THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 21, Number 5, 2015, pp. 304–306 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2014.0145

Case Study

Combination Therapy of Traditional Chinese Medicine and Western Medicine to Treat Refractory Polymyositis: A Case Report Yu-Chen Cheng, MD,1 Ming-Yen Tsai, MS, MD,1,2 Chung-Jen Chen, MD,3 and Yu-Chiang Hung, MD, PhD1,2,4

Abstract

Objective: To illustrate the potential for clinical improvement and regimen decrement in treating a patient with a refractory case of polymyositis (PM) with a combination of Western medicine and traditional Chinese medicine (TCM). Interventions and Outcome measures: A 40-year-old man diagnosed with steroid-resistant PM in January 2011 demonstrated a poor response to immunosuppressants. Complementary TCM treatments were applied to treat his weakness at a clinic integrating TCM and rheumatology in February 2012. He was treated with herbal formula powders named ‘‘Bu-Zhong-Yi-Qi-Tang’’ and ‘‘Si-Jun-Zi-Tan.’’ Within 1 month of treatment, the patient seemed to show significant improvement in the grade of disability. Daily doses of methotrexate and methylprednisolone were tapered to 25% and 95.8% after TCM treatments, respectively. Creatine phosphokinase also decreased from 6655 to 718 U/L until December 2013. Conclusions: In our experience, weakness related to PM can be improved by invigorating the spleen-Qi with TCM treatments. This might indicate that TCM treatments can not only play a role in symptom control but also accelerate steroid tapping for refractory cases. Long-term follow-up and future experimental studies are warranted to examine the efficacy and explore the mechanism of TCM treatments for PM.

Introduction

Treatment and Intervention

T

Clinical improvement and decreased CPK were not observed in this patient, although both methylprednisolone and MTX were increased to 20 mg/week and methylprednisolone to 48 mg/day. Neurological examination showed 3/5 bilaterally in the legs and 4/5 bilaterally in the arms with a strong grip. CPK was 6655 U/L, indicating that elevated CPK was due to PM muscle breakdown. In addition, the patient’s aspartate aminotransferase and alanine aminotransferase were maintained at higher levels after receiving MTX therapy. Based on the flaccidity syndrome, the TCM practitioner prescribed two herb formula powders, ‘‘BuZhong-Yi-Qi-Tang’’ (BZYQT) 2.5 g and ‘‘Si-Jun-Zi-Tang’’ (SJZT) 1.5 g, three times a day. We also regularly followed up on his CPK, liver/renal function, and C-reactive protein to monitor the disease activity and drug complications. Clinical improvements in muscle power and immunity were

he patient was a 40-year-old man with a history of polymyositis (PM). The initial clinical symptoms were having difficulty with heavy lifting, hardly standing-up after squatting, muscle pain, unable to ride a bike, and even difficult to put on clothes by himself. He had undergone high-dose corticosteroid therapy for months at another hospital, and the initial creatine phosphokinase (CPK) was over 20,000 U/L. However, he still felt muscular weakness and muscle pain after treatment. He was transferred to our rheumatology department for further immunosuppressive therapy in June 2011. After 9 months of treatment with oral methotrexate (MTX) in addition to corticosteroids, the patient had demonstrated no significant improvement in his condition. Drug-induced hepatic dysfunction and decreased immunity were also observed. He began to receive complementary traditional Chinese medicine (TCM) treatments in February 2012. 1

Department of Chinese Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Kaohsiung, Taiwan. Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan. 4 School of Chinese Medicine for Post Baccalaureate, I-Shou University, Kaohsiung, Taiwan. This case study has passed the Institutional Review Board investigation of Chang Gung Memorial Hospital, Kaohsiung, Taiwan. The application number is 103-1019B. 2 3

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TCM AND WESTERN MEDICINE COMBINED THERAPY FOR REFRACTORY POLYMYOSITIS

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FIG. 1. Serum creatine kinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, and dosage of Western medicine (methotrexate, methylprednisolone, and leflunomide) before and after traditional Chinese medicine treatment. gradually seen after TCM treatment. CPK level decreased over time, except during a counterattack that occurred on March 28, 2012, because of rapid dose decrement of methylprednisolone and MTX. Therefore, we prescribed 6 months of leflunomide to reduce the counterattack phenomenon and to facilitate the tapping dose of other Western medicines. The improvements in grade of disability and muscle enzymes were significant until December 2013 (Fig. 1). Interestingly, abnormal liver function has returned gradually to normal range in patients treated with TCM treatment. His disease activity was successfully controlled with MTX 15 mg/week and methylprednisolone 2 mg/day. Discussion

PM is an idiopathic inflammatory myopathy that causes symmetrical, proximal muscle weakness, elevated skeletal muscle enzyme levels, and characteristic electromyography and muscle biopsy findings.1 It often gives rise to severe chronic disability and may be complicated by life-threatening impairment of swallowing and respiratory function. The median survival for PM is 11.0 years (95% CI: 9.5–13.3). Only 20–40% of treated patients will achieve disease remission, and 60–80% will experience suffering in the course of the disease.2 Corticosteroids are used as the standard treatment for PM, but some patients suffer troublesome side effects and insufficient efficacy. Immunosuppressive agents, especially MTX and azathioprine, are often used in refractory cases. For patients who are unresponsive to standard therapy with high doses of steroids supplemented by MTX, the next best choice for therapy is not clear.3 In our case, the combination of methylprednisone plus MTX had not improved the functional disability, and it was necessary to use less me-

thylprednisone for disease control. Therefore, TCM was tried as a treatment for refractory PM. In TCM theory, the physiological functions of spleen-Qi include governing transformation and transportation, controlling blood, and ascending essence. It also dominates muscle strength and the nutrients of the limbs. From the viewpoint of molecular biology, the clearance of apoptotic cells related to autoimmune diseases such as systemic lupus erythematous and rheumatoid arthritis matches the spleen-Qi theory.4 The prescribed formula, BZYQT, has been used to treat the effects of spleen-Qi descending, visceroptosis with hyposplenic Qi, organ prolapse, and immunity disequilibrium since the Jin dynasty in China, and it has been identified as an effective drug for the treatment of TCM spleen-Qi deficiency in clinical practice. This formula has been reported to produce clear benefits and good results in patients with muscle weakness and is even used in PM practically.5,6 In addition, SJZT can be used as a tonic supplement for refractory PM and alleviate the adverse effects of Western medicine.7 Our results showed that muscle power was recovered within 1 month of additional TCM treatment. CPK levels were gradually halved at the 8th month after TCM treatment onset. TCM treatment in conjunction with an aggressively tapered course of steroids and immunosuppressants showed a good response. Treating patients with low-dose regimens can increase tolerance and prevent side effects such as osteonecrosis, myelosuppression, and liver or kidney injury.3 Furthermore, we clearly demonstrated the protective effects of BZYQT on drug-induced hepatoxicity of PM, which is consistent with Ochi et al.8 Limited data have indicated that TCM treatment could accelerate recovery from disability and decrease CPK levels in PM patients. In this patient with refractory PM, muscle strength increased and CPK levels decreased with

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combination therapy. Furthermore, combination treatment permitted the dose of steroids and MTX to be reduced. Long-term follow-up and future experimental studies are warranted to examine the efficacy and explore the mechanism of TCM treatment for PM, given the relative lack of research on this topic. Author Disclosure Statement

No competing financial interests exist. References

1. Dalakas MC. Polymyositis, dermatomyositis and inclusionbody myositis. N Engl J Med 1991;325:1487–1498. 2. Airio A, Kautiainen H, Hakala M. Prognosis and mortality of polymyositis and dermatomyositis patients. Clin Rheumatol 2006;25:234–239. 3. Marie I. Therapy for dermatomyositis and polymyositis. Presse Med 2011;40:e257–e270. 4. Elliott MR, Ravichandran KS. Clearance of apoptotic cells: Implications in health and disease. J Cell Biol 2010;189:1059– 1070. 5. Xiao-ming G, Ming-li G. Professor Gao Ming-li dialectical treatment of dermatomyositis and polymyositis. J Pract Tradit Chin Intern Med 2012;26:19–20. [Article in Chinese]

CHENG ET AL.

6. Zhenga X, Tiana J, Liub P, Xinga J, Qin X. Analysis of the restorative effect of Bu-zhong-yi-qi-tang in the spleen-qi deficiency rat model using (1)H-NMR-based metabonomics. J Ethnopharmacol 2014;151:912–920. 7. Liu L, Han L, Wong DY, Yue PY, Ha WY, Hu YH, Wang PX, Wong RN. Effects of Si-Jun-Zi decoction polysaccharides on cell migration and gene expression in wounded rat intestinal epithelial cells. Br J Nutr 2005;93: 21–29. 8. Ochi T, Kawakita T, Nomoto K. Effects of Hochu-ekki-to and Ninjin-youei-to, traditional Japanese medicines, on porcine serum-induced liver fibrosis in rats. Immunopharmacol Immunotoxicol 2004;26:285–298.

Address correspondence to: Yu-Chiang Hung, MD, PhD College of Medicine Chang Gung University No. 123, Dapi Road Kaohsiung City 833 Niaosong District Taiwan E-mail: [email protected]

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Combination therapy of traditional Chinese medicine and Western medicine to treat refractory polymyositis: a case report.

To illustrate the potential for clinical improvement and regimen decrement in treating a patient with a refractory case of polymyositis (PM) with a co...
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