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Treatment Of Aplastic Anemia With Acupuncture
Tony V. Lu, MD
ABSTRACT
Background Aplastic anemia is a hematopoietic disorder characterized by a reduction or absence of white blood cells, red blood cells, and platelets. Patients with aplastic anemia can be treated with immunosuppressive therapy or bone marrow transplantation. However, if they have no compatible donor or do not respond to immunosuppressive therapy, supportive therapy with blood and platelet transfusions is the only remaining option. This option carries short- and long-term risks and complications.
Objective To determine at what threshold levels of thrombocytopenia acupuncture can be safely used in patients with aplastic anemia, and if acupuncture can be used in the management of patients with aplastic anemia who have not responded to conventional therapy and/or have developed adverse effects from prolonged immunosuppressive therapy.
Design, Setting, and Patients A case report of a patient with aplastic anemia, thrombocytopenia, and features of myelodysplastic syndrome and paroxysmal nocturnal hemoglobinuria was seen in an Illinois clinic from May 2002 to March 2003. The patient also had multiple compression fractures in the low back secondary to prolonged treatment with prednisone.
Intervention Shu points with moxa, N-N+1 therapeutic input with Yang Ming-Tai Yin Principal Meridian subcircuits, and Yin Wei Mo/Yang Wei Mo Extra Meridians were used for aplastic anemia. PENS (percutaneous electrical nerve stimulation) was used for low back pain.
Main Outcome Measures The improvement of the patient's anemia and thrombocytopenia, the reduction or resolution of the need for blood and platelet transfusions, the clinical improvement of symptoms, and the decrease or discontinuation in pain medications. Also, any bleeding at or around acupuncture needle sites.
Results This patient tolerated acupuncture treatments without untoward effects, even at a platelet count of 32 x 103/mL providing that the acupuncture needles were placed in the back. He has been able to maintain his red blood cell and platelet counts without further need for transfusions, resume his regular activities including golfing without fatigue, walking without a cane, and reducing his pain regimen.
Conclusions Acupuncture can be safely used in the back of a patient with a platelet count of 32 x 103/mL or higher. In addition, acupuncture can be used in the management of patients with aplastic anemia who have not responded to conventional therapy, as well as those who have developed compression fracture pain in the low back from prolonged prednisone use.
KEY WORDS
Acupuncture, Aplastic Anemia, Thrombocytopenia, Compression Fracture, Prednisone
INTRODUCTION
A plastic anemia is a blood disorder characterized by a reduction or absence of erythroid, granulocytic, and megakaryocytic cells resulting in pancytopenia. The incidence in Western countries has been estimated as 5 to 10 cases per million persons per year.1 Aplastic anemia can be acquired or hereditary. However, the majority of the cases are idiopathic. The most common presenting symptoms are those from anemia and thrombocytopenia with fatigue and bleeding. Neutropenia is rarely a presenting symptom although its presence denotes a more severe prognosis. Patients with aplastic anemia can subsequently develop paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome. The natural course of the disease is progressive and life-threatening if untreated. There are 2 therapeutic approaches in the treatment of idiopathic aplastic anemia: allogeneic bone marrow transplantation or an immunosuppressive regimen of antithymocyte globulin (ATG), cyclosporine, and prednisone. Cases that fail immunosuppressive therapy can resort to supportive therapy with blood and platelet transfusions. However, blood and platelet transfusions can present with short- and long-term complications such as sensitization and refractoriness. Described herein is a patient with aplastic anemia who had not responded to immunosuppressive therapy and was relying on frequent blood and platelet transfusions as supportive therapy. He had compression fractures pain in his low back resulting from prolonged prednisone use.
Case Report
The patient was a 69-year-old Midwestern white man who self-referred for evaluation and treatment of aplastic anemia and low back pain. He began having symptoms of shortness of breath, fatigue, and increased bruising in September 2001 and was diagnosed with aplastic anemia. A bone marrow aspirate and biopsy and cytogenetic analysis showed pancytopenia with features of myelodysplatic syndrome and paroxysmal nocturnal hemoglobinuria. He was treated with ATG, cyclosporine, and prednisone. He also required transfusions of packed red blood cells for his anemia and platelets for his thrombocytopenia as needed. He received a single 4-day course of ATG followed by a 6-month course of cyclosporine and prednisone. The patient developed a reaction to the initial dose of ATG with hypertension, hyperthermia, and seizures. The reaction improved and he received 3 more doses. At this time, he began prophylactic antifungal, antibiotic, and antiviral medications.
Several months later, the patient presented to the emergency department and was diagnosed with cyclosporine toxicity. In February 2002, he consulted at another major institution for a 2nd opinion. Their diagnosis was the same, aplastic anemia with features of hemoglobinuria. Their recommendation was to discontinue cyclosporine and to continue prednisone at a higher dose together with folic acid and multivitamin. In March 2002, it was decided to again restart ATG therapy together with prednisone (a protocol in phase 2 trial for the treatment of myelodysplastic syndrome). Over the next few months, the patient had several trips to the emergency department for hip and back pain and was diagnosed with several vertebral compression fractures at L3, L4, and L5 and decreased muscle mass secondary to high dose, prolonged prednisone use. Prednisone was discontinued. At that time, the patient was told by his oncologist that he had failed immunosuppressive therapy. In May 2002, he felt that he had no remaining options and wanted to try some complementary and alternative approaches.
On the initial visit, the patient's white blood cell (WBC) count was 18.5 x 109/L, his hematocrit was 25.0%, and his platelet count was 20 x 103/mL. Physical examination was remarkable for weak liver, spleen, and kidney pulses, a thick diffuse white tongue coating, a slightly enlarged spleen, and positive straight crossed-legged raise.
He was using a walker to ambulate. Medications included andronol 25 mg twice daily, fentynal 125 mg patch daily, and dilaudid 4 mg every 4 hours. In addition, he took folic acid, vitamin B12, and multivitamin. At that time, he required platelet transfusion every 3 days for his thrombocytopenia and packed red blood cell transfusion weekly for his anemia. Despite this frequency of transfusion, his counts would only increase from below 10 to 30 x 103/mL, and would only last for less than 24 hours. The patient's primary goals and objectives were to (1) decrease the frequency of transfusions, eventually to none, (2) decrease the symptoms of anemia and thrombocytopenia (shortness of breath, fatigue, echymosis), and (3) decrease the back pain and the number and dose of pain medications needed.
METHODS
The patient was instructed to begin acupuncture treatment on the day that he received PLT transfusions. After obtaining patient consent and on the day of his 1st treatment (day 1), his platelet count was 32 x 103/mL. He received a total of 12 acupuncture treatments in a period of 4 months; 6 treatments were done during the 1st month. The 1st treatment involved tonification of the KI, SP, LR, and blood Shu points by piquring BL 23, BL 20, BL 18, and BL 16 bilaterally with electrical stimulation at 4 Hz for 20 min.
The 2nd treatment involved an N/N+1 Yang Ming/Tai Yin Principal Meridian subcircuits with movement through Tai Yin. Acupuncture points included LI 4, ST 36, SP 6, SP 9, and LU 7 with electrical stimulation for 30 min at 4 Hz with the negative handle on SP 6 and the positive handle on SP 9.2
Since the patient's pain was severe, the 3rd and 4th treatments were modified. PENS (percutaneous electrical nerve stimulation) with moxibustion of the KI, SP, LR, and blood Shu points was used. A standard arc montage was chosen for the PENS. The acupuncture points used were BL 28, BL 27, BL 25, BL 23, and BL 19 bilaterally with electrical stimulation at 4 Hz for 15 min followed by electrical stimulation at 100 Hz for 10 additional min. This exact treatment was repeated for the 6th session.
For the 5th treatment, 2 Extra Meridians, Yin Wei Mo-Yang Wei Mo, were chosen because the Yin channel pulses (KI, SP, and LR) were thought to be weak. The acupuncture points, done in succession, included SP 4, MH 6, KI 9, GB 41, and TH 5. No electrical stimulation was used for this treatment. However, because the patient complained of depression, HT 3 and LR 3 were piqured bilaterally, and electrical stimulation at 4 Hz was applied with the negative handle on HT 3 and the positive handle on LR 3. These 2 treatments were carried out simultaneously for 30 min.
The remaining 6 acupuncture treatments consisted of 1 more modified PENS treatment as described above, 2 additional Yang Wei Mo-Yin Wei Mo Extra Meridians, and 3 Yang Ming-Tai Yin Principal Meridian subcircuits.
All acupuncture needles used were DBC Spring Handle acupuncture needles (0.18 x 30mm). No attempt was made to elicit the traditional De Qi sensations for all acupuncture treatments. Electrical stimulators used were the IC 1107 model with asymmetric biphasic square waveform pattern and 70 ms pulse width.
RESULTS
The patient tolerated all acupuncture treatments without untoward effect. There was no bleeding or ecchymosed lesions at or around acupuncture needle sites even with a platelet count of 32 x 103/mL. After 6 acupuncture treatments, his hematocrit went from 25% to 30.7%,
and continued to climb without further need of transfusion to 42.8% 11 months after his 1st acupuncture treatment. Similarly, his platelet counts increased from 20 x 103/mL on the initial date of visit into the 40 x 103/mL to 50 x 103/mL range, and continued to rise to 120 x 103/mL 11 months after his 1st acupuncture treatment. At one point, the patient's platelet counts rose as high as 197 x 103/mL. He required 3 units of platelet and 1 unit of red blood cell transfusions, all during the 1st 10 days of acupuncture treatments. He has not required any further blood or platelet transfusions since that time.
In December 2002 (230 days since the 1st acupuncture treatment), the patient's platelet count was 176 x 103/mL [150-400], his WBC count was 4.4 x 109/L [4-10], and his hematocrit was 40.7% [40.0%-54.0%] (Figures 1-3). In addition, based on his stable blood counts, the patient was told by his oncologist that he is in complete remission. At present, his back pain and fatigue are dramatically improved. He is able to ambulate without a walker or cane and perform his daily activities without restrictions (he is able to play golf on a regular basis).
The patient discontinued the use of dilaudid and is currently prescribed the fentynal 125 mg patch every 3 days (instead of every day). Previously stated goals and objectives have been fulfilled.
DISCUSSION
Acupuncture can be safely performed in the back and extremities for patients with aplastic anemia providing that their platelet counts are at least 32 x 103/mL or higher. Acupuncture can be considered as a complementary treatment in conjunction with conventional therapy for the treatment of aplastic anemia. In cases of refractory aplastic anemia, acupuncture can be used as an alternative treatment to enhance and improve marrow function and symptoms.
In reviewing the literature on using complementary and alternative medicine in the treatment of aplastic anemia, there are only 4 published studies.3-6 They all included the use of Traditional Chinese Medicine (TCM) herbal formulas. There is thus far no published study on the use of acupuncture in the treatment of aplastic anemia. The TCM herbal formulas used in those studies followed the same concept of tonification of Kidney Yin and Kidney Yang, Spleen Qi, Liver Qi, Blood Qi, and blood circulation.
In a recent article on the treatment of aplastic anemia with TCM herbal formula,3 the author discussed the pathogenesis of aplastic anemia from the TCM standpoint. Aplastic anemia is not just a syndrome of pure blood deficiency manifested by Kidney Yin and Kidney Yang deficiencies and Spleen Qi deficiency. Aplastic anemia also falls into the category of excess with liver blood stasis, noxious heat, and damp heat. Indeed, tonifying the Kidney Yin and Yang deficiencies alone is not sufficient because aplastic anemia is an intermingling of deficiency and excess syndrome, a problem of both Heat and Cold. To appropriately address this issue, the author used a TCM formula with a Kidney-tonifying and a mediating method at the same time. The Kidney-tonifying formula contained Kidney Qi, Kidney Yin, Kidney Yang, Lung, Spleen, and blood tonics together with some immune enhancing herbs. The mediating method formula contained Kidney Qi, Kidney Yin, Kidney Yang, and blood tonics as well as herbs to dispel the Liver fire, damp heat in the Lower Burner, and empty heat in the Kidney. In addition, there were herbs for detoxification and to motivate blood circulation and eliminate blood stasis. In this study, the group taking the kidney-tonifying and mediating method was significantly better in symptoms improvement and peripheral blood counts compared with the kidney-tonifying-alone group, and the standard Western drug-alone group.
In this case report, acupuncture treatments received by this patient addressed both the deficiency and the excess issues. In the 1st treatment with tonification of the Shu points, BL 23 (Kidney Shu) toned Kidney Yang, nourished the blood, and promoted formation of blood. At the same time, BL 23 also resolved dampness for the Lower Burner. Similarly, BL 20 (Spleen Shu) tonified Spleen Qi and blood as well as resolved dampness and phlegm; BL 18 (Liver Shu) resolved damp heat in the Liver, and BL 16 (Governing Vessel Shu) invigorated the blood and removed blood stasis. In the PENS treatment, in addition to the functions of BL 23 as described above, BL 19 (Gallbladder Shu), BL27 (Small Intestine Shu), and BL 28 (Bladder Shu) addressed the excess side of the imbalance by resolving and eliminating damp heat.2,7
In the Yang Ming/Tai Yin subcircuits treatment, ST 36 tonified Qi, Blood, and Spleen, and at the same time, expelled dampness. Similarly, SP 6 tonified Kidney Yin as well as resolved dampness, moved the blood, and eliminated stasis. While LI 4 strengthened the defensive Qi, SP 9 removed damp heat, and LU 7 conducted heat downward away from the head. Yin Wei Mo is often used for deficiency of blood and/or Yin. While MH 6 regulated Qi and blood, SP 4 removes blood stasis and stops the bleeding. In Yang Wei Mo, GB 41 resolved damp heat and promoted the smooth flow of Liver Qi by eliminating Liver fire stagnation. TH5 can expel heat, dampness, and fire. Finally, HT 3 cleared Heart fire and empty heat while LR 3 subdued Liver Yang and nourished Liver blood. Thus, all acupuncture treatments administered to this patient mirrored the Kidney-tonifying and Kidney-mediating approaches.2,7
CONCLUSION
Acupuncture can be safely used in the back and extremities of a patient with platelet count of at least 32 x 103/mL or higher. In addition, acupuncture can be utilized in the management of patients with aplastic anemia who have not responded to conventional therapy, as well as those who develop compression fracture pain in the low back from prolonged prednisone use. In this patient, acupuncture helped improve his peripheral blood counts and resolve the need for blood and platelet transfusions. It helped his low back pain and fatigue resulting in his resuming normal activities without restrictions. In addition, as seen in this case, acupuncture can be used to appropriately address the complex and concurrent syndrome of deficiency and excess seen in patients with aplastic anemia.
REFERENCES
- Braunwald E, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 1998.
- Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995.
- Yu Y, Sun W, Cao K, et al. Treatment of aplastic anemia by the kidney-tonifying and mediating method. J Tradit Chin Med. 2001;21:252-255.
- Zhang L, Wang X, Chen S. Experimental study on the effect of yiyuan shengxue capsule on gamma-interferon and tumor necrosis factor-alpha in patients with chronic aplastic anemia. Chung-Kuo Chung Hsi i Chieh Ho Tsa Chih. 1999;19(10):599-601.
- Wang SQ, Li JH, Zhang SM. Effect of bushen huayu recipe on DNA content of myeloid cells in aplastic anemia patients. Chung-Kuo Chung Hsi i Chieh Ho Tsa Chih. 1996;16(7):411-413.
- Su EY, Chen HS. Clinical observation on aplastic anemia treated by Spatholobus suberectus Composita. Chung-Kuo Chung Hsi i Chieh Ho Tsa Chih. 1997;17(4):213-215.
- Maciocia G. The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists. London, England: Churchill Livingstone; 1989.
AUTHOR INFORMATION
Dr Tony V. Lu is Board-certified in Internal Medicine, and is Medical Director for integrative medicine at Loyola University Health System, and Assistant Professor of Medicine at Loyola Stritch School of Medicine. Dr Lu teaches complementary and alternative medicine at Loyola Stritch School of Medicine and practices Medical Acupuncture full-time at the Family Health Center of La Grange Park, Illinois.
Tony V. Lu, MD, DABMA, FAAMA*
Family Health Center of La Grange Park
321 No La Grange Rd
La Grange, IL 60526
Phone: 708-485-1020 • Fax: 708-485-1173 • E-mail: Tlu1@lumc.edu
*Correspondence and reprint requests
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