Fu Ji Ning Decoction Treatment On Regulation And Research Of Immunological Indexes In Patients With Ocular Myasthenia Gravis

Ocular myasthenia gravis is a form of myasthenia gravis (MG) in which muscles that control the eyelids and move the eye are easily fatigued and weakened. The main clinical symptoms are ptosis (drooping eyelids), diplopia (double vision) or strabismus, limited eyeball movement. Among all the affected muscle groups, more than90%of myasthenia gravis patients show ocular muscle involvement dysfunction. It is often considered the first symptom.The study was conducted in the Xiyuan Hospital China Academy of Chinese Medical Sciences, from September2011to April2014. The effect of "Fu Ji Ning Decoction" developed by Xiyuan Hospital used for more than30years by chief physician Xu Bao Yu and TCM professor Shang Er Shou, has been clinically researched and examined in77cases of ocular myasthenia gravis patients. The results have shown great effectiveness of "Liver Wind" treatment method used in "Fu Ji Ning Decoction". The research showed great change in patient’s Chinese medicine symptoms, high overall treatment effectiveness. Its treating mechanism shows results in both humoral immunity and cell immunity.1"Liver wind treatment method" on regulation and research of immunological indexes in patients with ocular myasthenia gravis1.1Case selectionA total of77patients with ocular myasthenia gravis were enrolled. The research was conducted in the Xiyuan Hospital China Academy of Chinese Medical Sciences, from September2011to April2014.Gender and age:44male and33female patients; age5～79years, average age (47.50±22.52) years.Course of disease:2month-23years, average course (11.57±6.34) years.1.2Diagnostic criteriaDiagnostic criteria by western medicine:(1) Ptosis or ocular fatigue test is positive, the symptoms may be mild to severe, symptoms are lighter in the early morning-get worse by the evening, ophthalmoplegia (diplopia and strabismus or restriction of eye movements) (2) Neostigmine test or edrophonium test positive(3) EMG changes consist of decreasing reaction of repetitive nerve stimulation(4) Serum acetylcholine receptor antibody membrane (AchR-QM) and serum acetylcholine receptor antibody membrane (AchR-HM) elevated (normal range<1.10)Diagnostic criteria by Chinese medicine, symptom diagnosis standards in TCM: Main symptoms:(1) Ocular deviation (strabismus) or eyeball rotation failure (restriction of eye movements)(2) Drooping of the upper eyelid (ptosis)-lighter in the early morning and getting worse by the evening(3) Double vision(4) Red tongue, little tongue coating, or no tongue coating(5) String wiry weak pulseAdditional symptoms:(1) Dizziness and tinnitus(2) Blurred vision(3) Dryness in the eyes(4) Irritability(5) Soreness and weakness in waist and knees(6) Heart palpitations and forgetfulness(7) Heat feeling in hands, feet and chest(8) Short menstruation cycle (women)/seminal emission (man)1.3Treatment methodThe treatment group was given "Fu Ji Ning Decoction"(formula composition: gastrodia elata Bl.10g, eucommia ulmoides oliver10g, scorpio10g, geosaurus6g, saposhnikovia divaricata1Og etc) decoct with water, one pack, divide the pack in two, take2times a day orally.The following herbs were added according to the symptoms:(1) Qi deficiency add Radix Astragali, Radix Codonopsis etc(2) Blood deficiency add Radix Angelicae Sinensis, Colla Corii Aaini etc(3) Dampness stagnation add Rhizoma Acori Tatarinowii, Pericarpium Citri Reticulatae, Caulis Bambusae in Taenia etc(4) Qi stagnation add Radix Bupleuri, Fructus Aurantii etc All the patients in the group were treated for three month. 1.4Statistical processingFor statistical processing the following were used:SPSS22.0statistical software, measurement data-1test, counting data-x2test, rating information-Ridit test.1.5Result1.5.1Clinical studyThe treatment of77ocular myasthenia gravis patients using "Fu Ji Ning " decoction1.5.1.1Clinical research shows that "Fu Ji Ning" decoction shows effective results in elimination and treatment of main eye symptoms in77ocular myasthenia gravis patients (P<0.05).1.5.1.2Clinical research shows that "Fu Ji Ning" decoction shows effective results in elimination and treatment of main Chinese medicine symptoms like liver and kidney yin deficiency, wind yang disturbance (P<0.05).1.5.2Mechanism research1.5.2.1Effects of "Fu Ji Ning" in humoral immunological indexes AchR-Ab in ocular myasthenia gravis patients:AchR-Ab is an international diagnosis standard for myasthenia gravis patients. The results of this study show that:"Fu Ji Ning" decoction is effective in the treatment of ocular myasthenia gravis patients, the levels of immunological humoral AchR-Ab index improved (P<0.05).1.5.2.2Effects of "Fu Ji Ning" in cellular immunity T cell subsets in ocular myasthenia gravis patients: Resent study shows that in ocular myasthenia gravis patients T cell subsets (CD4+/CD8+) and helper T cells (Thl, Th2) are in a disordered state.(1) Observation of T cell subsets (CD4+/CD8+) before and after treatment for ocular myasthenia gravis patients:The results show that:""Fu Ji Ning" decoction can improve T cell subsets CD4+/CD8+(P<0.05). It may also signify that "Fu Ji Ning" decoction from liver from wind treatment is one of important way in treating ocular myasthenia gravis.(2) Observation of helper T cells (Thl, Th2) before and after treatment for ocular myasthenia gravis patients:The results show that:"Fu Ji Ning" decoction decreased the helper T cells Thl, Th2levels, but the statistical analysis showed no significant differences (P>0.05). The study shows:myasthenia gravis patients not only have the abnormal humoral immunity, their cellular immunity, is also in an abnormal state. Therefore, in this study we have measured the change of the immune status before and after treatment. With the use of radioimmunoassay and enzyme-linked immunosorbent assay measured the patients AchR-Ab level and by taking immunofluorescence test measured T cell subsets in CD4+/CD8+, Thl, Th2.The results of this study show,"Fu Ji Ning Decoction" can significantly improve patients humoral immune system (AchR-Ab) and cellular immune system (T cell subsets CD4+/CD8+). This may be one of the important ways in the treatment of ocular myasthenia gravis.2"Liver wind treatment method" ocular myasthenia gravis theoretical research2.1Myasthenia gravis literature recordsThe word "myasthenia gravis" is not found in any ancient literature review, instead other names have been documented to describe ocular myasthenia gravis symptoms. For example 《Yellow Emperors Canon of Internal Medicine》:"double vision",《Zhengzhi Zhunsheng Canon》:"vision of two instead of one","pupil disorder",《Treatment Hou Theory Canon》:"fatigued eyelids","partial vision",《Shengji Zonglu Canon》:"drooping eyelids",《Mujing Dacheng Canon》:"drooping eyelids, obstructing the vision".2.2Mechanism of "Fu Ji Ning Decoction" liver wind treatment method of ocular myasthenia gravisCurrently many doctors believe, that etiology and pathogenesis of myasthenia gravis comes from spleen qi deficiency or spleen kidney deficiency. Therefore, most of the treatment comes from the theory of invigorating spleen and kidney. But according to the clinical reports, the effect is not ideal.After years of clinical research, the late famous Chinese medicine scientist Professor Shang Ershou and his graduate student Professor Xu Baoyu have come to a conclusion:etiology and pathogenesis of myasthenia gravis is closely related with liver and wind (mainly internal wind).2.2.1Liver theory in treatment of myasthenia gravis2.2.1.1Liver-eye connectionResearch shows that, ocular muscle involvement is the initial symptom in patients with myasthenia gravis:clinical manifestations like ptosis, diplopia, restriction of eye movement etc.Traditional Chinese medicine believes that, the relationship between "eye"and"liver" is mainly manifested in the following aspects:(1) Eye is the orifice of liver. In 《Su Wen Canon》 it is said:"East is connected with liver, liver orifices are the eyes". Among all organs the heart opens into the tongue, the liver opens into the eyes, the spleen opens into the mouth, lungs open into the nose, and kidneys open into the ears.(2) Liver blood helps the vision. Liver stores blood and regulates blood amount. Fresh and clean blood from the liver nourishes the eyes, helping the eyesight.(3) Liver channel connects with eyes.《Ling Shu Canon》 said:Jue yin liver meridian flows through the liver, passes the gall bladder and connects with the eyes.Eyes are the orifices of liver; blood itself nourishes the liver. Liver stores blood and purifies it. Therefore liver needs to be clean for maintaining its normal function.2.2.1.2Liver governs the tendons(1) Tendons mainly connect the joint system in our body. If a person has atrophy, it will restrict his movement. Most of the MG patients have weak tendons.(2) Theory of liver governing the tendons. In 《Su Wen Canon》 it is said:"Liver governs the tendons and its glory (physiological condition) manifests in the fingernails. The nourishment from the food comes to the liver to strengthen the tendons". The MG patients often have full body weakness, because of liver yin blood deficiency, lack of nourishment to the tendons; this is why the treatment should begin with liver.(3) Liver the source of endurance. In 《Su Wen Canon》 it is said:"Liver controls the tendons, controls endurance and strength". Liver controls our normal movement function; it is the center that fights the fatigue, the endurance center. MG patients show low fatigue resistance; therefore we say that the epicenter of the disease is in the liver.2.2.2Wind theory in treatment of myasthenia gravis2.2.2.1Wind conceptChinese medicine believes that there are two kinds of pathogenic wind inside our body:external and internal wind. External wind comes from the weather, or the outside pathogenic wind. Internal wind comes from excessive yang liver energy, or excessive heat, yin energy depletion; it is also called empty wind. 2.2.2.2Wind and liver connection(1) External wind and liver. In 《Su Wen Canon》 it is said:"The wind energy moves through the liver". It means that the wind that comes from the outside world, from the nature, is closely connected with the liver organ. External pathogen wind can hurt the liver, because the wind itself is yang energy, that when comes to its height can exhaust yin energy, causing the internal wind.(2) Internal wind and liver. The internal viscera, specially the liver, generate internal wind. In summary, pathological changes of liver, internal and external wind are closely related.(3) Wind and eyes. In 《Su Wen Canon》 it is said:"The wind energy moves through the liver, and moves up to the eyes". Wind energy goes through the liver, the liver opens through the eyes, eye are the connecting pathway between the outside world and the liver inside our body. That means that if the wind affects the liver, it would also affect the eyes. Patients with myasthenia gravis show symptoms like ptosis, double vision, strabismus etc,-this means that their pathological change is closely related to endogenous (internal) liver wind.(4) Wind characteristics and myasthenia gravis. In 《Su Wen Canon》 it is said:"The wind can change rapidly......cause hundred diseases". Myasthenia gravis patients often show rapid change of symptoms. The muscle weakness is not continuous, symptoms show significant fluctuation:lighter in the early morning-getting worse by the evening. Some patient can develop myasthenia crisis. This proves that the symptoms show rapid change.The main pathogenic problem for ocular myasthenia gravis patients mainly occurs in the liver, its pathogenesis is closely related with wind (external and internal). Therefore, the treatment of ocular myasthenia gravis should be focused on "Liver Wind Treatment Method".