A TCM Approach to Aplastic Anemia After Cancer Treatment
Some cancer patients develop aplastic anemia after radiotherapy, chemotherapy, or TCM "using poison to attack poison" treatment. Clinically this presents as decline of the bone marrow's hematopoietic function, with a tendency to anemia, bleeding, or infection. Epistaxis and gingival bleeding are common, and even cerebral hemorrhage may occur. Patients are prone to infection and to low-grade afternoon fever. Aplastic anemia patients also commonly present with weakness, sweating, palpitations, shortness of breath, dizziness, tinnitus, blurred vision, fainting, dry mouth and tongue, soreness and weakness of the lower back and knees, low libido, aversion to cold and cold limbs, and menstrual irregularity.Aplastic anemia is most often seen in young and middle-aged adults or in patients over 60; in cancer patients who develop aplastic anemia after chemotherapy, radiotherapy, or poison-attacking drugs, it is most often seen in children, the elderly, or those with long-standing weak constitutions.The diagnostic criteria for aplastic anemia revised at the Fourth National Academic Conference on Aplastic Anemia in 1987 are as follows: (1) pancytopenia with a reduced absolute reticulocyte count. (2) Generally no splenomegaly. (3) Bone marrow examination showing hypoplastic or markedly hypoplastic marrow in at least one site (if marrow is hyperplastic, megakaryocytes should be markedly reduced; non-hematopoietic cells should be increased among the bone marrow particles; bone marrow biopsy should be done where feasible). (4) Other diseases causing pancytopenia must be excluded, such as paroxysmal nocturnal hemoglobinuria, refractory anemia in myelodysplastic syndrome, acute arrest of hematopoiesis, myelofibrosis, acute leukemia, and malignant histiocytosis. (5) General anti-anemia drugs are ineffective.Aplastic anemia, though stubborn and hard to cure, is not usually fatal. Severe aplastic anemia can be sustained with whole-blood transfusions, but mild and moderate aplastic anemia can be treated with TCM, and even some severe cases can be substantially relieved by TCM.Based on the clinical manifestations of aplastic anemia, TCM symptomatic treatment must proceed on three fronts: first, generate blood; second, stop bleeding; third, clear fever. In addition, when aplastic anemia patients develop an externally contracted fever, it must not be treated as in an ordinary patient, because such patients belong to the TCM blood-deficient type; using ordinary sweat-releasing, exterior-resolving herbs easily commits the error of "making the deficient more deficient."Tonifying the blood in aplastic anemia requires pattern differentiation.If the patient has dizziness and blurred vision, becomes exhausted with slight exertion, has numbness of the fingers and toes, twitching of the sinews and flesh, a lusterless complexion, nails lacking moisture, and a fine, weak, fine-rapid, or fine-wiry pulse, use the method of nourishing the liver and tonifying blood—herbs such as Shengdi (Rehmanniae Radix), Danggui, Baishao (Paeoniae Radix Alba), Ejiao (Asini Corii Colla), Maidong (Ophiopogonis Radix), Tusizi (Cuscutae Semen), and Hongzao (Jujubae Fructus). If the patient has blood deficiency with qi deficiency, a vacuous, soft, forceless pulse, timid qi, a low voice, profuse sweating, and breathlessness on exertion, use the method of boosting qi and tonifying blood—herbs such as Sheng Huangqi (Astragali Radix), Dangshen, Baizhu, processed Gancao, Shudi (Rehmanniae Radix Praeparata), Danggui, Baishao, Ejiao, and Hongzao. If the patient has marked dizziness, tinnitus, lower-back soreness and pain, weakness of the feet and knees, tidal fever, heat in the palms and soles, a red tongue, and a fine-rapid or soggy-rapid pulse—a picture of liver-kidney yin deficiency—use the method of supplementing the kidney and nourishing the liver—herbs such as Shengdi, Shudi, Huangjing (Polygonati Rhizoma), processed Heshouwu (Polygoni Multiflori Radix), Danggui, Baishao, Nüzhenzi (Ligustri Lucidi Fructus), fried Guiban (Testudinis Plastrum), and processed Biejia (Trionycis Carapax). If the patient has a pale complexion, aversion to cold with cold limbs, listless spirits, frequent nocturia, a pale tongue, and a fine-weak or floating-large forceless pulse—a pattern of dual deficiency of yin and yang—consider the method of vigorously supplementing true yin and true yang, using herbs such as Shudi, Fuzi (Aconiti Radix Praeparata), Gouqi (Lycii Fructus), Lujiaojiao (Cervi Cornus Colla), Buguzhi (Psoraleae Fructus), Gouji (Cibotii Rhizoma), Ziheche (Placenta Hominis), Danggui, Rougui (Cinnamomi Cortex), and Shanzhuyu (Corni Fructus).Stopping bleeding also requires pattern differentiation. In general, TCM holds that bleeding in aplastic anemia patients is either due to yin deficiency with internal heat, or to spleen deficiency with failure of qi to command the blood. Epistaxis, gingival bleeding, petechiae or purpura on the skin, and a red tongue or tongue with prickles usually indicate yin deficiency with internal heat. To stop bleeding in such patients use blood-cooling hemostatics; Diyin Yin or Liangxue Dihuang Tang may be used, with common herbs including Shengditan (charred Rehmannia), Ejiao, Xianhecao (Agrimoniae Herba), Cebotan (charred Platycladi Cacumen), and Xueyutan (charred human hair). Hematemesis, hematochezia, and uterine bleeding (benglou) in women are mostly due to spleen deficiency with failure of qi to command the blood; Guipi Tang, Huangtu Tang, and Guben Zhibeng Tang may be used, with heavy doses of Renshen, Huangqi, Ejiao, and Hongzao.A small number of patients also have bleeding due to exuberant fire in the liver channel; this is generally fundus bleeding, and should be treated mainly with Danzhi Xiaoyao San and Niuxi San. When aplastic anemia patients develop cerebral hemorrhage, it is usually accompanied by coma, high fever, and bleeding elsewhere in the body; such patients require precious formulas such as Zhibao Dan or Angong Niuhuang Wan.Clearing fever must likewise be individualized. Most aplastic anemia patients have blood-deficiency fever or yin-deficiency fever. For blood-deficiency fever, nourish blood while clearing heat—Baishao, Shengdi, Ejiao, Mudanpi, Qinghao (Artemisiae Annuae Herba), Baiwei (Cynanchi Atrati Radix), Yinchaihu (Stellariae Radix), and Huhuanglian (Picrorhizae Rhizoma) both nourish blood and clear heat. For yin-deficiency fever, use the method of enriching yin and clearing fever—commonly Shengdi, processed Biejia, processed Heshouwu, Baishao, Zhimu (Anemarrhenae Rhizoma), and Digupi (Lycii Cortex). Some patients with dual deficiency of qi and blood also develop fever; this requires Buzhong Yiqi Tang or Guipi Tang.