An Integrative Approach to a Case of Idiopathic Immune Mediated Arthritis

An Integrative Approach to a Case of Idiopathic Immune Mediated Arthritis

By Barbara Allard-Ward, DVM, CVA

Author: Chi Institute/Saturday, August 1, 2009/Categories: Student Case Reports, TCVM Newsletter, 2009 Summer Issue

Molly, a 57 pound, 6-year-old female spayed Boxer/Pit Bull mix, was sent to me for surgical evaluation of a 5 month duration lameness of her right hind leg in 2005. Response to non-steroidal medications had been poor.

Molly’s right stifle joint was painful and had marked joint effusion and heat. There was no cranial tibial translation or medial buttress formation; radiographs failed to demonstrate changes that would support a diagnosis of cruciate ligament injury.  Results of a joint tap were diagnostic for idiopathic immune mediated arthritis.  

Molly was treated by her regular DVM with prednisone and Imuran® which resolved the lameness. Unfortunately, Molly became aggressive when on high dose prednisone treatment.  The first remission lasted 8 months after which occasional flare-ups would occur.  

In 2006, 10 months after Molly’s initial visit, I saw her again, this time for left hind limb lameness. It was determined that the lameness was not a surgical case, but rather idiopathic immune mediated arthritis again.  At this point in time I had completed my TCVM Acupuncture training and I performed a TCVM exam as well.

Molly had a “Wood” personality; she was confident, strong and alert.  Her ears were 3 (out of 4) fingers warm; she was panting and overall warm.  Her left stifle joint was warm and swollen.  Her pulses were very weak on the left side and her tongue was red/purple. The front 1/3 of the tongue was large and shaped like a “lollipop”!  Molly’s skin was dry. 

My TCVM pattern diagnosis was Blood Heat with Liver Yin Deficiency. 
 Overall, Molly presented with an Excess condition showing primarily heat signs (warm ears, panting, large, red/purple tongue and warm, swollen joint). Response to steroids previously indicates a heat pattern and Excess, at least initially, because the initial effect of steroids is cooling.
 The four stages of heat in the body are Wei, Qi, Ying and Xue.  The Wei and Qi stages are often lumped together and are referred to as the Wei (External or defensive) Qi; the Ying and Xie stages are often lumped together and referred to as the Ying (Internal or nutritive) Qi.  Heat in the Ying and Xie stage causes Blood Heat.  
 The Yin Deficiency signs are:  weak pulse on left, dry skin, panting.  Heat can boil the body fluids leading to Yin Deficiency. 
 Molly was aggressive when on corticosteroids, joint pain moving around (the Liver tends toward wind), depth of disease at Xue level and constitution.  The increased aggressiveness when on large doses of prednisone indicates Liver Heat, which led to Liver Yang Rising.  (Heat in the Liver can cause Liver Qi Stagnation and/or Liver Yin/Blood Deficiency.  Any of these can cause Liver Yang Rising.)

Molly was again referred back to her regular veterinarian for treatment and was treated with Imuran®, Deramaxx® and prednisone.  The prednisone was used as sparingly as possible and the regular DVM (who also does integrative medicine) also prescribed a Yin tonic, Yi Guan Jian to counteract the side effects of the prednisone.  Yi Guan Jian formula treats Kidney and Liver Yin deficiencies accompanied by Liver Qi Stagnation and Blood dryness.

In 2007, nearly 11 months since Molly’s second visit I saw her again, this third time for right front limb lameness.  She had been doing great until about a week prior to the visit.  At this time she was taking 25 mg Imuran once a week (half dose) and Yi Guan Jian herbal formula.  Molly’s right carpus was warm and swollen.  Her tongue was red and dry with cracks.  Her pulses were normal to strong, wiry on the left side.  

Radiographs of Molly’s right carpus showed erosive and periosteal proliferative lesion on the anterior aspect of the distal radius and of the proximal row of carpal bones.  A joint tap showed inflammatory joint fluid cells with no evidence of neoplasia. 

The Western diagnosis was: recurrence of the previously diagnosed disease with a lesser cytologic presentation due to being on immunosuppressive medications.

The TCVM pattern diagnosis was: Blood Heat/Bony Bi right carpus, Liver and Kidney Yin Deficiency (Kidney is involved now – lameness, age, bony bi changes seen on radiographs)

Molly’s owner was due to go out of town immediately and didn’t not have a chance to see his regular DVM prior to leaving so I needed to begin an integrative treatment plan for the relapse of her immune mediated disease.
My integrative treatment strategy was to use the Western medications that had previously worked well  (Deramaxx® daily and Imuran® 2x a week); to use acupuncture for immediate pain relief and to use herbals for as long as needed to treat the Excess pattern. I instructed the owner to discontinue the Yi Guan Jian formula for now.

Dry Needle acupuncture points used to clear the Heat, cool the Blood, harmonize the Ying/Wei and resolve Stagnation:
  • LI 4, 11 and GV 14 to clear heat and regulate immune functions (Ying-Wei) 
  • LIV 3 and GB 34 (source points) to move and soothe Liver Qi 
  • BL 17 and Sp 10 to nourish and cool Blood and clear heat
  • BL 18 (along with LIV 3 and LI 4) to reduce pain and resolve stagnation) 
  • GB 20 to open the surface to get rid of heat.  

Hemoacupuncture point used: Wei-Jian – to clear heat, clear Blood Heat.

Herbal Formula Used:  Blood Heat Formula™ (JT E2044)

The dietary use of cooling foods for Molly was discussed with the owner.
Molly’s fourth visit was 17 days later.   Molly was happy and getting around very well.  She only limped occasionally.  She had been out of Deramaxx® for over a week.  Because she still showed some heat signs I recommended continuing the Blood Heat Formula for a total of 3 months after which I recommended using a yin tonic if the Excess problem had cleared.  

Molly returned to her regular veterinarian for follow-up treatment and has continued to do very well.  At present (2009) she only takes half the immunosuppressive dose of Imuran® and is not on any other treatment.

Adding TCVM was beneficial for Molly because it allowed remission of clinical signs without the need to use a corticosteroid. Western treatments alone resolved the inflammation, but did not resolve the Ying-Wei disharmony, the heat trapped in the Ying level.  The acupuncture and herbal treatments helped to resolve this disharmony.

Integrating TCVM into my veterinary practice has been beneficial to my patients and very pleasing to me.  Molly agrees!  Many thanks to all the excellent staff at the Chi Institute.

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