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TCVM perspective and treatment of equine metabolic syndrome

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In the last few decades, the overall quality of health in our equine patients has been deteriorating.1 We are seeing an increase in several chronic conditions, including those indicative of immune-mediated inflammatory diseases such as recurrent uveitis. We are also seeing diseases that indicate significant failure of normal function, such as the complex of conditions known as Metabolic Syndrome. 

“Metabolic Syndrome” is a term used to describe horses with both a metabolic and hormonal disorder characterized by obesity, regional adiposity, insulin resistance and laminitis. According to figures from the American Association of Equine Practitioners, we are facing an epidemic of over 20% of all horses at risk of developing Metabolic Syndrome. Many breeds are also at increased risk of developing immune-mediated diseases; for example, the Appaloosa has an 8x risk over other breeds of developing recurrent uveitis and is responsible for 25% of all cases.2 Recurrent uveitis is often incited by viral, bacterial or spirochete organisms.2 These diseases are becoming difficult to control and cure, even with the help of alternative modalities.

The Six Stages of disease were first developed by the great master of Chinese Herbology, Zhang Zhong Jing (142 to 220 ACE) when he wrote the Shang Han Lun on Cold Damage. When examining these diseases in the context of the Six Stages of disease, conditions found at the level of the Jue Yin are serious and occurring at the deepest stage in the body. A Jue Yin disease reflects the separation of Yin and Yang and the collapse of Zheng Qi. Metabolic Syndrome with concurrent signs of Heat in the upper body or in the extremities is indicative of a Jue Yin syndrome.

ASSESSMENT AND TREATMENT CHALLENGES OF METABOLIC SYNDROME

Snowflake is a 19-year-old Appaloosa mare, a companion and trail horse. Her early history only made note of a tendency toward obesity, a full complement of yearly vaccines (tetanus, rhino, flu, EEE and WEE, West Nile and rabies), and frequent administrations of anthelmintic drugs. She had an initial episode of uveitis in April of 2006 which was treated with conventional steroidal eye medications and a triple antibiotic ophthalmic ointment. This initial episode resolved within a month. Over the next six years, Snowflake continued to have periodic episodes that were progressively more severe with poorer resolution and longer recovery times. Her worst episodes seemed to occur during the change of seasons in the spring and fall.  Concurrent with the intermittent use of corticosteroids, Snowflake was experiencing weight gain. 

Throughout this time, her other health issues included periodic high fecal egg counts that were unresponsive to the conventional veterinarian’s “power pack”, and two mild episodes of colic characterized by poor bowel motility. In 2013, Snowflake’s owner had received a grim long-term prognosis. Her vision was deteriorating, with significant cataract formation seen in both eyes, and her conventional veterinarian stated the outlook was “hopeless”.

In 2014, her owner decided to investigate alternative forms of treatment. In September, she presented to me with unresolved hyperemia in the conjunctival tissue of both eyes, with marked cataract development in the right eye, and mild development in the left. She had significant blepharospasm, worse in the right eye, with excessive lacrimation in both. She was very reactive on BL-18, her tongue was red and swollen with copious phlegm, her pulse was fast but wiry with tone. There was strong evidence for Liver Fire, but Snowflake was also Spleen Qi Deficient and had Qi Stagnation. Her initial acupuncture treatment included dry needling of BL-18, BL-19, BL-20, LIV-3, GB-20, ST-36, BL-1 and ST-2. She received an autosanginous injection of Aqua-AP of Traumeel (Heel) in the local eye points. Her TCVM diagnosis was Liver Damp Heat with Liver Fire Rising, and a slight Spleen Qi Deficiency with Stagnation. Due to the intense Damp Heat in her eyes, her herbal formula was Long Dan Xie Gan Tang (JT) to clear the Liver Damp Heat. Within a week after her treatment, Snowflake’s eyes were much less red, with the blepharospasm resolved.

Over the next year, Snowflake was treated four times. Although much better, she still exhibited signs of Liver Damp Heat with increased tearing and slight redness in her conjunctiva, and her underlying Qi Deficiency and Stagnation seemed to worsen. Her tongue was still swollen with marked phlegm. It was felt that the draining effect of Long Dan Xie Gan Tang was contributing to this further weakening of her Qi. Yet if she was taken off of Long Dan Xie Gan Tang, her eyes would immediately worsen. To treat this underlying Qi deficiency, several herbal modifications were made with moderate response: Si Miao San (JT) was incorporated; increased percentage of Poria, Fu Ling; and finally Wei Qi Booster (JT). Although these herbal modifications helped diminish signs of Qi deficiency, Snowflake continued to show signs of simmering Heat in her eyes with the slow progression of cataract formation. There were more signs of Qi Stagnation as her tongue was slightly lavender and her adipose deposits were increasing. During the summer months, Snowflake started to exhibit overt signs of insulin resistance with increased weight grain, increased fat deposition and a subtle increase in digital pulses in all four hooves. There was definitely a deeper unresolved issue.

On October 24, 2015, the day after the first heavy frost, Snowflake was out on an eaten-down pasture for an hour. Later that day, she could hardly walk. On physical exam, her pulse was very toned, wiry and rapid, her tongue was purplish red, swollen with phlegm. She was showing signs of acute laminitis, with bounding digital pulses. She was standing in the classic foundered posture with her forelegs extended, was constantly shifting her weight and seemed agitated. Her eyes were acutely red, with marked swelling in the infraorbital fossa. She was reactive on BL-15, BL-18, BL-19 and BL-22.   This time, Snowflake was diagnosed with a Jue Yin pattern. She was in a critical state with a deficient but stagnated immovable Yin; her Yang energy was evident as Heat in her extremities and upper body. This Yang entrapment in the upper body was reflected in her purple red tongue, restlessness and agitation; the acute eye redness and inflammation; and the heat forced to her extremities in the signs of laminitis.  Her immovable Yin energy was characterized by the building signs of insulin resistance, adipose deposits and weight gain.

CHINESE MEDICAL ETIOLOGY AND ATHOGENESIS

A Jue Yin stage is characterized by a marked dysfunction of the Liver and Pericardium. The pattern occurs when there is an accumulation of Jue Yin (Liver).  The Yang energy is unable to penetrate into the Yin and is then squeezed outward and upward. The Yang energy is then trapped in the extremities and upper body.  This is a critical stage as Yin and Yang are separated and will become unable to produce Zheng Qi.3 This is a potentially life-threatening state; if Yin and Yang separate, death will occur.

The theory of the Six Stages was written by Zhang Zhong Jing in response to an epidemic that killed over 200 of his relatives. The Shang Han Lun attributes Cold damage to the invasion in the body by pathogenic evils. “In the four seasons, all qi that is not right qi is called cold damage”.4 As an Appaloosa, a breed known for its higher rate of immune-mediated diseases, Snowflake is genetically susceptible to the ills of an invading pathogen. She would have even greater difficulty clearing an invading pathogenic “evil”, allowing for the establishment of uveitis, an auto-immune condition. When pathogenic evils are not cleared as they enter the body, they can move into deeper stages in the body. There are many possible inciting pathogenic factors, including vaccine antigens or adjuvants, GMO particles, or one of the other recognized predisposing pathogens of uveitis – viral, bacterial or spirochete organisms. Regardless of which specific pathogenic factor is involved, it’s theorized that this invading “evil” progressed through the various channels until it reached the Jue Yin stage in Snowflake This stage generally develops some time after the onset of Cold damage disease. It is more complicated and severe than disease in any other channel.

HERBAL MEDICINE USED

Wu Mei Wan (Mume Plum Pill) is the formula indicated for a Jue Yin state characterized by Yang trapped upward, with Cold impenetrable Yin. (see table below). This herbal formula contains both Hot and Cold ingredients to address the ColdHeat complex, and also includes ingredients that are sour, bitter and acrid. Ginseng rhizome (Ren She) restores Qi formation, while ginger rhizome (Gan Jiang), prickly ash bark (Hua Jia) and aconitum prepared root (Fu Zi) inject Yang into the accumulation of Yin. Acrid and sweet ingredients together can warm Yang. Bitter Cold coptis rhizome and phellodendron clear Heat accumulated in the upper body, and descends Yang back to where it can be integrated. Angelica root (Dang Gu) and Mume plum (Wu Mei) soften Jue Yin while cinnamon promotes its expansion.5 Wu Mei Wan contains sour and sweet to enrich Yin, sour and bitter to drain Heat; acrid and sweet to warm Yang; acrid and bitter to open and bear downwards. This formula should be considered the primary choice for treating reverting Yin Cold-Heat complex patterns. Wu Mei Wan is designed to resist the extreme Jue Yin state with cinnamon by strengthening the next phase of Yin development associated with the Lung.

Chinese Pin-Yin

English Name

Action

%

Wu Mei

Mume plum

Calms parasites; softens Jue Yin

13

Huang Lian

Coptis rhizome

Clears Heat in the upper body

23

Gan Jiang

Ginger rhizome

Injects Yang back into Yin; warms the interior and dispels Cold

13

Hua Jiao

Prickly ash bark

Injects Yang back into Yin; warms the interior and dispels Cold

9

Huang Bo

Phellodendron bark

Clears Heat accumulated and sends it downward

9

Fu Zi

Aconitum

root (prepared)

Injects Yang back into Yin; warms the interior and dispels Cold

9

Gui Zhi

Cinnamon twig

Promotes the expansion of Jue Yin

9

Ren Shen

Panax ginseng

Tonifies Qi and Blood; restores Qi

9

Dang Gui

Angelica root

Softens Jue Yin and tonifies Qi and Blood

6

 

Dosage:

2 tsp. twice a day

Concurrent therapy:

Snowflake also received dry needle acupuncture with her primary points being LIV-1, LI-4, SP-4 and PC-6 to treat her Jue Yin state; PC-9 for a local fore foot point; and ST-36 for general harmonizing.

Follow-up/outcome:

Within 24 hours, Snowflake’s digital pulse had resolved and she was walking normally! The redness in her eyes was gone, although there was still some infraorbital swelling. Her owner felt she was acting her best since 2006. This was felt to be a truly rapid response to treatment.

Her re-check six weeks later, on December 2, 2015, showed clear eyes, no digital pulses, a pinker and not-so-swollen tongue, and pulses that were still slightly wiry. Overall, she was much better and the plan was to continue Wu Mei Wan.

On February 12, 2016, Snowflake’s eyes were at their best ever. She was still struggling with obesity, so has continued with Wu Mei Wan.

DISCUSSION

Snowflake is an example of a horse that had subtle signs of a Jin Yin stage a decade ago. She had a tendency toward obesity, a persistently high parasite count – both signs of excessive Yin accumulation – with concurrent signs of Yang energy being entrapped upward, leading to uveitis. Although the initial herbal and acupuncture treatments palliated the signs of her Yang entrapped energy, it was not resolved and her accumulation of Yin continued. During the approaching winter of 2015/16, with the extra sugar stress of recently frosted grass, she exhibited a final acute aggravation of her underlying chronic disease, and her Jue Yin stage was finally recognized. 

Classical literature considers Wu Mei Wan a formula for parasites.6 The main clinical manifestations are ascariasis characterized by Heat in the Stomach and Cold in the Intestines. The presence and movement of roundworms cause a disruption in normal Qi flow and, if severe, the flow of Yin and Yang Qi will be disrupted. The clinical manifestations of a Jue Yin stage is a feeling of energy rising to the chest, pain and a sensation of heat in the heart region.7 But this formula should not only be considered for roundworm reversal; it should also be the primary formula for treating reverting Yin Cold-Heat complex patterns.4

When looking at the energetics of a disease in the Jue Yin stage, Wu Mei Wan is the formula of choice since it treats conditions in which there are signs of overt Heat and Yang energy in the extremities and upper body, along with signs of extreme Jue Yin accumulation in the lower abdomen. The Yang energy is squeezed out and is forced up and out. Jue Yin states are often aggravated in the winter as Yang energy naturally tends to move toward the interior. (Snowflake had some of her worst episodes in the fall.) As Yang energy migrates inward, it is repelled out and up from the impenetrable accumulation Yin in the abdomen. This was seen in Snowflake’s final aggravation, when the sugar stress increased her Yin accumulation while the cold weather aggravated the inability of her Yang energy to penetrate her Yin; she had an acute separation of her Yang and Yin.

The absence of Yang energy in the abdomen prevents proper Spleen function; this is a characteristic symptom of Metabolic Syndrome. This Yang energy can instead accumulate in the Heart, giving the very common symptom of laminitis. When recognizing the serious nature of a Jue Yin stage, it becomes clear the peril our horses are in with Metabolic Syndrome; not only is it a barometer of the overall poor level of health of horses, but it also explains why it’s so difficult to cure this syndrome. (See Fall IVC Journal for four more cases.)


1Lankenau C. “The Deterioration in Equine Vital Health”. The Academy of Veterinary Homeopathy, 2008 Annual Meeting; pp. 63-69.

2Gilger B. “Equine Recurrent Uveitis in Appaloosa Horses”. Equine Ophthalmology 2 ed., Saunders; 2011: p. 307.

3Tierra M, Tierra L. East West Herb Course, Ben Lomond, CA; p.32-21, 2011.

4Zhang Zhong Jing Shang Han Lun on Cold Damage; translations and commentaries by Mitchell C, Ye F, Wiseman N. Paradigm Publications, 1999; p. 9.

5Marsden S. “Chinese Medical Diagnoses Common in Winter”, NAVA Conference, 2015, p.32.

6Chen J and T, Beebe S, Salewski M. Chinese Herbal Formulas for Veterinarians. Art of Medical Press; City of Industry, 2012, pp. 1054-1057.

7Maciocia M. Diagnosis in Chinese Medicine, a Comprehensive Guide. Elsevier, 2004; p. 968


References

Evergreen Herbs & Medical Supplies, City of Industry, CA

Heel, Albuquerque, NM

Dr. Xie’s Jing Tang Herbal, Inc., Reddick, FL

Dr. Cynthia Lankenau received her DVM from Cornell University in 1981, and started studying alternative modalities in 1992. She is certified with the IVAS, AVCA and AHV, and in Chinese Herbal Medicine through the Chi Institute and CIVT. She is a registered herbalist through the American Herbal Guild and is currently working on CIVT’s Western Graduate Herbal program. She is Past President of the Veterinary Botanical Medicine Association, and owns a private integrative mixed practice.