Treating Long COVID Should Follow Li Dongyuan's Principle of "Sweet Warmth Eliminating Great Heat"

Doctor zhou January 11, 2023

As the peak of the pandemic has passed, most people infected with COVID have recovered, but a considerable number of long COVID patients have emerged. Most of these patients are constitutionally weak or elderly, and already had multiple chronic diseases before infection. Children and young adults with no prior underlying disease can also become long-COVID patients or even die suddenly if they are excessively obese or underweight. The COVID virus destroyed their already fragile immune systems, producing a series of severe symptoms.

Whether we call them post-COVID patients or long COVID patients, we cannot ignore this group. Some long COVID patients have very prolonged courses. Media reports describe Muzaffer Kayasan, a Turkish leukemia patient who remained PCR-positive for 14 months after COVID infection. Sequelae such as fatigue and shortness of breath are quite common among middle-aged and elderly people. Weak patients may also have long-term night sweats and recurrent low fever, fluctuating blood pressure and blood glucose, fluctuating platelet counts, low hemoglobin, absence of hunger or excessive hunger, and incontinence of urine and stool.

No one can say clearly how long the COVID virus will linger in a person. It is an individual matter. People with good constitution and strong immunity recover completely in a short time; those with weak constitution and poor immunity may have the virus linger a long time, perhaps with lifelong effects.

These long-COVID patients are no longer TCM wind-cold or wind-heat common colds; the exterior-releasing method cannot solve their problems. Treatment of such patients should follow the method of "sweet warmth eliminating great heat" created by Li Dongyuan. The formulas of choice are Buzhong Yiqi Tang (Center-Building Qi-Boosting Decoction) and Guipi Tang (Spleen-Returning Decoction). The herbs should be mild and the duration of use long; even after the patient feels cured, the medicine should be continued for a while to consolidate the effect. Because the harm of the COVID virus is highly insidious, symptoms recur as soon as the patient becomes fatigued or catches cold, so apparent recovery may be false.

Buzhong Yiqi Tang: Huangqi (Astragalus) one qian (3 g), Zhigancao (honey-fried licorice) five fen (1.5 g), Renshen (ginseng), Shengma (Cimicifuga), Chaihu (Bupleurum), Jupi (tangerine peel), Danggui (Angelica) each three fen (1 g each).

Guipi Tang: Baizhu (Atractylodes macrocephala), Fushen (Poria with host wood, wood removed), Huangqi (rootlets removed), Longyanrou (longan flesh), Suanzaoren (fried, husks removed) each one liang (18 g each); Renshen, Muxiang (Saussurea, not fired) each half a liang (9 g each); Zhigancao two-and-a-half qian (6 g); Danggui one qian (3 g); Yuanzhi (honey-fried polygala) one qian (3 g).

Both of these formulas are now produced as patent medicines by many manufacturers. The Buzhong Yiqi Pills on the market are the pill form of Buzhong Yiqi Tang; Guipi Pills and Renshen Guipi Pills on the market are the pill form of Guipi Tang. If gastrointestinal function is adequate to digest pills, pills should be taken. If gastrointestinal function is weak and cannot digest hard pills, Guipi granules and Buzhong Yiqi granules may be purchased.

Constitutionally weak patients should take Buzhong Yiqi Pills or granules in the morning and Guipi Pills or granules in the evening, because Guipi Pills have a calming and sleep-promoting effect. Taking Buzhong Yiqi Pills in the morning gives energy through the day; taking Guipi Pills at night gives good sleep.

Some elderly patients develop severe yang deficiency after infection and long-term aversion to cold; such elderly patients should also take Guifu Dihuang Wan (Cinnamon-Aconite Rehmannia Pills) or Yougui Wan (Right-Restoring Pills). If in addition to aversion to cold there is edema of the eyelids or lower limbs, Jinkui Shenqi Wan (Golden Chamber Kidney-Qi Pills, which must contain Cheqianzi plantain seed and Niuxi Achyranthes in the formula) should be taken. If the patient cannot digest the pills, take the corresponding decoctions below.

Guifu Dihuang Tang: Shudihuang (prepared Rehmannia) 12 g, Shanzhurou (cornus fruit) 6 g, Huaishanyao (Dioscorea) 6 g, Mudanpi (Moutan) 5 g, Zexie (Alisma) 5 g, Fuling (Poria) 4.5 g, Fuzi (aconite) 3 g, Rougui (cinnamon bark) 3 g.

Jinkui Shenqi Wan decoction: Shudihuang four qian = 12 g, Shanzhurou 6 g, Huaishanyao 6 g, Mudanpi 5 g, Zexie 5 g, Fuling 4.5 g, Fuzi 3 g, Rougui 3 g, Cheqianzi (plantain seed) 6 g, Huainiuxi (Achyranthes) 6 g.

Most patients present with dual deficiency of qi and yin, insecure exterior, and spontaneous sweating; such patients need Shengmi Oral Liquid and Yupingfeng Granules (Jade Screen). If these patent medicines cannot be obtained, or if the diabetic patient cannot take sugar-containing oral liquid, decoct the following formulas.

Shengmai Powder: Xiyangshen (American ginseng) 3 g, Wuweizi (Schisandra) 3 g, Maidong (Ophiopogon) 3 g, decoct in water.

Yupingfeng Powder: raw Huangqi 6 g, Baizhu 6 g, Fangfeng (Saposhnikovia) 3 g. For patients with constitutionally deficient yin, replace Baizhu with Baishao (white peony).

Patients who have not fully recovered and still have cough may temporarily use my self-formulated Yiqi Huayu Pills; the reasoning behind this formula is explained in my article My Experienced Formula for COVID-Induced Cough and Wheezing: Yiqi Huayu Pills.

Yiqi Huayu Pills: raw Huangqi 50 g, Xiyangshen 10 g, Maidong 20 g, Tiandong 20 g, Wuweizi 20 g, Dilong (earthworm) 10 g, Rougui 5 g, Danggui 10 g. Grind all herbs into fine powder, mix with refined honey to form soybean-sized pills; take 15–40 pills per dose, twice daily, after rising in the morning and after the midday nap.

This formula can also be converted to a decoction: raw Huangqi 10 g, Xiyangshen 2 g, Maidong 4 g, Tiandong 4 g, Wuweizi 4 g, Dilong 2 g, Rougui 1 g, Danggui 2 g. Decoct in water. Take one or two doses per packet; severe cases may take 2–3 packets per day.

I am currently improving this formula; if the improved version proves more effective in future, I will publish it.

When treating immunocompromised patients, remember that you cannot treat them like strong young adults. Strong young adults recover whether treated or not, but immunocompromised patients become weaker and weaker under repeated attacks of the COVID virus; we must help them build an extra layer of immune defense. Do not reach immediately for acrid-cool or acrid-warm exterior-releasing herbs as soon as fever appears; that will only make them more deficient.

I am extremely cautious when prescribing for fever in immunocompromised patients. All exterior-releasing formulas are given as one packet or half a packet, and I require patients to report their reactions at any time. Such formulas are dangerous for them: excessive sweating can desert yang, and since their yang is already exhausted, further desertion of yang can be life-threatening.

When exterior-releasing formulas must be used for weak patients, the physician must do as Zhang Zhongjing said—"observe throughout the entire day-night cycle." That is, closely watch the patient's response after taking the medicine, and immediately take remedial action at the first sign of trouble.

Recent data from the National Health Commission shows that about 8% of COVID-infected people in China have pneumonia—that is, nearly 100 million people. Because of medical overload, most of them have not yet sought hospital care; in fact hospitals have no particularly good solutions anyway. In addition, a large number of patients have developed cardiovascular and cerebrovascular problems due to COVID. Many of these will become chronic. Exploring treatments for long COVID is an urgent matter.

I am myself still feeling my way across the river by touching stones, and I cannot claim my treatment protocols are mature. So patients must judge from actual efficacy whether to continue using my protocols. If the medicine works clearly, continue; if it is ineffective and makes the patient feel worse, stop. The principle of cautious and safe medication must always be kept in mind; do not blindly trust anyone.

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