Traditional Chinese Medicine Practitioner oral assessment prep

Knowledge: Danshen (Salvia miltiorrhiza) and Dang Gui (Angelica sinensis) both have reports of potentiating warfarin and raising the INR, and the evidence is mostly case reports and small pharmacological studies, so I would be honest that the data are limited but the risk is real and the consequence, a major bleed, is serious. Other blood-moving materials such as Tao Ren and Hong Hua also invite caution, as do Ginkgo, garlic and ginger in larger doses, while some herbs such as Gan Cao can disturb blood pressure and potassium.

Management: I would not prescribe a blood-moving formula to a patient on warfarin without the knowledge of his anticoagulation team. I would take a full history of what he already takes, including over-the-counter and imported products, examine the knee and assess the cause of the pain and sleep disturbance, and offer what is safer: acupuncture with sterile single-use needles, once I have confirmed that his INR is stable and he has no bleeding tendency, and sleep hygiene advice. If he still wants herbal treatment, I would propose that I write to his cardiologist, with his permission, to agree an agent, a dose and an INR monitoring plan.

Ethics and communication: I would not agree to keep this from his cardiologist as a condition of treatment, and I would explain, without judgement, that the only risk I am worried about is an unexpected bleed. Patient autonomy means he may decline to tell the cardiologist, but I am not obliged to prescribe, and I would document the discussion, his decision and the advice given. I would also respect that his view of conventional medicine is shaped by earlier experience, and show that integrated care is the safer route.

Reference: Bensky, Clavey and Stoger, Chinese Herbal Medicine: Materia Medica (Eastland Press) and Izzo and Ernst, Interactions Between Herbal Medicines and Prescribed Drugs (Drugs, 2009)

Knowledge: Han Fang Ji and Mu Tong are names that have been used for different plants, and some species or substitutes (Guang Fang Ji from Aristolochia fangchi, Guan Mu Tong from Aristolochia manshuriensis) contain aristolochic acid, which causes a progressive tubulointerstitial nephropathy and is linked to urothelial cancer. The slimming-clinic nephropathy outbreak in Belgium in the 1990s is the classic example, and the harm is cumulative and may continue after the herb is stopped. An unlabelled product may also contain undeclared pharmaceuticals, heavy metals or sibutramine-type weight-loss drugs, so I cannot rely on the label.

Management: I would stop the product immediately, ask her to bring all packaging and any remaining tablets, and advise her to see a nephrologist or her family doctor urgently the same day for repeat renal function, urinalysis with protein and sediment, and imaging. I would explain that this may be a herbal cause and write to her doctor with the product name and the ingredient concern. I would not treat her with any further herbs. Long term she needs renal follow-up and, because of the cancer link, discussion of urinary tract surveillance with the specialist.

Ethics and communication: My duty is to the patient's safety first and to the regulator second, and I would report the product through the correct channel (the DOH, DHA or MOHAP pharmacovigilance or product-safety route, depending on the emirate) rather than treat it as a private matter. I would be open that the product may be at fault without alleging a cause I cannot prove, and I would document everything. I would also review my own supply chain, because I must only dispense herbs from a registered, licensed source with certificates of identification and contaminant testing.

Reference: WHO Guidelines for Assessing Quality of Herbal Medicines with Reference to Contaminants and Residues (2007) and Debelle, Vanherweghem and Nortier, Aristolochic Acid Nephropathy: A Worldwide Problem (Kidney International, 2008)

Knowledge: Pleuritic chest pain with breathlessness after thoracic needling is a pneumothorax until proven otherwise. The thoracic wall is thin over the upper back, and deep or oblique needling of the thoracic points, or of points near the lung apex, carries a risk that I would have explained to him beforehand. Symptoms can appear after some delay, and a small pneumothorax can enlarge, particularly with air travel or diving.

Management: I would tell him to stop driving, call 998 if he is alone or his breathlessness is marked, and attend the nearest emergency department immediately rather than wait; I would offer to ring ahead and to provide a clinical summary saying which points were needled, the depth and the needle length. I would not advise him to rest. I would also ask if he has any other symptoms such as palpitations or light-headedness, and tell him not to fly or dive until he has been cleared.

Ethics and communication: This is an adverse event that I must disclose openly: I would tell him plainly what I suspect, apologise for the harm without speculating on fault, and follow up with him personally. I would record the event in the notes, report it through the facility's incident system and to the regulator if the DOH, DHA or MOHAP requires notification, and review my needle depths, positioning and consent process. I would add a documented pre-treatment discussion of risks for thoracic needling for future patients.

Reference: WHO Guidelines on Basic Training and Safety in Acupuncture (1999) and White, A Cumulative Review of the Range and Incidence of Significant Adverse Events Associated with Acupuncture (Acupuncture in Medicine, 2004)

Knowledge: Stopping insulin in a patient with long-standing diabetes and a HbA1c over 11 per cent risks diabetic ketoacidosis or a hyperglycaemic hyperosmolar state, and I would ask about thirst, weight loss, vomiting and drowsiness. TCM may be a reasonable complementary approach to symptoms such as neuropathic pain or stress, and some small trials of acupuncture and herbs show benefit, but there is no evidence that it cures diabetes and I should not suggest it.

Management: I would measure capillary glucose and ketones if my clinic has the equipment, and if he is unwell or the glucose is very high I would send him by ambulance to the emergency department. If he is stable, I would still arrange same-day review by his physician or an endocrinologist to restart insulin, and I would not start any treatment until I know that has happened. Once he is back on his medication I would offer acupuncture for the neuropathic symptoms, with foot checks, and provide a letter to his physician describing any treatment I give.

Ethics and communication: I would be straightforward that no herb or needle treatment will replace his insulin, and avoid shaming him for his choice. I would document his decision and my advice. The poster is a breach of the rules on advertising of healthcare services and is false, so I would ask the owner to remove it, and if the owner refuses I would raise it with the regulator, because my licence and my patients' safety depend on it. I work within the scope set for TCM practitioners by the licensing authority and refer outside it.

Reference: DOH TCIM Practitioners Scope of Practice (DOH/SOP/TCIM-Practitioners/HCWS/V2/2024) and WHO Benchmarks for Training in Traditional Chinese Medicine (2010)