This article is written by: 林醫師 On The Move
On 7th May 2020, this piece of news was announced:
Personally, I am not excited about this. The concerns about the potential misuse by the public can be haunting. And I notice that this medication was sold online on Online retail app such as Lazada and Qoo10.
On an objective note, Health Sciences Authority (HSA) made statements on 12th May 2020 that:
Lianhua Qingwen Capsule is locally registered as a proprietary Chinese medicine and this does not mean that the capsule can be used as a medicine to treat or relieve COVID-19 symptoms. In response to an inquiry from Channel 8 News, HSA said that the authorities approved the capsule as a proprietary Chinese medicine for relieving cold and cold symptoms according to the efficacy of the ingredients of this capsule, and did not recognize this drug as a treatment or relief of COVID-19 symptoms. They further explained that Chinese patent medicines are supplementary health products controlled by the authorities, not products approved for the treatment of infectious diseases and other conditions. So far, there is no scientific evidence that any herbal medicine can help to treat COVID-19. (The above statements are translated based on this link: https://www.8world.com/news/singapore/article/hsa-on-lianhua-qingwen-jiaonang-1128681)
In addition, on 8th May 2020, a celebrity TCM physician also informed Channel 8 News that this medication does have the TCM efficacy to eliminate heat and detoxify. And based on the clinical research papers published in China, this medication did provide clinical evidence of efficacy in the treatment of COVID-19. However, due to the geographical and weather differences, the TCM syndrome in Singapore may differ from China and this medication may not be necessarily applicable locally. She added a note of caution that this should not be taken if you are not sick, and even if the individual is feeling under the weather, he or she should approach his or her doctor for diagnosis and prescription of the appropriate medication. (The following paragraph is translated based on this link: https://www.zaobao.com.sg/znews/singapore/story20200508-1051728)
This announcement was mainly reported in local Chinese media. This raised my concerns for the public’s potential misuse (despite HSA’s efforts to advise the public) and the public’s lack of understanding of this medication, as well as some members of the public who might seek medical opinions from their western medicine doctors, with regards to this “popular” TCM medication. However, many reports and research papers on this medication were published in mandarin, forming a language barrier for the non-Chinese speaking healthcare professionals who are interested to find out more. Therefore, I hope this post can provide general information and an objective understanding of this medication.
Certainly, please do not solely rely on this post and I highly recommend the readers to do more research on this topic on your own.
Brief History of Lianhua Qingwen Capsule
The Lianhua Qingwen medication was first developed in China in the year 2003, specifically in response to the SARS outbreak in China. In July 2003, the first Lianhua Qingwen product and preparation method patent CN1194752C disclosed an antiviral traditional Chinese medicine composition and preparation method. The instructions in the specification confirmed that the traditional Chinese medicine composition can be used as a treatment for atypical pneumonia and prophylactic drugs. According to reports, Lianhua Qingwen had played a vital role in respiratory-related public health incidents many times since its launch. During the SARS epidemic in 2003, this anti-SARS Chinese patent medicine Lianhua Qingwen Capsule entered China’s National New Drug Fast Track (国家新药快速通道) as a prescription drug in May 2003. In May 2004, it obtained China’s National Pharmaceutical Standard Number and was listed by Ministry of Health of the People’s Republic of China as one of the first Chinese patent medicines for the treatment of SARS.
Since then, this medication had been included as one of the recommended drugs for the following public health treatment programmes in China:
Year 2005: “Diagnosis and Treatment Plan for Avian Influenza” 《人禽流感诊疗方案》, Ministry of Health of the People’s Republic of China
Year 2009: “Diagnosis and Treatment Plan for H1N1″《人感染甲型H1N1流感诊疗方案》, Ministry of Health of the People’s Republic of China
Year 2010: “Diagnosis and Treatment Plan for Wind-warm Pathogenic Pulmonary Fever (Non-severe Community-acquired Pneumonia)”《风温肺热病（非重症社区获得性肺炎）诊疗方案》, National Administration of Traditional Chinese Medicine
Year 2011: “Diagnostic and Treatment Guidelines for Influenza”《流行性感冒诊断与治疗指南》, Ministry of Health of the People’s Republic of China
Year 2012: “Chinese Medicine Prevention and Treatment Program for Influenza B”《乙型流感中医药防治方案》, National Administration of Traditional Chinese Medicine
Year 2013: “Diagnosis and Treatment Plan for H7N9″《人感染H7N9禽流感诊疗方案》, National Health and Family Planning Commission
Year 2013: “Medical Expert Consensus on Treatment for H7N9” 《人感染H7N9禽流感医疗救治专家共识》, National Health and Family Planning Commission
Year 2014 and 2017: “Diagnosis and Treatment Plan for H7N9″《人感染H7N9禽流感诊疗方案》, National Health and Family Planning Commission
Year 2018 and 2019: “Diagnosis and Treatment Plan for Influenza” 《流行性感冒诊疗方案》, National Health Commission
The Theory of TCM Behind Lianhua Qingwen Capsule
TCM Pathogenesis of COVID-19
Before I move on to talk about the list of TCM herbs within this medication, I would like to quickly give you a summary of how TCM analyses the pathogenic nature of COVID-19.
TCM categorises COVID-19 as plague under the epidemiology of TCM*. According to the COVID-19’s clinical symptoms displayed, the basic pathogenesis can be summarized as:
Invasion of the epidemic virus,
Pathogenic attack upon the lungs, and
Deficiency in the vital qi.
The TCM pathological properties involve dampness (湿), heat (热), poison (毒), deficiency (虚) and stasis (瘀).
As such, the TCM principles of treatment would be:
Pay attention to the combination of treatment based on “different diseases, combination of syndromes and special prescriptions” (“辨病为主、病证结合、专病专方”)
Pay attention to the body’s physical factors
Pay attention to the pathogenicity of the epidemic
Pay attention to the main lesions and main syndromes
Pay attention to judging mild and severe conditions according to the rapid changes of the disease and make corresponding treatment
According to the characteristics of the new coronavirus infectious pneumonia, combined with the results of modern pharmacological research, a comprehensive treatment method for the clinical evolution of the disease is to be proposed
In China, specifically, a combination of western medicine standard care and Chinese medicine treatment strategy was adopted in some of the treatment facilities. And Lianhua Qingwen medication was one of the recommended TCM medications to relieve mild and moderate COVID-19 conditions, as indicated in China’s “Diagnosis and Treatment Plan for COVID-19 (version 7)” (新型冠状病毒肺炎诊疗方案（version 7）).
*The epidemiology of TCM was well recorded in several renowned TCM works of literature, e.g.《温疫论》by 吴又可(Ming Dynasty),《温热论》by 叶天士 (Qing Dynasty),《湿热病篇》by 薛生白 (Qing Dynasty),《温病条辨》by 吴鞠通 (Qing Dynasty),《温热经纬》by 王孟英 (Qing Dynasty),《伤寒温疫条辨》by 杨栗山 (Qing Dynasty),《疫疹一得》by 余师愚 (Qing Dynasty),《广瘟疫论》by 戴天章 (Qing Dynasty),《松峰说疫》by 刘松峰 (Qing Dynasty) and 《辨疫琐言》by 李炳 (Qing Dynasty).
TCM Herbal Ingredients & Their Respective TCM Pharmaceutical Functions
There are 13 raw TCM herbs and their respective TCM pharmaceutical functions in this medication:
Primary Herb (君药)
01. 连翘, Fructus Forsythiae – Disperse the pathogen exogenously, eliminate the stasis of heat endogenously （外疏肌表、内清郁热）
Secondary Herbs (臣药)
02. 金银花, Flos Lonicerae – Enhance Fructus Forsythiae’s function of eliminating heat（助连翘清热之功）
03. 炙麻黄, Herbal Ephedrae – Disperse the external pathogen, improve the respiratory network（宣肺疏表，宣畅肺络）
Tertiary Herbs (佐药)
04. 炒苦杏仁, Semen Armeniacae Amarum – Soothe the lungs to stop the coughing symptom （肃肺止咳）
05. 石膏, Gypsum Fibrosum – Enhance the effect of eliminating heat（增加清热效果）
06. 板蓝根, Radix Isatidis – Enhance the effect of eliminating heat（增加清热效果）
07. 绵马贯众, Dryopteris bissetiaha – Enhance the effect of eliminating heat（增加清热效果）
08. 鱼腥草, Herba Houttuyniae – Clear and detoxify the lungs, remove carbuncle and excrete pus（清肺解毒、消痈排脓）
09. 广藿香, Herba Agastaches – Warm to improve the flow of qi（芳香辟秽、宣畅气机、化温畅中）
10. 大黄, Radix Er Rhizoma Rhei – Enhance the effect of eliminating heat（增加清热效果）
11. 红景天, Root of Kirilow Rhodiola – Tonify qi and nourish yin, clear and detoxify the lungs（益气养阴、清肺解毒）
12. 薄荷脑, Herba Menthae – Disperse the pathogenic wind-heat（芳香开窍、疏散风热）
Quaternary Herbs (使药)
13. 甘草, Radix Glycyrrhizae – Act as detoxification and neutralisation of all herbs（解毒、调和诸药）
Precautions (Reference: Baidu “连花清瘟胶囊”)
Avoid smoking, alcohol and spicy, cold, greasy food.
It is not advisable to take nourishing Chinese medicine at the same time while taking the medicine.
Not suitable for people with a cold caused by TCM pathogenic wind-cold.
Use with caution in patients with hypertension and heart disease. Those with severe chronic diseases such as liver disease, diabetes, and kidney disease should take it under the guidance of a physician.
Children, pregnant women, lactating women, elderly frail and spleen-deficiency (e.g. experience loose stools) should be taken under the guidance of a doctor.
Patients with fever and body temperature exceeding 38.5 ℃ should go to the hospital for treatment.
Take strictly according to usage and dosage, this product should not be taken for a long time.
After taking the medicine for 3 days, the symptoms are not relieved, so you should go to the hospital for treatment.
It is forbidden for those who are allergic to this product, and those with allergies should be used with caution.
This product is forbidden to use when the property changes.
Children must be used under adult supervision.
Please put this product out of the reach of children.
If you are using other drugs, please consult your physician or pharmacist before using this product.
Athletes use with caution.
After opening the moisture-proof bag, please pay attention to moisture-proof.
So, why can’t we use this medication immediately in the local hospital settings since this had been clinically proven in China?
There are areas of considerations when reviewing the clinical trial papers and one of them would be the design of the clinical trial (e.g. determination of sample size, the procedure of subject randomisation, the method of administration of drug use, etc.). Clinical trials are essential to go through stringent rounds of reviews and approval before conducting to determine the efficacy and safety of the proposed treatment. Besides, the identification and classification of TCM syndromes presented for COVID-19 can differ from one geographic location to another, hence the treatment strategy can differ as well (this had been reported in some research papers presented by various provinces in China due to the difference in the weather condition). So this could be one of the possible reasons that we cannot hastily introduce a certain drug into a hospital setting before conducting clinical trials to determine the efficacy and safety of proposed treatment.(Please note that this paragraph is based on my personal opinions and my current understanding of the topics discussed.)
Singapore’s Ministry of Health had recently opened up a TCM research grant call to “to harness TCM principles and scientific research methodologies and expertise to validate the use of TCM as an adjuvant therapy, for the prevention, treatment and rehabilitation of mild and moderate for COVID-19 patients in Singapore.” With this grant, it provides a structured channel to understand more about TCM treatment in a scientific and evidence-based approach. You may click on this link to find out more.
Hence, if you are experiencing flu-like symptoms, please proceed to see a western doctor immediately so that he or she can proceed with the appropriate diagnosis. Please do not try to self-medicate yourself, especially with TCM herbs. This would only increase the chance of worsening your condition and delay the appropriate treatment.
This article first appeared on 林醫師 On The Move
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Open Access (OA) Online-First Publishing of Research Papers on COVID-19, CNKI (China National Knowledge Infrastructure)
Efficacy and safety of Lianhua Qingwen capsule for influenza: a systematic review (Abstract provided only)