This article is a part of our series on food allergy therapies. Our goal in this series is to provide an overview of the various forms of food allergy therapies currently being offered in North America. This month’s spotlight is on Chinese herbal allergy remedies with Dr. Xiu-Min Li.
Dr. Xiu-Min Li is Professor of Pediatrics, Allergy and Immunology at New York’s Mount Sinai Medical Center. She studied both traditional Chinese medicine (TCM) and Western medicine in China before coming to the United States to conduct research at several medical schools, including the Jaffe Food Allergy Institute at Mount Sinai. She researches and uses TCM formulas to treat allergies, including food allergies, asthma, and eczema. She also works in private practice.
[Editor’s note: TCM is an ancient system of Chinese medicine that includes treatment with such therapies as exercise, diet, herbs, acupuncture, creams, and massage. The system is also based on the treatment of a circulating body energy known within TCM as “qi”.]
Dr. Li’s practice is informed by the principles of integrative medicine, which combines Western and Eastern medicine, and by TCM. In her practice at Mount Sinai, Dr. Li is working to build collaborations with Chinese universities as well as such institutions as the Whitehead Institute in Cambridge, Mass. and Columbia University, NYC. They recently held their third conference on integrative medicine for immune diseases and wellness.
We had the opportunity to speak with Dr. Li on her treatments, below is our interview.
Can you describe the process of selecting candidates for your Chinese herbal treatment protocol? How do you choose candidates, and what excludes them from participation?
We have a varied practice. Protocols are individualized to the patients. Patients do fall under a spectrum of mostly allergic immune diseases that have been difficult to control with mainstream medicine.
In order to determine if patients are good candidates for this protocol, the patients need to work with doctors who can order specific requisite tests. My office sends a list of things to patients for them to do in advance of the first appointment, including filling out intake and medical history forms encompassing food allergy, asthma, eczema, etc. If patients have eczema, they fill out a quality-of-life form, because eczema is associated with severe discomfort and daily suffering.
Because most of my patients have multiple allergies, my office also asks for a copy of their recent (within three months) total and specific IgE levels. [Editor’s note: Total IgE, or Immunoglobulin E, is a blood test of general allergic immune response in the body, and specific IgE can be measured in response to different foods tested.] Also, the Complete Blood Count (CBC) tests for liver and kidney function, and the IgE results are generally provided to us by the family prior to our clinical visit. Either kidney or liver disease may exclude patients from participating in treatment.
Beyond that, to some extent, patients select themselves. They must be committed, as our protocols are demanding. They have to be sure that their health and quality of life are sufficiently affected to warrant taking lots of medicines by mouth, drinking teas, taking baths, and using rubbing creams. Someone with only one allergy to, say, peanuts, may be better off with some form of immunotherapy or avoidance. But someone with frequent, severe food allergy — an average of once or more per month – or bad eczema or hives might be better off with us. Some may already be doing immunotherapy or wish to add it. We often work in combination with those therapies, in collaboration with other doctors.
Are there any specific age criteria for treatment?
No. We have young babies and much older people as patients. But younger patients have more malleable immune systems. [Editor’s note: A more malleable immune system means that treatment effectiveness, and success, is easier to achieve.]
What is a typical appointment like?
An initial appointment begins with a review of the patient’s medical record and blood test results. We need to establish a baseline for treatment, so I like to look at the patient’s skin and discuss their general health. Gastrointestinal symptoms such as stomach pain, reflux, and bowel movements are very important, but so are mood and growth. The most important thing is to ask them questions about their lives and what they hope to accomplish in treatment.
When the patient is a child, there are family members present, and in addition to the history, we talk about how important teamwork is to treatment. Everyone needs to provide support so that compliance will be good and patient morale stays high. Sometimes I will do acupuncture or acupressure for co-morbid diseases, such as atopic dermatitis (or eczema) in one third of cases. Although there have been no direct publications on acupuncture for food allergy, studies have shown that acupuncture can be as effective as antihistamine (cetirizine) for type I hypersensitivity itch and skin reactions in atopic dermatitis. It was also shown that the acupuncture effect was associated with reduced basophil activation in response to house dust mite and grass pollens. Since basophil activation and histamine release are also involved in food allergy reactions, acupuncture may have a potential for treating food allergy. This requires further clinical study.
But herbal treatment doesn’t take place in the office. This isn’t like allergy shots. Treatment is done at home. All patients must have an annual office visit, with monthly phone calls for follow-up, or sometimes every two months. Many patients come from far away, Asia and Europe as well as many US states, so they cannot come for frequent visits. We may adjust the protocol based on various considerations. In very severe cases, patients will come more frequently and in some instances stay in New York for intensive treatment.
What general kinds of herbs are used, and are they the same for every patient?
While we sometimes use individual herbs such as ling zhi [Editor’s note: A type of mushroom] or ginseng boiled for drinking, most of the treatments involve prepared formulas taken orally and through the skin in the form of creams and baths. Herbs usually work best in combination with other herbs, as they have synergistic effects. We use a limited number of formulas that are derived from classical formulations, but we have our own refinements of some to make them more effective and easier to take than they would be if they used raw herbs. Different patients receive differing combinations based on need. This is not something you can duplicate at home.
There is one more reason to use these formulas. If this form of medicine is ever to achieve mainstream use, it will have to be in the form of standardized formulas that can be administered by mainstream practitioners in an integrative setting where allopathic medicine [Editor’s note: This means Western medicine] can be combined with TCM. Most doctors acknowledge the weaknesses of the current standard of care for asthma, which involves management through the regular use of inhaled corticosteroids, or topical steroids for atopic dermatitis, to name two examples. Employing herb-based medicines whose ingredients have been proven safe over centuries, and whose effectiveness has been demonstrated in clinical practice and reported in peer-reviewed journals offers patients an alternative to the current standard of care. Many U.S. MDs have already received certification in holistic integrative medicine. If we can treat a spectrum of allergic and other immune diseases using a proven set of medicines, we will make a great contribution to public health.
How long does it take to become desensitized to an allergen via your herbal remedy treatment? How many sessions, and over what typical time duration?
TCM is directed at immunomodulation, that is, re-educating the immune system over the long-term so it doesn’t do nasty things to skin, the airways, and the digestive system. [Editor’s note: For example, the overreaction of the immune system that takes place in allergic reactions.] However, some treatments have short-term effects, such as inhibiting mast cell activation. [Editor’s note: Mast cells are cells that degranulate, or burst, during an allergic reaction, releasing the chemicals, such as histamine, that cause allergic symptoms.] One important thing to keep in mind is that we don’t only treat the immune system. If you look at the definition of anaphylaxis, many body systems are involved. Any two, e.g., skin, respiration, vomiting, and so forth, are considered diagnostic for giving epinephrine. Therefore, we try to treat all of them. Food allergies aren’t “just” an immune disease; they are also a disease of the digestive system, so we treat that, too.
As for the duration of treatment, this varies by patient goals. Eczema treatment is relatively brief and it’s easy to track progress, as it is for chronic hives. Asthma treatment operates on a different timetable but again, it’s pretty easy to track improvement, you breathe better. Food allergy treatments take longer, and are harder to evaluate because you can’t just challenge with the foods all the time.
Most food allergic patients are asymptomatic, averaging fewer than one accidental reaction per year. That’s why we are working on biomarkers to register reactivity. [Editor’s note: A biomarker is a measurable indicator of a condition, in this case, food allergy]. Some very sensitive individuals have frequent reactions even with strict avoidance. Their reactions can be triggered by skin contact and inhalation of offending foods. [Editor’s note: For example, the steam from fish is inhaled by an individual with an allergy to fish. This differs from simply smelling an allergen.] We can see progress with these patients because they stop having these reactions, and their quality of life improves. These patients also tend to have frequent hives because their mast cells and basophils [Editor’s note: a type of white blood cell that is involved in inflammation, especially in allergic reactions] are very sensitive. I generally see quick improvement with them, even before seeing any improvement of their IgE levels. This might be due to the direct inhibitory effect of the treatment on mast cell and basophil activation.
What kind of effectiveness rate have you noted?
We have a high effectiveness rate, but since this is a heterogeneous treatment for a diverse patient population, it’s hard to make apples-to-apples comparisons as you would in a clinical study. For example, if you were studying another treatment, you would very likely exclude poorly-controlled asthma. We treat the asthma right away. In general, patients with multiple food allergies and functional GI disorders respond well to the treatment. But for exceedingly sensitive individuals, I sometimes need to work with the patients much longer to develop a protocol.
Is treatment generally well-tolerated by patients?
Yes. Some don’t tolerate the taste of the oral treatment, some don’t like the smell of the external, skin treatments, or the way they stain their pajamas. We are trying to refine the medicines so they are more effective at lower doses. For very sensitive individuals, I have a starter protocol.
Is there a dropout rate? If so, what is this generally attributed to?
As I said earlier, this is an arduous treatment. “Medication fatigue” can take place, as it can with any treatment for chronic disease. I’ve had patients drop out, but some of them come back. This is why I like to establish treatment priorities. In general, our patients have good adherence rates, because most have multiple allergic conditions.
We focus on the conditions that affect their quality of life the most first, and then we turn our focus to other conditions. Parents may say food allergies are the first priority, but when the patient also has severe eczema, I treat the eczema first. When it is well-controlled, and the patient is able to taper down on topical steroids, we then have the opportunity to focus on their other conditions such as food allergy, which takes much longer to treat. After early results, most patients and families continue their efforts.
But treatment doesn’t continue forever. Once I see their immune system move in a good direction, I develop new protocols to start to reduce the use of traditional Chinese medicine, with room for occasional treatment boosts. [Editor’s note: This refers to interim treatments where they may be needed during the tapering period.]
Is there long-term tolerance of various food allergens after treatment?
Yes. Patients can add many former allergens to their diets. We have also seen good results with EoE patients. [i.e., Eosinophilic Esophagitis, an inflammatory condition of the esophagus.]
What are the costs of treatment, and any other associated costs, such as travel?
It’s hard to give estimates. That said, I think this reflects the cost of health care without health insurance, which masks the real cost. If you look at the retail costs of things like asthma inhalers and auto-injectors, it’s not out-of-line, with a bonus being the prospect of actually doing something about the disease instead of just managing it. In the U.S., some insurance covers visits and acupuncture fees. In other countries or regions such as Hong Kong, Taiwan, Japan, Korea and China, herbal medicines are also covered by insurance. I don’t know how it works in Canada. As the body of literature increases, U.S. insurance may start to cover more.
Is there anything we haven’t asked that you would like us to know about your work and/or herbal treatments?
Thanks for asking. Chinese doctors like to think of our medicine as a gift to the world. But we know that acceptance outside China, Japan, and Korea requires a strong research effort to demonstrate the effectiveness of TCM within the context of Western standards of proof. The Chinese regulators have brought their standards up to those of the West.
At Mount Sinai, we have a vigorous research program that will have benefits beyond our own clinical needs. One very exciting new study is for biomarkers that can help us understand highly reactive food allergy patients with eczema, to include things like basophil activation, transdermal water loss, and the intestinal microbiome.