Evaluation of the Chinese Herbal Remedies San Ren Tang, Wei Lin Tang, and Alisma for Feline Urinary Tract Disease

Though herbal remedies often have an aura of being somehow fundamentally different from drugs used as medicines, they are really just collections of chemical compounds. As such, they ought to be evaluated just as conventional pharmaceuticals are: identification and isolation of active compounds, in vitro experiments establishing potential beneficial and harmful effects, in vivo studies looking at absorption, metabolism, and safety, and finally well-controlled clinical trials escalating in size and complexity to determine safety and effectiveness in the target species and disease conditions. There is no reason such remedies cannot be effective therapies, but there is also no reason to assume they are safe or effective without following these steps. For a variety of practical and philosophical reasons, unfortunately, many potentially useful herbal products are not properly tested, and their use is based on much less reliable foundations, such as folk tradition and personal experience.

Therefore, I always appreciate it when I see important and necessary, though often not glamorous, preclinical research on such remedies. This kind of research can be invaluable in guiding us towards or away from specific remedies, though it is only one piece of the puzzle and cannot definitively confirm or refute the potential usefulness of specific herbal products. An abstract being presented at the upcoming American College of Veterinary Internal Medicine Forum presents the data from just such a laboratory study.

M. Daniels; J.W. Bartges; D.M. Raditic; C.A. Kirk; A. Callens; S. Marsden; G. Galyon
Evaluation of 3 Herbal Compounds Used for Management of Lower Urinary Tract Disease in Cats

The study evaluated three herbal products to see if they increased urine volume or changed the chemical constitution of the urine in was believed to reduce the risk of Feline Lower Urinary Tract Disease (FLUTD), a common and uncomfortable condition in cats. 6 healthy cats were used in the study, and they were randomly assigned to be given each of three products or a placebo in turn: San Ren Tang, Wei Ling Tang, and Alisma. A 24-hour urine sample was collected and analyzed after 2 weeks of treatment with each product for each cat. None of the products showed a significant difference from the placebo in any variable measured.

I am not familiar with the basis on which these products are recommended for FLUTD, so I cannot evaluate the plausibility of the underlying theory. However, the products are herbal remedies within the Traditional Chinese Medicine (TCM) approach, and I have already discussed elsewhere the principles of TCM and why they are fundamentally inconsistent with a scientific approach to medicine. Individual herbal products undoubtedly have active chemical compounds, both from the plant ingredients and often deliberate or accidental contaminants, but without proper scientific evaluation there is no valid way to designate specific products as treatments for specific conditions or to evaluate their safety and efficacy.

This study was not intended, of course, to definitively answer the question of whether these herbal preparations are safe or beneficial for cats with FLUTD. The particular urine characteristics measured are known to play a role in the risk of developing FLUTD symptoms, but there are other risk factors, and the precise steps leading to the condition in individual cats are not clearly understood. So these products could conceivably be beneficial even if they do not influence the variables looked at in this study. However, given the apparent lack of a sound scientific rationale for using them, and the lack of a plausible mechanism or established preclinical effects, such remedies cannot be routinely recommended. And given the limited resources available for research into new veterinary therapies, it seems it would be most efficient to focus those resources on therapies that seem promising on the basis of established scientific knowledge, rather than the far less reliable criteria of traditional use. Studies on herbal remedies should, therefore, focus on developing this important preclinical knowledge before proceeding with clinical trials.

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16 Responses to Evaluation of the Chinese Herbal Remedies San Ren Tang, Wei Lin Tang, and Alisma for Feline Urinary Tract Disease

  1. Linda says:

    I would love to know more details on how the study was conducted. This sounds like a classic case of testing Chinese medicine on the principle of Western medicine. It doesn’t work… Because in Chinese medicine, the diagnosis works on a ‘pattern’ and not a ‘disease’. For example, in this case, Urinary Tract Infection. Three different people diagnosed with the same ‘disease’ can have a different ‘pattern’. Rarely are two people (or animals) completely the same and therefore the treatment would naturally be different. So hence, I believe that the test was invalid. To change this, a diagnosis would be needed by a trained professional, rather than blindly using herbs that are ‘traditionally known to treat’.

  2. skeptvet says:

    Unfortunately, your objection hinges on the idea that the TCM system for diagnosis is different from the scientific system but equally valid. TCM diagnosis involves a set of metaphors and explanations for health and disease based on astrology, folk mythology, vitalism, and other pre-scientific ways of understanding illness, and there is no reason to believe these accurately represent reality. Such metaphorical systems developed in every culture prior to the implementation of the scientific approach, and they have been largely replaced by the scientific way of understanding health and disease in every part of the world because science has repeatedly proven more effective. Cultural relativism would suggest that all ways of describing health and illness should be viewed as equally valid, but empirical testing shows that some ideas are accurate reflections of reality and others are not. Science has achieved unprecedented improvements in human health and longevity that thousands of years of TCM, Ayurveda, Humoral Medicine, and other prescientific approaches could not. This is probably why TCM accounts for no more than 10% of the healthcare utilized by people in Taiwan, regardless of the cultural traditions there. http://skeptvet.com/Blog/2011/03/from-sbm-how-popular-is-acupuncture/

    So regardless of how the study was conducted, the notion that following TCM pattern diagnosis would have made a difference makes no sense unless one accepts that TCM diagnosis is accurate and meaningful, and there is no evidence for this beyond the usual claims based on history and anecdote, which are unreliable. If TCM remedies do have benefits, it is because they contain pharmacologically active compounds, and these need to be identified and tested the way any other plant-derived medicines are to establisht heir real risks and benefits.

  3. Pingback: Finally, A Journalist Takes a Skeptical View of Claims for Veterinary Acupuncture | The SkeptVet Blog

  4. Forrest says:

    Skeptvet. It’s like looking at women through the eyes of a man, or looking at men through the eyes of a woman. Which is right? Both are actually. The beauty of life is recognizing that different colors can come together to form a wonderful picture. Harmony is important. Divisiveness causes conflict!

  5. skeptvet says:

    Beautiful sentiments, but really just an expression of the post-modernist notion that there is no truth or reality, only opinion. That make work in assessing beauty, which is merely a cultural concept. But the actual, physical word has its true nature, and it matters whether our understanding of that is accurate or inaccurate. If you think childhood diseases is caused by imbalances of Qi, then most of your children die before 5 from infectious disease. If you apply science to those diseases and discover the true cause, then you can invent vaccines and your children mostly get to live to adulthood. The beauty of science is that truth reduces suffering and pretty, poetic statements about how there is no right answer allow that suffering to persist unnecessarily.

  6. Cynthia Weeks says:

    Try it..you’ll like it. Alopathic medicine didn’t work for me. Holistic and TCM DID.

  7. skeptvet says:

    Yeah, here’s a collection of articles explaining why anecdotes like this aren’t helpful or reliable:

    Why Anecdotes Can’t Be Trusted

  8. Ayse Batova says:

    Traditional Chinese Medicine has developed the most intricate and advanced form of patient stratification using specific patterns presented by the patient. This is analogous to the stratification that is conducted in personalized western medicine but it is much more simplified in western medicine. For example, in clinical trials of breast cancer patients, all the patients have breast cancer, but, they are not equal. Patients are stratified as to whether or not they have BRACA1 and/or BRACA2 mutations and treated accordingly. They are not treated the same or the trials would not work! Similarly, in a trial of L-Alamodome in T-ALL (T-cell acute lymphocytic leukemia) use of L-Alanosine was found ineffective. It was not until patients were stratified according to MTAP gene status that L-Alanosine was found to be effective. Hence, just because patients have the same disease label, they are not the same!!! Patients have to be stratified to be treated with a particular drug or not. This is one of the keys to a successful drug trial. One must also keep in mind that a lack of evidence is not evidence. Trials using Chinese herbs have to be used according to the principles of TCM to be evaluated effectively or it is a waste of time and resources as one cannot make any conclusions that are meaningful. In other words, one cannot conduct trials of Chinese herbs without the patient stratification that TCM uses.

  9. skeptvet says:

    The problem is that the “stratification” in TCM is based entirely on tradition and clinical experience (aka anecdote) rather than controlled scientific research, so it is meaningless. It is exactly like the “individualization” that homeopaths and many other alternative practitioners claim to employ. Until TCM can prove, scientifically, that the classification of patients according to TCM patterns (5 elements, Chi., etc.) is anything other than folk mythology, the fact that patients are classified this way doesn’t have any meaning. Here’s a more in-depth discussion of this issue:

    The “Individualization” of alternative medicine

  10. Heidi Vollmer says:

    I have a middle-aged cat who suffers from chronic rhinitis, due to FHV. I’ve tried the traditional Lysine treatment, with no effect – which is no longer surprising, as studies are coming out questioning whether it ever helped. Antibiotics helps temporarily, but symptoms are ongoing. Now I’ve run into a interesting paper, that is giving hope in using San Ren Tang as a treatment, although it really only focuses on a single cat. As someone who believes as you do, that herbal medicine is really based on their chemical compounds, I’m wondering about your opinion on this. Here is a link to the paper: http://www.civtedu.org/uploads/41572/ufiles/Journal/Traditional_Chinese_Herbal_Treatment_for_Chronic_Rhinitis_in_a_Cat.pdf

  11. skeptvet says:

    Thanks for the link. I will look into the paper and the herbs used in more detail when I have a chance. To begin with, though, I have to point out that this is a case report, which is just a well-documented anecdote. As such, it can only suggest a hypothesis to test; it is not good evidence for any claim. There are similar anecdotes for every therapy veer tried, from bloodletting to herbal medicine to homeopathy to lobotomy to….. It is a “test” no therapy can fail, so we can’t rely on it.

    Secondly, the schema used in diagnosis and treatment here was pure TCVM. Assessments such as “Damp Heat” and “excess Spleen” and treatments such as “tonify spleen” and “Draining damp” are meaningless mysticism from a time before we had any real understanding of physiology. They are not simply a different way of describing modern physiological or pathophysiological concepts but a completely alternative system based on nothing substantive. We might as well use bloodletting to reduce blood excess or purging to managing accumulation of black bile. It is a meaningless system, which makes it that much more difficult for it to lead to real results.

    As you say, the real question is whether or not the components of the herbal remedy have real phsyiologic effects that lead to clinical benefits and acceptable risks. Remember, cats are obligate carnivores and have a very difficult time processing plant toxins. The fact that the author worries about negative effects from dietary carbohydrates but assumes all of these plant chemicals are benign in cats indicates a weird, unscientific view of cat physiology.

    Thanks again, and I’ll take a closer look when I can.

  12. v.t. says:

    Heidi, have you considered ruling out something (in addition to) than herpesvirus? (i.e., resistant bacteria, polyps, foreign body, etc)? In the meantime, keep stress to the barest minimum, don’t use harsh cleaning agents in the home, no smoking, excessive dust, etc.

  13. doug E. says:

    Wei Ling Tang and San Ren Tang don’t fit the symptoms so I’m not surprised they didn’t have a good effect.

  14. skeptvet says:

    Or, they didn’t work because TCVM isn’t a valid approach. Seems a more likely explanation.

  15. Jim says:

    I’m sorry. This “study” made me laugh. This test was setup to prove what the Center of Excellence, College of Veterinary Medicine wanted to prove, and they didn’t hide their motive very well. Chinese Herbs are about balancing the body, if you’re already healthy you wouldn’t see a difference unless you’re overdosing on it.

    The fact they admit that the cats (and a puny sized test group at that) were ALL HEALTHY to begin with shows this as the one sided “study” it really is. Why aren’t they testing this on a group of cats that ACTUALLY have FLUTD? Or sick cats in general? Well because they’d likely get some results on that test and don’t want to have to report that. If the effects of Chinese Herbs are just “folk tales and voodoo”, then they would get the same results on a legit study with unhealthy cats. That would be the real evidence and a valid study. Yet they choose to do this on healthy cats only, at the recommend dosage for a short amount of time… No bias in this study!

  16. skeptvet says:

    Your criticisms of the study don’t reflect how science actually works. Way before we test treatments in sick patients, we need a plausible explanation for how it could work (and there is none for TCM) and then evidence that the treatment does things that might actually be helpful in real patients (bit we start with healthy animals because it is unethical to expose sick patients to a treatment with no good reason to think it will help. The failure of the treatments to do anything in these cats doesn’t show that they were already in perfect “balance” but that the chemicals in the herbs don’t do the things they would need to do to treat FLUTD. The bias here is not in the study but in the fact that you already believe the mystical nonsense explanations for TCM, and you don’t understand how science is used to test medical treatments.

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