Experience in Treating Insomnia in a Lung Cancer Patient with Guizhi Jia Gegen Tang

The patient, Ms. Shi, female, 65, from Laoshan, Qingdao, Shandong Province, was diagnosed with lung cancer in 2021. On October 16, 2021, a PET/CT scan at the local Zhouxin Medical Imaging center (exam no. PET00001894) showed: 1. A left thoracic mass with unevenly elevated FDG uptake, considered a malignant tumor with left lung atelectasis and multiple lymph node metastases (bilateral supraclavicular and infraclavicular fossae, left axilla, mediastinum, bilateral internal mammary regions, left hilum, retroperitoneum, bilateral medial diaphragm); extensive left pleural metastasis; multiple bilateral lung metastases; multiple liver metastases; bilateral adrenal metastases; multiple bone metastases; uneven density and uneven FDG metabolism in the left temporal lobe, recommending MR examination. 2. Calcification in the right upper lobe; pericardial effusion. 3. Diverticulum in the descending duodenum. 4. Uterine fibroid. 5. Uneven thyroid density, no abnormal FDG metabolism. 6. Spinal degenerative changes; lipoma within the left erector spinae muscle at the L2 level.

Since diagnosis, the patient had taken targeted drugs and the Chinese patent medicine Huachansu, and the tumor was fairly well controlled, but with serious side effects. The patient's family had several times asked the author to handle problems such as pleural effusion. Recently, irritated by the targeted drug, she suffered from reflux esophagitis and gastric ulcer, with heartburn and acid regurgitation, giving her a very poor quality of life.

On March 14, 2022, she video-called the author, hoping he would resolve her acid regurgitation, heartburn, diarrhea, and insomnia. Because the patient had a chronic stomach condition, the author initially thought it might be "when the stomach is not harmonized, sleep is restless"; treating the stomach disease and reflux esophagitis might resolve the insomnia.

For the patient's reflux esophagitis and gastric ulcer, the author suggested she take the Chinese patent medicine Zuojin Wan together with Shugan Hewei Wan, supplement vitamin B2, take licorice-zinc granules for targeted-drug-induced oral ulcers, or use Kangfuxin Ye for oral ulcers. At the same time, Huachansu tablets were discontinued because this medicine irritates the stomach, replaced by another anticancer drug provided by the author. Before bed, Gancaomazaotang tea bags were used to aid sleep.

After a week of the above medication, on March 21 the patient reported to the author that acid regurgitation, heartburn, and oral ulcers had basically resolved, but the insomnia was unchanged. This time the patient told the author that her insomnia problem had existed for more than twenty years; previously she could still sleep one or two hours at night, but after taking the targeted drug she could not sleep at all through the night and could not sleep during the day either, which was very distressing. She also reported long-standing heat in the palms and soles. The author suggested she try Zhibai Dihuang Wan plus Jieyu Anshen Wan. After taking Zhibai Dihuang Wan and Jieyu Anshen Wan, the patient's long-standing heat in the palms and soles resolved, but she still could not sleep all night.

On March 28, the patient again asked the author to change the medication plan to solve the insomnia.

By this point the author also found the case tricky, but the patient was very patient, because the problems of acid regurgitation, heartburn, and heat in the palms and soles, which had resisted many medicines before, had recently all been solved by the author. So the patient and her family told the author not to feel pressured; instead they comforted him that the insomnia had lasted more than twenty years and even sleeping pills worked poorly, so they were in no rush to solve it all at once.

During this consultation, the author carefully asked whether there were other symptoms, such as neck discomfort or shoulder discomfort. The patient reported that she did indeed have shoulder discomfort, and that it had existed for quite a long time. The author analyzed that the patient had likely originally developed shoulder-neck syndrome from overwork plus wind-cold, leading to insufficient carotid artery blood supply and affecting cerebral circulation, hence the insomnia. Long left untreated, it became a refractory, complicated condition. Treating this kind of insomnia with sedative and sleep-promoting drugs alone is ineffective; it should be considered as the Guizhi Jia Gegen Tang pattern of "stiff and tight neck and back."

The original formula of Guizhi Jia Gegen Tang was prescribed: Guizhi (Cinnamomi Ramulus) 10 g, Baishao (Paeoniae Radix Alba) 10 g, Gegen (Puerariae Radix) 20 g, Zhigancao (processed Glycyrrhizae Radix) 6 g, Shengjiang (Zingiberis Rhizoma Recens) 5 slices, Dazao (Jujubae Fructus) 5 pieces. Two doses per day, one in the morning and one in the evening; decoct two bowls of water down to half a bowl and drink.

After taking the above formula for five days, the patient reported that the all-night insomnia problem had finally been resolved. Now on good nights she could sleep five hours, and during the day she felt drowsy, but dared not sleep for fear of affecting nighttime sleep. The author told her to continue taking the formula and that she could nap when drowsy during the day.

Insomnia is not among the indications of Guizhi Jia Gegen Tang, and this patient also had many other problems sufficient to confuse the doctor, so it was hard to immediately think of her as having the Guizhi Jia Gegen Tang pattern. Treating her with the Guizhi Jia Gegen Tang pattern resolved her stubborn insomnia, fully demonstrating that the key to TCM treatment is grasping the main pattern and not being confused by accompanying signs.

In addition, such difficult and complicated illnesses require both physician and patient to have sufficient patience, continually communicating and trying to find an effective solution. A doctor is not a god; room for trial and error is needed, and patients and their families must be patient, tolerant, and understanding of the difficulties of medicine. Only with mutual trust can we feel our way to a suitable solution in real diagnosis and treatment. Expecting a doctor to solve complex problems at once often ends only in disappointment.