prescriptions of chinese herbal medicine for constipation under...

J Chin Med Assoc • July 2010 • Vol 73 • No 7 375

Introduction

Constipation is a condition in which bowel movementsare infrequent, irregular, or difficult.1 It is a disorderresulting from different causes such as insufficientintake of dietary fiber, emotional influence, dysfunctionof the nervous system, structural abnormality, systemicdisease, or drug effects.1 Constipation is a commongastrointestinal problem worldwide, and it affects atleast 8.5% of individuals in Taiwan, based on Rome II

diagnostic criteria.2 It often occurs in females, withadvanced age, low socioeconomic class and low educa-tional position.2,3

The aim of treating constipation is to treat the un-derlying causes, improve symptoms, and resume thenormal physiological function of the bowel. Treatingconstipation can be a comprehensive therapy tailored tothe individual.4 Drugs commonly used include bulk lax-atives, osmotic laxatives, non-absorbable sugar, stimu-lant laxatives, cholinergic agents and other prokinetic

ORIGINAL ARTICLE

Prescriptions of Chinese Herbal Medicine forConstipation Under the National Health

Insurance in TaiwanMaw-Shiou Jong1,5, Shinn-Jang Hwang2,4, Yu-Chun Chen2,4, Tzeng-Ji Chen2,4,

Fun-Jou Chen3, Fang-Pey Chen1,5*1Center for Traditional Medicine, 2Department of Family Medicine, Taipei Veterans General Hospital, Taipei;

3Graduate Institute of Integrated Chinese and Western Medicine, Chinese Medical University, Taichung; 4Division of Family Medicine, Department of Medicine, and 5Institute of Traditional Medicine,

National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C.

Background: Constipation is a common gastrointestinal problem worldwide. The aim of this study was to determine the

frequency of use and prescriptive patterns of Chinese herbal medicine (CHM) in treating constipation by analyzing the

claims data of traditional Chinese medicine (TCM) from the National Health Insurance (NHI) in Taiwan.

Methods: The computerized claims dataset of the TCM office visits and the corresponding prescription files in 2004

compiled by the NHI Research Institute in Taiwan were linked and processed. Visit files with the single diagnostic coding

of constipation (ICD-9-CM code 564.0) were extracted to analyze the frequency and pattern of corresponding CHM pre-

scriptions. The association rule was applied to analyze the co-prescription of CHM in treating constipation.

Results: There were 152,564 subjects who visited TCM clinics only for constipation in Taiwan during 2004 and received

a total of 387,268 CHM prescriptions. Subjects between 20 and 29 years of age comprised the largest number of those

treated (25.5%). Female subjects used CHM for constipation more frequently than male subjects (female:male = 3.31:1).

There was an average of 4.6 items of single Chinese herbs or formula in a single prescription for constipation. Ma-zi-ren-

wan was the most commonly prescribed herbal formula, while Da-huang (Rheum palmatum) was the most commonly

used single Chinese herb. According to the association rule, the most common prescribed pattern of 2-drug combination

of CHM for treating constipation was Ban-xia-xie-xin-tang plus Ma-zi-ren-wan, while the 3-drug combination of CHM was

Fang-feng-tong-sheng-san, Rheum palmatum and Ma-zi-ren-wan.

Conclusion: This study showed the pattern of single Chinese herbs or herbal formulae used in treating constipation

in Taiwan. Further clinical trials are needed to evaluate the efficacy and safety of these CHMs in treating constipation.

[J Chin Med Assoc 2010;73(7):375–383]

Key Words: Chinese herbal medicine, constipation, pharmacoepidemiology, traditional Chinese medicine

© 2010 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

*Correspondence to: Dr Fang-Pey Chen, Center for Traditional Medicine, Taipei Veterans GeneralHospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, R.O.C.E-mail: [email protected] ● Received: December 9, 2009 ● Accepted: June 22, 2010

agents. Selective chloride channel activators, which canincrease intestinal water secretion, thereby increasingintestinal motility and facilitating the bowel movement,are also used.4,5

After excluding secondary constipation caused byother problems, primary (idiopathic) constipation canbe classified into 3 categories: normal transit or irrita-ble bowel syndrome, pelvic floor dysfunction, and slowtransit constipation. These 3 types of constipation over-lap frequently. Normal and slow transit constipation areusually treated by the drugs mentioned above.5 InEastern countries, traditional Chinese medicine (TCM)is another option in addition to Western medicine fortreating constipation.6 The principles of diagnosis andtreatment of constipation in TCM are primarily basedon the manifestations of the syndrome Therefore, theprincipal signs and symptoms of patients from whicha corresponding prescription of Chinese herbal medi-cine (CHM) is provided, is largely dependent on theexperience of the Chinese herbal doctors or from therecords of ancient Chinese books. The optimal choiceof CHM prescription for constipation is unknown.Furthermore, whether these Chinese herbs or formulaehave modern pharmacological effects in the treatmentof constipation remains to be elucidated.

In Taiwan, the National Health Insurance (NHI)has reimbursed medical expenses for Western medicinefor nearly all inhabitants since 1995 (22,134,270 bene-ficiaries at the end of 2004, covering nearly 98% of thetotal population in Taiwan).7,8 The use of TCM hasbeen reimbursed by the NHI since 1996. People inTaiwan are free to choose Western medicine or TCM,and are allowed to visit primary care clinics or hospitalswithout referral. Because all claims data are available toresearchers in electronic form, a large-scale survey ofpharmacoepidemiological issues can be easily con-ducted. The aim of the current study was to explore thefrequency and pattern of CHM use for subjects withconstipation by analyzing the NHI database in 2004 inTaiwan.

Methods

Data sourcesThe NHI program in Taiwan was initiated in 1995, andthe Bureau of the NHI began to release all claims datain electronic form to the public under the NationalHealth Insurance Research Database (NHIRD) projectsince 1999. The structure of the claims files is describedin detail on the NHIRD website and in our previousreport.6 Briefly, we obtained the database of TCMclaims, including the visit files and prescription files

(CM_CD2004.DAT and CM_OO2004.DAT), for2004 from the NHIRD in Taiwan. The visit files re-corded the dates of encounters, the medical care facili-ties and specialties, patients’ sex, birth date, and up to 3diagnoses according to the International Classificationof Diseases, 9th Revision, Clinical Modification (ICD-9-CM). For privacy protection, the identification data ofpatients and institutions was scrambled cryptographi-cally to ensure anonymity. The prescription files con-tained the prescription records of CHM correspondingto the office visits. A CHM prescription contains 1 toseveral single Chinese herbs or herbal formulae. TheChinese herbal formulae or single herbs are made inpowder or fine granules in Taiwan, and can be easilymixed and dispensed into small packages so that 1 pre-scription can be taken at a time.

All TCMs are provided only in ambulatory clinicsunder the coverage of NHI in Taiwan and there is noinpatient care. In addition, only licensed TCM physi-cians are qualified for reimbursement. The insurancebenefits of TCM in Taiwan include CHM, acupunctureand traumatology manipulative therapy, especially forjoint dislocation.

Study designAlthough the concept of disease entities in TCM isquite different from that in Western medicine, theTCM physicians in Taiwan are requested to make thediagnosis based on ICD-9-CM coding for visitingclaims. In this study, we utilized the data of subjectswith the single diagnostic code for constipation (i.e.ICD-9 code 564.0) among TCM visits.

According to the theory of TCM, a single prescrip-tion from a TCM physician may contain a single Chi-nese herb or multiple herbs of various dosages, namelya compound (Fu-Fang) or a classical formula (regimen,remedy or Fang-Ji). These are a combination of com-patible Chinese herbs in fixed dosages ascribed to clas-sical or well-known Chinese textbooks of medicine, ora classical formula plus some Chinese herbs called Chia-Chien-Fang. In addition, several formulae can be puttogether with or without 1 or several Chinese herbs fordifferent symptoms and signs manifested by a patient.

Data analysisThe database software, IBM DB2 version 8.1 (IBM,Armonk, NY, USA), was used for data linkage and pro-cessing. Regular statistics (mean and percentage) weredisplayed for the frequency of use and pattern of CHMprescriptions for constipation. Association rule min-ing, originally developed in the 1990s to identify whichgroups or sets of items were likely to be purchasedtogether in the market, was applied to calculate the

J Chin Med Assoc • July 2010 • Vol 73 • No 7376

M.S. Jong, et al

prescription of the Chinese herbs for constipation.9,10

An association rule was applied to prescriptions as fol-lows: when a physician prescribes drug A (or drugs{A1,A2}, drugs {A1,A2,A3}, etc.), he/she will also pre-scribe drug B in X% of cases, and this co-prescribing ispresent in Y% of all prescriptions. The support factoris the ratio of co-prescriptions of all prescriptions (i.e.Y% in the above example). The confidence factor is theratio of co-prescriptions to prescriptions for drug A(i.e. X% in the above example). For executing the pro-gram to identify association rules in our dataset, wechose 0.5% as the minimum support factor and 30%as the minimum confidence level.11

Results

EpidemiologyAmong the 22,134,270 valid beneficiaries of the NHIat the end of 2004 in Taiwan, 6,224,436 (28.1%) sub-jects had used TCM during that year, and 152,564(2.5%) subjects visited the TCM clinics and used CHMonly for constipation. Among these constipation sub-jects, there were a total of 387,268 CHM prescriptions.The peak age of subjects with constipation treated byTCM was between 20 and 29 years of age (25.5%), fol-lowed by 30–39 years of age (19.4%), and 40–49 yearsof age (15.7%; Table 1). Female subjects used CHMfor constipation more frequently than male subjects(female:male = 3.31:1).

Chinese herbal formulaeMa-zi-ren-wan (34.4%) was the most commonly pre-scribed Chinese herbal formula for subjects with constipation, followed by Fang-feng-tong-sheng-san(17.6%), Run-chang-wan (12.4%), Run-chang-tang(7.7%), Da-chai-hu-tang (6.6%), Ping-wei-san (4.9%),

Mu-xiang-bin-lang-wan (4.8%), San-huang-xie-xin-tang(4.7%), Tao-ren-cheng-qi-tang (4.6%), and Gan-lu-yin (4.5%; Table 2).

Single Chinese herbsThe most common single Chinese herb prescribed for constipation was Rheum palmatum (Da-huang)(18.4%), followed by Magnolia officinalis (Hou-pu)(6.6%), Scrophularia ningpoensis (Xuan-shen) (6.3%),Citrus aurantium (fruit; Zhi-shi) (6.1%), Rehmanniaglutinosa (Sheng-di-huang) (6.0%), Ophiopogon japon-icus (Mai-dong) (6.0%), Crataegus pinnatifida (Shan-zha) (5.7%), Cannabis sativa (Huo-ma-zen) (5.1%),Glycyrrhiza uralensis (Gan-cao) (5.0%), and Citrusaurantium (peel; Zhi-ke) (4.5%; Table 3).

Combination of CHMThere was an average of 4.6 Chinese herbal items in asingle prescription for subjects with constipation. Themost common number of items in the prescription ofChinese herbal formulae or single Chinese herbs forsubjects with constipation in Taiwan is 5 (16.6%), fol-lowed by 4 (16.5%), and 3 (15.3%; Figure 1). Ac-cording to the association rule, the most commonlyprescribed pattern of a 2-drug combination of CHMfor treating constipation was Ban-xia-xie-xin-tang plusMa-zi-ren-wan (Table 4), while the 3-drug combina-tion of CHM was Fang-feng-tong-sheng-san, Rheumpalmatum and Ma-zi-ren-wan (Table 5). The mostcommon 4-drug combination of CHM for constipa-tion was Ophiopogon japonicus, Rehmannia glutinosa,Scrophularia ningpoensis and Run-chang-wan, whichaccounted for 0.3% of all prescriptions. The most com-mon 5-drug combination of CHM was An-zhong-san,Mu-xiang-bin-lang-wan, Run-chang-tang, Fang-feng-tong-sheng-san and Ma-zi-ren-wan, which accountedfor 0.2% of all prescriptions.


Chinese herb use for constipation in Taiwan

Table 1. Age-specific frequency of the use of TCM in patients with constipation in Taiwan during 2004*

Age (yr)Subjects with constipation using TCM

Total patients Males† Females†

0–9 11,013 (7.2) 4,997 (3.3) 6,016 (3.9)10–19 16,713 (11.0) 3,716 (2.4) 12,997 (8.6)20–29 38,961 (25.5) 4,203 (2.8) 34,758 (22.7)30–39 29,969 (19.6) 4,279 (2.8) 25,690 (16.8)40–49 23,938 (15.7) 4,480 (2.9) 19,458 (12.8)50–59 11,607 (7.6) 3,311 (2.2) 8,296 (5.4)60–69 7,621 (5.0) 3,275 (2.1) 4,346 (2.9)70–79 8,968 (5.9) 5,131 (3.4) 3,837 (2.5)≥ 80 3,774 (2.5) 1,978 (1.3) 1,796 (1.2)Total 152,564 (100) 35,370 (34.05) 117,194 (65.95)

*Data presented as n (%); †male:female ratio is 1:3.31. TCM = traditional Chinese medicine.

Discussion

The current study, the first large-scale survey of theuse of CHM in the treatment of constipation in aChinese population, analyzed the claims dataset ofTCM office visits covered by the NHI in Taiwan. Ourresults showed that females were dominant amongTCM users, which is in agreement with the results of

a systematic review by Peppas et al,3 who reported thatfor those aged between 20 and 29 years, the female-to-male ratio was 8.1. Chiarelli et al12 proposed thathormonal factors may contribute to constipation inwomen. Progesterone secreted during the luteal phaseof the menstrual cycle or during gestation is thought todecrease the intestinal transit time, leading to consti-pation.12 In addition, we also found that most people


M.S. Jong, et al

Table 2. Top 10 Chinese herbal formulae prescribed for constipation in Taiwan during 2004*

Chinese herbal formulae Ingredients Prescriptions, n (%)

(Chinese name)

Ma-zi-ren-wan Cannabis sativa, Paeonia lactiflora, Citrus aurantium, Rheum palmatum, 133,288 (34.4)Magnolia officinalis, Prunus armeniaca

Fang-feng-tong-sheng-san Saposhnikovia divaricata, Forsythia suspenae, Gardenia jasminoides, 68,264 (17.6)Schizonepeta tenuifolia, Ephedra sinica, Ligusticum chuanxiong, Angelica

sinensis, Paeonia lactiflora, Atractylodes macrocephala, Rheum palmatum,Mirabilite, Scutellaria baicalensis, Talcum, Gypsum Fibrosum, Mentha

haplocalyx, Platycodon grandiflorum, Glycyrrhiza uralensis, Zingiber officinale

Run-chang-wan Angelica sinensis, Notopterygium incisum, Rheum palmatum, Prunus persica, 47,870 (12.4)Cannabis sativa

Run-chang-tang Rheum palmatum, Angelica sinensis, Rehmannia glutinosa, Cannabis sativa, 29,927 (7.7)Prunus persica, Prunus armeniaca, Citrus aurantium, Scutellaria baicalensis,Magnolia officinalis, Glycyrrhiza uralensis

Da-chai-hu-tang Bupleurum chinense, Scutellaria baicalensis, Paeonia lactiflora, Pinellia ternate, 25,504 (6.6)Citrus aurantium, Rheum palmatum, Ziziphus jujuba, Zingiber officinale

Ping-wei-san Atractylodes lancea, Magnolia officinalis, Citrus reticulate, Glycyrrhiza uralensis, 18,885 (4.9)Zingiber officinale, Ziziphus jujuba

Mu-xiang-bin-lang-wan Saussurea lappa, Areca cathechu, Rheum palmatum, Coptis chinensis, 18,689 (4.8)Phellodendron amurense, Cyperus rotundus, Ipomoea nil, Citrus reticulate,Citrus reticulate (unripe), Curcuma phaeocaulis, Citrus aurantium, Sparganium

stoloniferum, MirabiliteSan-huang-xie-xin-tang Rheum palmatum, Coptis chinensis, Scutellaria baicalensis 18,081 (4.7)Tao-ren-cheng-qi-tang Prunus persica, Rheum palmatum, Cinnamomum cassia, Glycyrrhiza 17,935 (4.6)

uralensis, MirabiliteGan-lu-yin Rehmannia gultinosa, Asparagus cochinchinensis, Ophiopogon japonicus, 17,482 (4.5)

Dendrobium nobile, Artemisia scoparia, Eriobotrya japonica, Scutellaria

baicalensis, Citrus aurantium, Glycyrrhiza uralensis

*Total number of prescriptions = 387,268.

Table 3. Top 10 single Chinese herbs prescribed for constipation in Taiwan during 2004*

Single Chinese herb (Chinese name) Generic name Prescriptions, n (%)

Da-huang Rheum palmatum 71,133 (18.4)Hou-pu Magnolia officinalis 25,379 (6.6)Xuan-shen Scrophularia ningpoensis 24,528 (6.3)Zhi-shi (fruit) Citrus aurantium 23,443 (6.1)Sheng-di-huang Rehmannia glutinosa 23,212 (6.0)Mai-dong Ophiopogon japonicus 23.052 (6.0)Shan-zha Crataegus pinnatifida 22,055 (5.7)Huo-ma-zen Cannabis sativa 19,708 (5.1)Gan-cao Glycyrrhiza uralensis 19,273 (5.0)Zhi-ke (peel) Citrus aurantium 17,501 (4.5)


using TCM for constipation were between 20 and 29 years of age (25.5%), followed by those between30 and 39 years of age (19.6%), with the majority beingfemales. This result is different from the findingsreported by Higgins and Johanson,13 who showed anincrease in the prevalence of constipation with age.Further studies are needed to clarify this issue and revealother causes.

Rheum palmatum, the most common single Chineseherb for constipation, is also a component of 8 of the 10most commonly used herbal formulae for constipation.Rheum palmatum was first recorded in the classicalChinese medical tome “Shennongbencaojing”, the ear-liest Materia Medica in China, before 25–225 AD. Atthat time, Rheum palmatum was used as a type of purga-tive agent. The major bioactive constituents of Rheum



33,968

18,926

8,553

49,405

26,663

59,172

63,853 64,227

54,187

4,105

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1 2 3 4 5 6 7 8 9

Number of Chinese herbal formulae orsingle herbs in a single prescription

Num

ber

of p

resc

riptio

ns

10≥

Figure 1. The number of combinations of Chinese herbal medicine related to the number of prescriptions. The most common combina-tion of Chinese herbal medicine used for treating constipation was 5, followed by 4 and then 3 items of Chinese herbal formulae or sin-gle herbs. There was a mean of 4.6 Chinese herbal items in a single prescription for subjects with constipation.

Table 4. Most common prescription patterns of a 2-drug combination of Chinese herbs in a single prescription for constipation in

Taiwan during 2004*

Chinese herbal formulae or single herbs Support (%) Prescription number

Ban-xia-xie-xin-tang plus Ma-zi-ren-wan 0.7 2,855Shao-yao-gan-cao-tang plus Ma-zi-ren-wan 0.7 2,781Yi-zi-tang plus Ma-zi-ren-wan 0.6 2,441Platycladus orientalis plus Ma-zi-ren-wan 0.6 2,301San-huang-xie-xin-tang plus Ma-zi-ren-wan 0.6 2,297Xie-fu-zhu-yu-tang plus Ma-zi-ren-wan 0.6 2,209Liu-wei-di-huang-wan plus Ma-zi-ren-wan 0.6 2,203Gan-lu-yin plus Run-chang-wan 0.6 2,150Da-huang-mu-dan-pi-tang plus Ma-zi-ren-wan 0.5 2,097Cyperus rotundus plus Ma-zi-ren-wan 0.5 2,087


palmatum are phenolic compounds, among which sen-nosides and anthraquinone glycosides are considered tobe the main purgative components.14 This stimulant lax-ative or its metabolites in the human body can stimu-late the intestinal wall, enhance intestinal peristalsis, orchange the transport of liquid and electrolytes, therebyenhancing gastrointestinal secretion and leading topurgation.15 Besides Rheum palmatum, other Chineseherbs also have the ability to modulate gastrointestinalfunction. Mirabilite (sodium sulfate decahydrate) hasbeen reported to have osmotic laxative activity throughpoor absorption of sulfate, which increases osmotic pres-sure and results in water and electrolytes being retainedin the intestinal cavity.16 Ipomoea nil extracts may affectthe ion transport of rat intestinal epithelia, leading towater movement.17 The aqueous crude extract ofPrunus persica possesses spasmogenic activity in isolatedguinea pig ileum, which may be partially through thecholinergic pathway.18 In animal experiments, the con-stituent arecoline in Areca catechu can stimulate colonicmotility through muscarinic acetylcholine receptors.19

Angelica sinensis may possess the ability to react withserotonin receptors and then promote serotonergicactivity, thereby stimulating intestinal motility.20,21

The active ingredient in Rehmannia glutinosa,catalpol, is an iridoid glycoside,22,23 and Gardenia jas-minoides, which contains iridoid, may also possess pur-gative activity.24 In ritonavir-treated rats with slowergastric emptying capability, gastrointestinal dysfunctionis improved after administration of a Scutellaria bai-calensis extract.25 Zingiber officinale can speed up gas-trointestinal transit in mice fed with a charcoal meal.26

The water-soluble components of Zizyphus jujuba canreduce gastrointestinal transit time, thus enhancingwater retention in feces.27

The components of commonly used herbal formu-lae for treating constipation mostly have a purgation

effect, as described above by modern pharmacology.However, there are some Chinese herbs that have anopposite pharmacological function. For example, can-nabidiol is a Cannabis sativa-derived compound thatcan selectively inhibit croton oil-induced intestinalhypermotility in mice,28 and decrease gastrointestinalmovement.29 Cyperus rotundus possesses antidiarrhealactivity.30 These Chinese herbs, which decrease gastro-intestinal movement, have been used for the treatmentof constipation. Different pharmacological functionsmay be due to the difference between a pure compoundand a crude extract of the herb, or the combined effectsof multi-component formulations, or through differentpathological mechanisms. How 1 Chinese herb canexert effects that are diametrically opposed is still notfully understood and deserves further investigation.

Glycycoumarin is 1 active component in Glycyrrhizauralensis. It has an antispasmodic effect on the con-traction of mouse jejunum through inhibition of thephosphodiesterase 3 mechanism.31 Other Chinesemedicines such as Magnolia officinalis,32 Mentha sp.,33

and Paeonia lactiflora34 have a spasmolytic effect, whichcould possibly be beneficial for spasmodic constipa-tion.35 In isolated animal tissue, the aqueous-methanolcrude extract of Saussurea lappa possesses a spasmogeniceffect through the cholinergic pathway. However,under conditions such as a higher drug concentrationor intestinal hypermotility, the spasmolytic effect ap-pears through a calcium channel blocker mechanism.36

Therefore, even for the same Chinese herb, there maybe different pharmacological functions with differentdosages or physical conditions.

Among the top 10 single Chinese herbs prescribedfor constipation, Scrophularia ningpoensis contains abioactive compound, iridoid, which possibly possessesa purgative effect,23 and Crataegus pinnatifida wasonce reported to have an antispasmodic effect.37 In the


M.S. Jong, et al

Table 5. Most common prescription patterns of a 3-drug combination of Chinese herbs in a single prescription for constipation in

Taiwan during 2004*

Chinese herbal formulae or single herbs Support (%) Prescription number

Fang-feng-tong-sheng-sa, Rheum palmatum and Ma-zi-ren-wan 0.6 2,462Angelica sinensis, Cistanche tubulosa and Ma-zi-ren-wan 0.5 1,817Citrus aurantium, Magnolia officinalis and Ma-zi-ren-wan 0.4 1,405Rehmannia glutinosa, Fang-feng-tong-sheng-san and Rheum palmatum 0.3 1,280Areca catechu, Saussurea lappa and Ma-zi-ren-wan 0.3 1,223Da-chai-hu-tang, Fang-feng-tong-sheng-san and Rheum palmatum 0.3 1,177Crataegus pinnatifida, Fang-feng-tong-sheng-san and Ma-zi-ren-wan 0.3 1,164Run-chang-tang, Rheum palmatum and Ma-zi-ren-wan 0.3 1,083Citrus aurantium, Rheum palmatum and Ma-zi-ren-wan 0.3 1,074Run-chang-wan, Rheum palmatum and Ma-zi-ren-wan 0.3 1,060




classification of Chinese medicine, Ophiopogon japoni-cus is categorized as a Yin-tonifying medicinal, capa-ble of nourishing Yin fluid and therefore moisteningthe intestine.

In the top 10 Chinese herbal formulae prescribedfor constipation, Fang-feng-tong-sheng-san (Bofu-tsusho-san in Japanese) is usually used to combatobesity.38 Da-chai-hu-tang extracts and San-huang-xie-xin-tang extracts relax smooth muscle tone in thegastrointestinal tract through phosphodiesterase inhi-bition, and are therefore capable of treating spasmodicconstipation.39 Ping-wei-san is usually applied for thetreatment of heartburn and gastritis.40 It is worth not-ing that Fang-feng-tong-sheng-san and Da-chai-hu-tanghave been reported to cause interstitial pneumonia orhepatitis during clinical practice.41,42 It is often difficultto completely understand the underlying mechanisms.Therefore, it is necessary to conduct randomized,double-blinded, placebo-controlled trials to assess theefficacy and safety of these Chinese medicines in patientswith constipation. Additionally, Cistanche tubulosa con-tains iridoid glycosides, and thus possibly has purga-tive effects.43 Ban-xia-xie-xin-tang is reported to haveantidiarrheal activity,44 and Shao-yao-gan-cao-tang hasan antispasmodic effect.45

In our study, an average of 4.6 items, either Chineseherbal formulae or single herbs, were contained in eachprescription for constipation. According to our results,the most commonly prescribed CHM drug combina-tion for treating constipation was mainly an herbalformula and single herb.

This study was a retrospective analysis of the use ofCHM to treat constipation. Unlike clinical trials, whichcan provide direct evidence of efficacy, many herbs inthe herbal formulae or single herbs frequently pre-scribed have been found to contain ingredients that as-sist defecation via varied mechanisms as discussed above.In fact, the principle of TCM treatment is differentfrom that of Western medicine, as TCM involves thepatient’s constitutional needs, e.g. Bianzheng Lunzhi( , syndrome differentiation and treatment),46

and therefore, it is difficult to create a constitutionally-matched control group. With regard to the treatmentof constipation, although Chinese and Western medi-cine view the causes of the disease differently, both arein agreement that constipation is a symptom rather thana diagnosis. TCM treatment for constipation is basedon the syndrome of its subclassification; for example, ifthe symptoms include a dry mouth, yellow urine, a redtongue and surging pulse, it is subclassified as excesssyndrome ( ) for which a formula such as Ma-zi-ren-wan can be prescribed, as it can discharge excessiveheat.47 On the other hand, if the symptoms include

fatigue, a pale complexion, pale tongue and a thready,weak pulse, it is subclassified as deficient syndrome( ). Therefore, a formula or single herb that can nour-ish Qi and Yin will be administered; in this case, Run-chang-tang or Ophiopogon japonicus is a good choice.In young people, constipation is mostly subclassifiedas excess syndrome, which may explain why this studyfound Ma-zi-ren-wan to be the formula most com-monly prescribed for the treatment of constipation.

In conclusion, based on the availability of electronichealth care claims data in Taiwan, a population-basedsurvey of Chinese herbal pharmacoepidemiology onconstipation determined the frequency of use and pat-terns of prescriptions in a Chinese population. Never-theless, the therapeutic effects and safety of those herbalformulae or single herbs used requires further eluci-dation through efficiency-based clinical studies orwell-designed randomized, double-blinded, placebo-controlled trials.

Acknowledgments

This study was based on a portion of data from theNHI Research Database provided by the Bureau ofNHI, Department of Health, and was managed bythe NHI Research Institutes in Taiwan. The interpreta-tion and conclusions contained herein do not representthose of the Bureau of NHI, Department of Health, orNational Health Research Institutes.

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M.S. Jong, et al

Angelica sinensisAreca catechuArtemisia scopariaAsparagus cochinchinensisAtractylodes lanceaAtractylodes macrocephalaBupleurum chinenseCannabis sativaCinnamomum cassiaCitrus aurantiumCitrus reticulateCistanche tubulosaCoptis chinensisCrataegus pinnatifidaCurcuma phaeocaulisCyperus rotundusDendrobium nobileEphedra sinicaEriobotrya japonicaForsythia suspenseGardenia jasminoidesGlycyrrhiza uralensisGypsum FibrosumIpomoea nil



Appendix I. Summary of the scientific and Chinese equivalents of herbs and names appearing in this article

Appendix II. Summary of the English (Hanyu Pinyin) and Chinese equivalents of formulae and names appearing in this article

An-zhong-sanBan-xia-xie-xin-tangDa-chai-hu-tangDa-huang-mu-dan-pi-tangFang-feng-tong-sheng-sanGan-lu-yinLiu-wei-di-huang-wanMa-zi-ren-wanMu-xiang-bin-lang-wan

Ping-wei-sanRun-chang-tangRun-chang-wanSan-huang-xie-xin-tangShao-yao-gan-cao-tangTao-ren-cheng-qi-tangXie-fu-zhu-yu-tangYi-zi-tang

Ligusticum chuanxiongMagnolia officinalisMentha haplocalyxMirabilite (sodium sulfate decahydrate)Notopterygium incisumOphiopogon japonicusPaeonia lactifloraPhellodendron amurensePinellia ternatePlatycladus orientalisPlatycodon grandiflorumPrunus armeniacaPrunus persicaRehmannia glutinosaRheum palmatumSaposhnikovia divaricataSaussurea lappaSchizonepeta tenuifoliaScrophularia ningpoensisScutellaria baicalensisSparganium stoloniferumTalcumZingiber officinaleZiziphus jujuba

prescriptions of chinese herbal medicine for constipation under...

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