Complementary medicine (CM) is used by a large percentage of the Australian community, with more than half the population reporting use in 2004 (1) and 2005 (2). The estimated annual expenditure on CM products by the Australian population was $1.86 billion, whereas the total national expenditure on CM (including visits to CM practitioners and the use of CM products) was about $4.3 billion (2).This means that more than half of out-of-pocket health-care costs in Australia were spent on CM (2).
The increasing use of CM is not driven by a large body of scientific evidence for its efficacy, and the phenomenon remains poorly explained; nevertheless, CM is steeped in tradition and ancient prescribing patterns. Many patients using CM will experience an improvement in symptoms and wellbeing while taking these products.
Across the world, efforts are being made to undertake meaningful studies of these products in a range of clinical and laboratory settings, and the data from these trials will have the potential to change clinical practice in the years ahead.
Results of studies of CMs in a range of settings suggest that these products (or their isolated constituents) may be targeting different aspects of the hepatitis B virus (HBV) disease process, such as viral replication (3-6), inflammatory mediators (7), fibrotic change and chemoprevention of malignant change (8, 9). Some agents appear to improve overall wellbeing, at least initially (9).
According to Wang (2012) (10), CM treatment in hepatitis B aims ‘(a) to relieve the symptoms and improve quality of life of patients; (b) to ameliorate liver inflammation; (c) to ameliorate hepatic fibrosis; (d) to improve immune function; and (e) to regulate lipid metabolism.’
Traditional Chinese medicine (TCM) and western herbal medicine use a number of plant-based chemicals with synergistic and overlapping pharmacological actions to address the above aims. Herbal medicines are chosen for their intrinsic characteristics to treat diseases, and to modulate viral and human physiological processes (11).
14.3.1 Studies demonstrating specific activities relevant to HBV management
A number of recent studies have attempted to randomise patients to active treatment with CM or control treatments, and have examined the effects of CM on both HBV kinetics and liver disease activity and severity. These studies have been analysed in a recent review (12), which makes it quite clear that – although many questions remain about the quality of some of the studies undertaken (an issue many reviewers have with studies from institutions in the western world) – the studies demonstrate some activity of the agents used against HBV.
The review shows that results can be achieved with TCM, although clinicians remain reluctant to take up the challenge of using them. The introduction of highly active and safe antiviral agents, such as entecavir and tenofovir, has radically changed the approach to the use of any other agents. The capacity of antiviral agents to control HBV DNA in over 90% of patients, with little drug resistance over 5 years of treatment, makes the use of interferon and lamivudine unnecessary in those countries where the new agents can be afforded and used widely. The role of TCM in this era needs further clarification.
14.3.2 Studies of the mechanism of action of complementary medicine products or their constituents
Other studies are seeking to define active components in CM medications, and the role of these components in various conditions. A recent paper examined the chemical nature of flavones isolated from one herbal product, and showed which components of the flavone molecules conferred anti-HBV activity. These data have been analysed in the review by Zhang et al (12). The mechanisms of action of CM products or constituents are summarised in Table 14.1.
|Agent or herb||Action||Reference||Comment|
|Artemisinin/artesunate||Inhibitors of HBV production||Romero et al (2005) (17)||Strong inhibition of HBV DNA and HBsAg|
|A flavonoid, wogonin, from Scutellaria baicalensis (baical skullcap)||Suppressed HBsAg production in an HBVtransfected liver cell line (MS-G2), and inhibited duck-HBV DNA polymerase in duck-HBV infected ducks||Guo et al (2007) (6)||Wogonin showed anti-HBV activity both in vitro and in vivo|
|A flavonoid apigenin/Ocium basilicum (sweet basil)||Reduced production and release of HB s and e antigens in HepG 2.2.15 cell lines||Chiang et al (2005) (18)|
|Sophora flavescens kurorinone||Reported to lower ALT and clear HBV DNA in a percentage of patients||Chen et al (2000) (19)|
|Radix Sophorae flavescentis Oxymatrine||Down regulates the expression of heat stress cognate 70 (HSC70), which is required for HBV DNA replication||Wang et al (2010) (20)||Host HSC70 could be a novel drug target against HBV|
|13 flavones in Euphorbia humifusa were tested for anti-
HBV activity in vitro in HepG2.2.15 cells
|Apigenin-7-O-β-Dglucopyranoside inhibited HBsAg by 77.2 % and HBeAg by 55.5% (40 μg/ml1) and apigenin-7-O-(6’’- O-galloyl)-β-Dglucopyranoside inhibited HBsAg by 88.2% and HBeAg by 65.6% (80 μg/ml–1)||Tian et al (2010) (4)||Galloyl group on the flavones (C-6 of glucoside) may be responsible for the anti-HBV activity|
|TCM formulation Compound 861 Salvia miltiorrhiza (scarlet root; Dan Shen), Astragalus membranaceus
(milk-vetch root; Huang Qi) and Spatholobus
suberectus (millettia root; Ji Xue Teng)
|Inhibition of human hepatic stellate cell (LX-2) proliferation||Wang et al (2004) (21)|
|Silibinin a flavonolignan in Silybum marianum (Saint Mary’s thistle)||Significantly reduced viability of human hepatocellular carcinoma Hep3B cells after 12 hours of treatment (p ≤0.001); also induced apoptosis||Varghese et al (2005) (22)|
|Astragalus membranaceus (Huang Qi)||Inhibition of HBV reverse transcriptase and DNA polymerase; inhibits secretion of HBsAg and HBeAg in HepG 2.215 cell line; lowers ALT, HBeAg and HBV DNA in treated patients||Yang et al (1997) (23)||May act in part by inducing endogenous IFN in vivo|
|Astragalus membranaceus (Huang Qi)||Astragaloside (100 μg) suppressed HBsAg by 23.6% and HBeAg by 22.9% after 9 days of treatment||Wang et al (2009) (24)||Inhibitory effect of astragaloside is more potent than 3TC|
|Astragali compound 208 HBV patients, (116 AC, 92 controls) for 2 months||Negative seroconversion of HBeAg by 27.7% (13/47) (p<0.01) and 28% (14/50) of HBV DNA, (p<0.05) compared to controls||Tang et al (2009) (5)||May inhibit HBV replication to some degree (5)|
|Polygonum cuspidatum (Hu Zhang) (its most active and studied component, resveratrol)||Suppresses lipid peroxidation, may inhibit HBV replication
in HepG2.2.15 cells
|Huang et al (1998) (25)||Resveratrol found in skin of red grapes|
|Radix et rhizome rhei (Da Huang); emodin an active
|Inhibits duck-HBV reverse transcriptase and DNA polymerase; inhibits secretion of HBsAg and HBeAg from HepG2.2.15 cell line||Li et al (2007) (26)|
|Phyllanthus urinaris (Ye Xian Zhu); ellagic acid, a flavonoid, an active component||May block HBV messenger RNA transcription in Huh-7 cell lines; may block HBeAg-induced immune tolerance||Ott et al (1997) (27)
Liu et al (2001) (28)
Xia et al (2011) (29)
|Expensive, not used as often as other cheaper herbal products Phyllanthus species plus antiviral drugs may be
better than the same antiviral drug alone
|Radix bupleuri Saikosaponin C||Inhibits viral DNA replication and HBeAg production||Chiang et al (2003) (30)||Reduction in HBV DNA level was more potent than LAM|
|RDBPCT of 300 HBV carriers were given Chinese herbal
formulae (CHF) for 52 weeks
|Reduction in HBV DNA >2 log10 IU ml in 19% (38/200) in CHF group compared to 5% (5/100) in the control group at week 52 (p=0.0011) Reduction in HBsAg by >0.5 log10 in 27% (54/200) in CHF group compared to 7% (7/100) in the control group (p=0.0000); no difference between HBeAg loss and seroconversion between the groups; increased IFN-ã and IL-2 and decreased IL-4 IL-6 and IL-10 in CHF group compared to control group (p=0.0000)||He et al (2013) (3)||Increases in the Th1 cytokines (IFN-γ and IL-2), which have been associated with viral clearance|
ALT, alanine aminotransferase; CHB, chronic hepatitis B; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; IFN, interferon; IL, interleukin; LAM, lamivudine; RDBPCT, randomised, double-blind, placebo-controlled clinical trial
AC = Radix Astragali 45 g, Bupleurum chinense 12 g, Curcumae 12 g, Paeoniae radix 12 g, Peony radix 15 g, Radix Salvia miltiorrhiza 20 g in three divided doses in hot water infusion for 10 minutes. The control group = silibinin 77 mg, oleanolia acid 40 mg and Yi-Gan Ling 2 g.
CHF = Achyranthes bidentata 15 g, Astragalus membranaceus 15 g, Atractylodes macrocephala 15 g, Cuscuta chinensis 10 g, Epimedium brevicornum 30 g, Eucomnia ulmoides 15 g, Fructus aurantii 15 g, Lycium barbarum 15 g, Panax notoginseng 5 g, Phyllanthus urinaria 15 g, Polyphorus umbellatus 10 g, Poria cocos 15 g, Radix curcumae 15 g, Salvia miltiorrhiza 20 g.
SPNS, Radix Astragali, Placenta hominis, Zhiling hypha, Fructus Ligustri lucidi, Radix Panax notoginseng. Each tablet containing 1.5 g crude drug, 4 tablets tds.
Previous claims that specific agents have had a beneficial role in the management of HBV have been questioned in more recent systematic reviews. These reviews have rigorously examined published work, and they conclude that the quality of the studies reported makes it impossible to recommend the use of agents reported in clinical treatment regimens. The call is for more and better research into the mechanisms of action and efficacy of herbal products, and their active components, in the treatment of HBV. Even for Phyllanthus species, which have been used in several countries for centuries, with clinical results that suggest an efficacy, it seems there is no documented evidence for the apparent efficacy (29).
Given the early stages of most of these clinical and laboratory studies, it is appropriate to suggest that none of these treatments should be given in place of the current highly effective antiviral agents available in Australia: entecavir and tenofovir (see Chapter 7).
A major area of concern in western medicine relates to the safety of herbal products in patients with liver disease.
Herbal medicines with well-documented evidence of hepatotoxicity are:
- Teucrium chamaedrys (wall germander) and Teucrium polium, both of which cause zonal necrosis, hepatitis and fibrosis (31-33)
- Mentha pulgeium (pennyroyal), which causes necrosis and microvesicular steatosis (32)
- Atractylis gummifera (pine thistle), which leads to panlobular hepatic necrosis and renal failure (31-36)
- certain pyrrolizidine alkaloids that can cause veno-occlusive disease (31, 32, 34-36)
- Larrea tridenta (chapparal), the ingestion of which has led to zonal necrosis (31-36).
There are, however, conflicting reports of hepatotoxicity in the literature, and case reports alone (without laboratory testing and verification of the presence of each of the listed ingredients) mean that it is difficult to make firm conclusions about hepatotoxicity.
In Australia, a recent death was attributed to the ingestion of Kava 1800 Plus. On laboratory analysis, Piper methysticum (kava) and Passiflora incarnata (passionflower) were found to be present in the formulation. However, Scutellaria lateriflora (skullcap), which was also listed as an ingredient in this product, was not found. The identity of the third ingredient has yet to be established (37).Teucrium is similar in appearance to skullcap, and there have been other reports of substitution of Teucrium for Scutellaria. Teucrium can lead to hepatotoxicity and renal failure, and has been banned as a slimming agent in Europe.
When hepatotoxicity occurs, it is important to verify each listed ingredient in a formulation, to accurately identify the causative agent so that both general practitioners and CM practitioners are aware of herbal medicines with demonstrated hepatotoxicity. Regardless, kava should be avoided in patients with chronic liver injury.
The variability in potency among different crops, the use of incorrect plant species, lack of product standardisation and the possibility of contamination (by fungi, bacteria or pesticides) are specific challenges associated with the therapeutic use of botanical products (38, 39). These problems are compounded by the fact that the Therapeutic Goods Administration (TGA) considers CM as ‘listed products’ (rather than ‘registered products’), which have to meet less stringent standards of safety and quality of manufacture (40).
The Australian and New Zealand expert group reviewing the safety of black cohosh (Actea racemosa, formerly named Cimicifuga racemosa) concluded that ‘there appears to be an association between the use of black cohosh and liver damage, but that it is very rare’. It is a TGA requirement that this advice appear on the label of products containing black cohosh (41).
From January to December 2004, all patients with chronic hepatitis B admitted to a Hong Kong hospital for liver biochemistry irregularities were prospectively screened for an intake of TCM within 6 months before admission. The inclusion criteria included a bilirubin of over two times the upper limit of normal (ULN), alanine aminotransferase (ALT) or aspartate aminotransferase (AST) over five times the ULN; alkaline phosphatase (ALP) and gamma glutamyl transferase (GGT) over two times the ULN. Exclusion criteria were HBV exacerbation (associated with HBV DNA level >1,000,000 viral copies/mL); co-infection with hepatitis A, C, D or E virus; intake of western medicine with known hepatotoxicity; alcohol intake of over 20 g/day for women and over 30 g/day for men; and any other liver disease apart from chronic hepatitis B (CHB) (42).
Of the 45 hospital admissions due to liver dysfunction in CHB patients, 15.6% were attributed to TCM-induced hepatoxicity. There were two deaths related to TCM intake, one of which appeared to be related to pre-existing cirrhosis. In another two patients, hepatotoxicity was based on a temporal relationship, although specific hepatotoxic elements were not found in the herbal formulae (42).
One study examined the risk of liver injury associated with Chinese herbal medicine products containing Radix bupleuri in 639,779 patients with HBV infection in Taiwan. It found that prescribing Xiao-Chai-Hu-Tang and Long-Dan-Xie-Gan-Tang, or Chinese herbal medicine products containing more than 19 g of Radix bupleuri, might increase the risk of liver injury (43). However, the authors did stress that this association may not be causal. Xiao-Chai-Hu-Tang contains 3–9 g of Radix bupleuri daily (43).
There are currently no herbal products that can be recommended for use by HBV patients, based on well-designed, large, randomised clinical trials. Some agents shown to have anti–inflammatory effects or anti-fibrotic effects will continue to be recommended by CM practitioners, and they may well have some beneficial effects in those with active inflammation. In an age where effective antiviral agents are available on the Pharmaceutical Benefits Scheme, it is imperative that, where appropriate, patients receive these drugs, which are safe, highly effective and funded by the government. Although the emphasis must be on effective antiviral therapy for the hepatitis B patient, CM may have a role in reducing the side effects of the antiviral therapy without interfering with its efficacy; and in some instances, CM may enhance the efficacy of the antiviral therapy (12). Due to drug resistance and adverse side effects of antiviral therapy, plant-based medicines warrant further examination (44).
There is clearly a need for well-designed, multicentre studies of the role of CM agents in HBV replication and control. It is to be hoped that such studies are undertaken soon. The consensus is clear that more rigorous studies are required to provide more definite results to guide the management of our hepatitis B patients (45). However, a Cochrane Collaboration for TCM in 2009 concluded that true evidence-based TCM is becoming a reality (46).
Patients should consult an accredited practitioner of TCM or western herbal medicine if they are interested in pursuing CMs. Details of TCM practitioners can be obtained from the Australian Health Practitioner Regulation Agency,11 and details of western herbal medicine or naturopathic practitioners from the National Herbalists Association of Australia.12
We thank Songmei Wu, Bilingual Research Officer, Centre for Complementary Medicine Research, University of Western Sydney, who translated selected research articles from China.
- MacLennan AH, Myers SP, Taylor AW. The continuing use of complementary and alternative medicine in South Australia: costs and beliefs in 2004. Med J Aust. 2006;184(1):27–31.
- Xue CC, Zhang AL, Lin V, Da Costa C, Story DF. Complementary and alternative medicine use in Australia: a national population-based survey. J Altern Complement Med. 2007;13(6):643–50.
- He J, Zhou D, Tong G, Xing Y, Chen Y, Zhang X, et al. Efficacy and safety of a chinese herbal formula (invigorating kidney and strengthening spleen) in chronic hepatitis B virus carrier: results from a multicenter, randomized, double-blind, and placebo-controlled trial. Evid Based Complement Alternat Med. 2013;2013:961926.
- Tian Y, Sun LM, Liu XQ, Li B, Wang Q, Dong JX. Anti-HBV active flavone glucosides from Euphorbia humifusa Willd. Fitoterapia. 2010;81(7):799–802.
- Tang LL, Sheng JF, Xu CH, Liu KZ. Clinical and experimental effectiveness of Astragali compound in the treatment of chronic viral hepatitis B. J Int Med Res. 2009;37(3):662–7.
- Guo Q, Zhao L, You Q, Yang Y, Gu H, Song G, et al. Anti-hepatitis B virus activity of wogonin in vitro and in vivo. Antiviral Res. 2007;74(1):16–24.
- Yin SS, Wang BE, Wang TL, Jia JD, Qian LX. [The effect of Cpd 861 on chronic hepatitis B related fibrosis and early cirrhosis: a randomized, double blind, placebo controlled clinical trial]. Zhonghua Gan Zang Bing Za Zhi. 2004;12(8):467–70.
- Jiang YF, Ma J, He B, Li NP, Tang W, Gong GZ. [The therapeutic effect of Anluohuaxian capsule combined with adefovir dipivoxil on patients with chronic hepatitis B and influence on hepatic histology]. Zhonghua Gan Zang Bing Za Zhi. 2012;20(5):344–7.
- Wang BE. Treatment of chronic liver diseases with traditional Chinese medicine. J Gastroenterol Hepatol. 2000;15 Suppl:E67–70.
- Wang G, Zhang L, Bonkovsky HL. Chinese medicine for treatment of chronic hepatitis B. Chin J Integr Med. 2012;18(4):253–5.
- Zhang W, Wang LQ, Liu YB. Evaluation on quality of life and analysis on its correlation with TCM syndromes in patients of chronic hepatitis B. Chin J Integr Med. 2009;15(1):30–3.
- Zhang L, Wang G, Hou W, Li P, Dulin A, Bonkovsky HL. Contemporary clinical research of traditional Chinese medicines for chronic hepatitis B in China: an analytical review. Hepatology. 2010;51(2):690–8.
- Pei S, Zhang Y, Xu H, Chen X, Chen S. Inhibition of the replication of hepatitis B virus in vitro by pu-erh tea extracts. J Agric Food Chem. 2011;59(18):9927–34.
- Liu T, Zhao J, Li H, Ma L. Evaluation on anti-hepatitis viral activity of Vitis vinifer L. Molecules. 2010;15(10):7415–22.
- Feng H, Zhang YH. Effect of Chinese medicine therapy for strengthening-Pi and nourishing-Shen in preventing lamivudine induced YMDD mutation and its immunologic mechanism. Chin J Integr Med. 2010;16(1):19–22.
- Ma L, Song J, Shi Y, Wang C, Chen B, Xie D, et al. Anti-hepatitis B virus activity of chickweed [Stellaria media (L.) Vill.] extracts in HepG2.2.15 cells. Molecules. 2012;17(7):8633–46.
- Romero MR, Efferth T, Serrano MA, Castano B, Macias RI, Briz O, et al. Effect of artemisinin/artesunate as inhibitors of hepatitis B virus production in an “in vitro” replicative system. Antiviral Res. 2005;68(2):75–83.
- Chiang LC, Ng LT, Cheng PW, Chiang W, Lin CC. Antiviral activities of extracts and selected pure constituents of Ocimum basilicum. Clin Exp Pharmacol Physiol. 2005;32(10):811–6.
- Chen C, Guo SM, Liu B. A randomized controlled trial of kurorinone versus interferon-alpha2a treatment in patients with chronic hepatitis B. J Viral Hepat. 2000;7(3):225–9.
- Wang YP, Liu F, He HW, Han YX, Peng ZG, Li BW, et al. Heat stress cognate 70 host protein as a potential drug target against drug resistance in hepatitis B virus. Antimicrob Agents Chemother. 2010;54(5):2070–7.
- Wang L, Wang J, Wang BE, Xiao PG, Qiao YJ, Tan XH. Effects of herbal compound 861 on human hepatic stellate cell proliferation and activation. World J Gastroenterol. 2004;10(19):2831–5.
- Varghese L, Agarwal C, Tyagi A, Singh RP, Agarwal R. Silibinin efficacy against human hepatocellular carcinoma. Clin Cancer Res. 2005;11(23):8441–8.
- Yang ZM, Yang XB, Gao WB, Shao XW, Chen HS. Inhibition of extracts of five traditional medicines on DHBV-RT-DNAP in vitro [In Chinese]. Special J Pharmacy of people’s Mil Surg. 1997;13:71–3.
- Wang S, Li J, Huang H, Gao W, Zhuang C, Li B, et al. Anti-hepatitis B virus activities of astragaloside IV isolated from radix Astragali. Biol Pharm Bull. 2009;32(1):132–5.
- Huang ZS, Wang ZW, Liu MP. The protective effect of resveratrol on rat hepatocytes injured by CCl4 in vitro [In Chinese]. J Pharmacol China. 1998;14:543.
- Li Z, Li LJ, Sun Y, Li J. Identification of natural compounds with anti-hepatitis B virus activity from Rheum palmatum L. ethanol extract. Chemotherapy. 2007;53(5):320–6.
- Ott M, Thyagarajan SP, Gupta S. Phyllanthus amarus suppresses hepatitis B virus by interrupting interactions between HBV enhancer I and cellular transcription factors. Eur J Clin Invest. 1997;27(11):908–15.
- Liu J, Lin H, McIntosh H. Genus Phyllanthus for chronic hepatitis B virus infection: a systematic review. J Viral Hepat. 2001;8(5):358–66.
- Xia Y, Luo H, Liu JP, Gluud C. Phyllanthus species for chronic hepatitis B virus infection. Cochrane Database Syst Rev. 2011(4):CD008960.
- Chiang LC, Ng LT, Liu LT, Shieh DE, Lin CC. Cytotoxicity and anti-hepatitis B virus activities of saikosaponins from Bupleurum species. Planta Med. 2003;69(8):705–9.
- Gunawan B, Kaplowitz N. Clinical perspectives on xenobiotic-induced hepatotoxicity. Drug Metab Rev. 2004;36(2):301–12.
- Schiano TD. Hepatotoxicity and complementary and alternative medicines. Clin Liver Dis. 2003;7(2):453–73.
- Stedman C. Herbal hepatotoxicity. Semin Liver Dis. 2002;22(2):195–206.
- Seeff LB, Lindsay KL, Bacon BR, Kresina TF, Hoofnagle JH. Complementary and alternative medicine in chronic liver disease. Hepatology. 2001;34(3):595–603.
- Stewart MJ, Steenkamp V. Pyrrolizidine poisoning: a neglected area in human toxicology. Ther Drug Monit. 2001;23(6):698–708.
- Pittler MH, Ernst E. Systematic review: hepatotoxic events associated with herbal medicinal products. Aliment Pharmacol Ther. 2003;18(5):451–71.
- Australian Government Department of Health and Ageing. Information for sponsors: safety of kava-containing medicines. Canberra: Therapeutic Goods Administration; 2002; Available from: http://www.tga.gov.au/safety/alerts-medicine-kava-020826.htm#.U4iYbpWKBow.
- Ko RJ. Adulterants in Asian patent medicines. N Engl J Med. 1998;339(12):847.
- Murch S, KrishnaRaj S, Saxena P. Phytopharmaceuticals: problems, limitations and solutions. Scientific Rev Alternative Med. 2000;4:33–7.
- Expert Committee on Complementary Medicines in the Health System. Complementary medicines in the Australian health system: Report to the Parliamentary Secretary to the Minister for Health and Ageing. Canberra: Commonwealth of Australia, 2003.
- Australian Government Department of Health and Ageing. New labelling requirements and consumer information for medicines containing Cimicifuga racemosa. Canberra: Therapeutic Goods Administration 2007; Available from: http://www.tga.gov.au/safety/alerts-medicine-black-cohosh-070529.htm#.U4iX5JWKBow.
- Yuen MF, Tam S, Fung J, Wong DK, Wong BC, Lai CL. Traditional Chinese medicine causing hepatotoxicity in patients with chronic hepatitis B infection: a 1-year prospective study. Aliment Pharmacol Ther. 2006;24(8):1179–86.
- Lee CH, Wang JD, Chen PC. Risk of liver injury associated with Chinese herbal products containing radix bupleuri in 639,779 patients with hepatitis B virus infection. PLoS One. 2011;6(1):e16064.
- Wohlfarth C, Efferth T. Natural products as promising drug candidates for the treatment of hepatitis B and C. Acta Pharmacol Sin. 2009;30(1):25–30.
- Zhan T, Wei X, Chen ZQ, Wang DS, Dai XP. A systematic review of RCTs and quasi-RCTs on traditional Chinese patent medicines for treatment of chronic hepatitis B. J Tradit Chin Med. 2012;31(4):288–96.
- Manheimer E, Wieland S, Kimbrough E, Cheng K, Berman BM. Evidence from the Cochrane Collaboration for Traditional Chinese Medicine therapies. J Altern Complement Med. 2009;15(9):1001–14.