Rumex
(yangdi; suanmo)

Rumex spp.
Although not frequently mentioned
anthraquinones: emodin in the Chinese literature, the rumex
plants are recommended for
bleeding in association with blood
stasis.

San-chi
sanqi

Panax notoginseng
dencichine

This is the key ingredient in the

popular hemostatic remedyYunnan
Baiyao.

Sanguisorba
diyu

Sanguisorba officinalis
saponins: sanguisorbin

Sanguisorba is especially used in

cases of rectal bleeding.

In development of herbal formulas for ITP, there may be some

influence of what has been called the doctrine of signatures in selecting
some of the herbs. The hallmark of the disease, as seen from the
traditional viewpoint without laboratory tests, is the petechia with a red to
purple color. Several of the herbs recommended for the treatments also
have a red to purple color. Examples are the purple-colored (zi)

lithospermum (zicao) and perilla stem (zisugeng), the cinnabar-colored

(dan) salvia (danshen) and moutan (mudanpi), and the red-colored
(chi or hong) herbs red peony (chishao) and carthamus (honghua). The
herb jujube used in the treatments may have been the red one (hongzao),
rather than the more common black one (dazao), though the variety was
not clearly specified in the literature. Similarly, there is the blood-colored
millettia (jixueteng;xue = blood), and the reddish herbs which are noted
for their color in their botanical names (Sanguisorba; sangui =
blood; Rubia; rubi = red). Isatis leaf, used in some formulas, is the source
of the purple dye indigo. The yin-tonic lycium fruit, which is used in some
formulas, is a bright-red colored fruit, while the astringent cornus fruit has
a purplish color. It is not clear to what extent the red to purple color of the
herbs has influenced their selection for treatment of ITP by modern
practitioners, but the color of herbs is known to have been a factor in the
early development of the Chinese herbal medical system.
DOSAGE
Information about herb dosage was not available for all the studies, but in
many cases doses of herbs used in decoction were given. The description
for most of the treatments is use of heavy dosage of the individual
herbs, with amounts of 915 grams per day of each ingredient, sometimes
more. Typically, the herbal formulas (or at least, the portion described)
would contain 810 ingredients, with possible additions (for particular
symptoms or disease manifestation) of 13 other ingredients. As a result,
the decoctions would be made from a minimum of about 100 grams to a
maximum of about 150 grams, with 125 grams being typical. In the West,
it is common to use dried extracts in place of decoctions; these dosages
correspond to about 1827 grams per day. In most of the reports, the
decoctions were divided into two doses per day. It is understood that
children receive lower doses, based on their age. In the Pharmacopoeia of
China, a dosage schedule relating childrens dosage to adult dosage is
presented as follows:

Age
12 years
24 years
46 years
69 years
914 years
1418 years

Dosage Range
1/5/14 of the dose for adult
1/41/3 of the dose for adult
1/32/5 of the dose for adult
2/51/2 of the dose for adult
1/22/3 of the dose for adult
2/3 to full dose for adult

A good example of dosing for adults and for children is offered by

examining two studies published in 1991, one (7) aimed at treating adults
(ages 1853) and the other (8) aimed at treating children (ages 6 months
to 13 years). Both studies involved decoctions that had a basic formula
which could be modified for the individual cases. The adult formula was
based on tonifying the spleen and kidney yang and was comprised of 12
grams each of psoralea, drynaria, cuscuta, atractylodes, and hoelen; 15
grams of tang-kuei; and 20 grams each of astragalus, codonopsis, and
rehmannia. The total dosage of the base formula was 135
grams. Modifications to the formula involved adding from 1030 grams of
one or two herbs, such as agrimony or salvia. For the childrens study, the

formula was based on vitalizing blood circulation and the formula was: 15
grams of leonurus; 10 grams each of salvia, red peony, and millettia; and
5
grams
of
cnidium. The
base
formula
dosage
was
50
grams. Modifications involved adding from 1 to 6 herbs, with dosages of
515 grams each. In this case, the dosage was about one-third the adult
dosage, which corresponds to the Pharmacopoeia dosing for ages 26
years of age. These two formulas also illustrate a difference in therapeutic
approach; the young children generally suffer from the early stage of an
acute ITP which is treated here by the principle of invigorating blood
circulation while the older patients, many of whom suffered the disease
chronically and therefore suffer the effects of the persistent disease and
the medical treatments (including steroids used before) were treated with
herbs that tonify the liver, kidney, and spleen.
In one study (5) of acute ITP (treatment time 10 days), a very large
dose of agrimony root (whole herb is more commonly used) is given. The
dosing of this ingredient in decoction form is described as follows: 100
grams for adults, 50 grams for 712 years, 30 grams for 56 years, 20
grams for 24 years, 10 grams for infants.
In two of the ITP reports (and the one report on IMBPAD), pills and
tablets were used rather than decoctions. The pills for ITP were made
from powdered herbs, consumed in the amount of 5 grams each time,
twice daily; the tablets for ITP were poorly described; they contained 380
mg per tablet, with a dosage of 1218 tablets per day, for a daily intake of
about 57 grams per day. It is common practice to use about 510 times
as much herb to make a decoction as to make a pill when treating the
same disorder, so these dosages fit the usual pattern. For IMBPAD, the
dosages reported for the tablets corresponded to 1229 grams per day of
crude herbs, but the processing to yield the tableted material was not
specified. The limited reporting of using non-decoction forms such as
these makes it difficult to know if they are as effective as the high dosage
decoctions.

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