Allergy 2006: 61: 13161318

2006 The Authors Journal compilation 2006 Blackwell Munksgaard DOI: 10.1111/j.1398-9995.2006.01152.x

Original article

The prescriptions frequencies and patterns of Chinese herbal medicine for allergic rhinitis in Taiwan
Background: The evaluation of Chinese herbal medicines (CHM) to allergic rhinitis (AR) by large-scale pharmaco-epidemiological study is not ease found, although CHM had been reported to have potential eect for AR in some clinical trials. Aims of the study: To explore the frequency and pattern of CHM prescriptions on AR, we have the study by analysing the population-based CHM database in Taiwan. Methods: The way for this study was linked and processed the complete traditional Chinese medicine database for Taiwanese recorded in the year 2002. The diagnosis of AR was extracted with the only single ICD-9 Code of 477 to calculate the frequency and pattern of prescriptions. Association rule was applied to analyse co-prescription of CHM for patients with AR. Results: In the year 2002, among the 22 520 776 valid beneciaries of the National Health Insurance, Taiwan, 914 612 subjects (3.8% of the total valid beneciaries) have diagnosed AR. There were 35.6% of AR patients been treated by CHM. The peak age of AR patients treated by CHM was at the rst decade (010). For the AR patients, the most common Chinese herbal formula prescription was Shin-yi-qing-fei-tang, or Angelica dahurica (Bai-zhi) for the single Chinese herb. While for the combination treatments the most common prescription was the two formulae, Xiao-qing-long-tang and Shin-yi-san. Conclusions: Because of the high utilization rate of the CHM treatment for AR, a large-scale randomized trial warrants further research for its ecacy and safety. Y. Y. Kung1, Y. C. Chen2, S. J. Hwang2, T. J. Chen2, F. P. Chen1
1 Center for Traditional Medicine; 2Department of Family Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan

Key words: allergic rhinitis; Chinese herbal medicine; National Health Insurance; pharmaco-epidemiology.

Dr F. P. Chen Center for Traditional Medicine Taipei Veterans General Hospital 201, Shih-Pai Road, Section 2 Taipei 111217 Taiwan Accepted for publication 3 April 2006

Despite the conventional therapies in allergic rhinitis (AR) had advance eects, a remarkable number of patients are seeking relieves from herbal medicine (1). The Chinese herbal medicines (CHM) had shown potentials to be an ecacious treatment option for AR patients reported from some clinical trials (24). However, the multiform formulae of CHM in these clinical trials make researchers confuse that, what kinds of CHM is the common usage for AR as the clinical practice treatment. A large-scale pharmaco-epidemiological study to evaluate CHM on AR is therefore a necessary project, to oer suggestive information for seeking potentially eective drugs for AR. In Taiwan, the National Health Insurance (NHI) which nearly covers the whole Taiwanese population (22 520 776 beneciaries at the end of 2002) was established since 1995. The CHM treatments are also reimbursed from NHI. Because the electronic form of all claimed data are available for researches, a populationbased survey of Chinese herbal pharmaco-epidemiology on AR can be investigated. The aim of this study is to explore the frequency and pattern of CHM prescriptions for AR by analysing the population-based CHM database in Taiwan. 1316

Methods
The complete database of Traditional Chinese medicine (TCM) claims (including the visit and prescription les) in year 2002 was obtained from the NHI Research Database (NHIRD; http:// www.nhri.org.tw/nhird/ ) in Taiwan. The essentials were two kinds of les, the visit les, which recorded the dates of encounters, medical care facilities and specialties, patients genders, birthdays, and the most recent three diagnoses in ICD-9-CM coding (the International Classication of Disease, 9th Revision, Clinical Modication), and the prescription les which contained the prescriptions, with several Chinese herbal drugs or formula items in each prescription. Chinese herbal drugs or formulae are made of powder or ne granules and can be easily mixed in a single prescription. For privacy protection, the identications of patients and institutions in the visit les had been scrambled cryptographically to attain anonymity. We also obtained the sample visit le of western medicine (S_CD2002.DAT) to estimate the portion of AR for the patients who were treated by western medicine. The sample visit le contained 149 471 records. The percentage of AR in the diagnosed coding can be got from this le. The database software IBM DB2 8.1 was used for data linkage and processing. Only single diagnosis code of AR (ICD-9 Code 477) was used to dene the research target. The regular statistics were displayed for the prescription frequencies. Association rule of data

Chinese herbs use for allergic rhinitis in Taiwan

mining was applied to calculate Chinese herbal drug prescriptions for AR. The details of the association rule of mining method were shown by Chen et al. (5).

Results Among the 22 520 776 valid beneciaries of the NHI in year 2002, Taiwan, an estimation of 2.4% of the total valid beneciaries (540 499 subjects) were diagnosed AR in the sample le of western medicine, and 1.4% of AR patients (374 113 subjects of the total valid beneciaries) were treated by TCM. Among the TCM treated AR subjects, 325 656 (87.0%) were prescribed CHM, 3312 (0.9%) with acupuncture and 45 145 (12.1%) with combined CHM and acupuncture. Therefore, there were about 35.6% of AR patients using CHM. The peak age of the AR patients treated by CHM was in the rst (25.2%) 10-year region, followed by the second (24.4%) 10-year region. Male patients were a little more than female (M : F 1.03 : 1) (Table 1). The commonly prescribed Chinese herbal formulae for AR patients were, in order, Shin-yi-qing-fei-tang (24.9%), Shin-yi-san (20.1%), Xiao-qing-long-tang (19.6%), Canger-san (19.2%), Ge-gen-tang (10.1%) (Table 2). While for
Table 1. Age-specific frequency of patients with allergic rhinitis (AR) treated by Chinese herbal medicine (CHM) in Taiwan during 2002 Patients with AR using CHM Age (years) 09 1019 2029 3039 4049 5059 6069 7079 > 80 Total Numbers of patients (%) 94 385 91 389 58 878 56 973 39 944 17 950 9107 4589 898 374 113 (25.2) (24.5) (15.7) (15.2) (10.7) (4.8) (2.5) (1.2) (0.2) (100) Male (%) 56 935 53 630 24 727 22 486 16 747 7781 4074 2578 537 189 495* (15.2) (14.3) (6.7) (6.0) (4.5) (2.1) (1.1) (0.7) (0.1) (50.7) Female (%) 37 450 37 759 34 151 34 487 23 197 10 169 5033 2011 361 184 618 (10.0) (10.1) (9.1) (9.2) (6.2) (2.8) (1.3) (0.5) (0.1) (49.3)

the single Chinese herb drug, the common prescriptions for AR were, in order, Angelica dahurica (Bai-zhi) (9.5%), Xanthium sibiricum (Cang-er-zi) (8.8%), Cryptotympana atrara (Chan-tui) (8.4%), Houttuynia cordata (Yu-xingcao) (7.7%), Glycyrrhiza uralensis (Gan-cao) (7.5%). According to the association rule, the most common combinations of prescribed with two kinds of CHM for AR were Xiao-qing-long-tang and Shin-yi-san; and Shinyi-qing-fei-tang, Houttuynia cordata and Xanthium sibiricum for the combinations with three kinds of CHM.

Discussion This study is the rst population-based survey of the AR patients treated by CHM. It shows a relatively high frequency of 35.6% of AR patients treated by CHM in the current study. The high utilization rate in Taiwan may be attributed that Taiwanese believe in herbal drugs for its gentle, less of side eects, made especially to individuals and improved constitutions (6). Shin-yi-qing-fei-tang, never reported in the scientic literature, was recorded in ancient Chinese medicine books for nasal stuness and discharge. It is still unknown that the eective component and mechanism of this formula cures AR, deserving further evaluations. Xiao-qing-long-tang was reported to have anti-allergic and immunomodulatory eect (7). So Xiao-qing-longtang and Shin-yi-san, the two most common formulae of CHM prescribed for AR, may be required herbal formulae for further clinical trials. Angelica dahurica (Bai-zhi), the most commonly prescribed single drug for AR in this study, has the activities of anti-microbial and cyclooxygenase-2 inhibitory (8, 9).So we can understand that the purpose of adding single herbal drugs into Chinese herbal formula in one prescription was to enhance the therapeutic eect or to deal with certain AR-related symptoms. However, some CHMs may have potential side eects. For example, Glycyrrhiza uralensis (licorice) may induce hypokalemia syndrome and hypertension when excess-

*Male : female 1.03 : 1

Table 2. The top five Chinese herbal formula prescribed for allergic rhinitis in Taiwan during 2002 (total prescription numbers, n 874 280) Chinese herbal formulae (Chinese name) Shin-yi-qing-fei-tang Numbers of prescription (percentage, %) 217 641 (24.9)

Ingredients Magnolia liliflora, Lilium brownie, Anemarrhena asphodeloides, Scutellaria baicalensis, Calcium sulphate, Eriobotyra japonica, Cimicifuga foetida, Ophiopogon japonicus, Gardenia jasminoides, Glycyrrhiza uralensis Magnolia liliflora, Asarum sieboldi, Ligusticum sinense, Ledebouriella divaricata, Angelica dahurica, Ligusticum wallichii, Cimicifuga foetida, Glycyrrhiza uralensis Ephedra sinica, Cinnamomum cassia, paeonia lactiflora, Zingiber officinale, Asarum heterotropoides, Schizandra chinensis, Pinellia ternata, Glycyrrhiza uralensis Xanthium sibiricum, Magnolia liliflora, Angelica dahurica, Mentha haplocalyx Pueraria lobata, Ephedra sinica, Cinnamomum cassia, paeonia lactiflora, Zingiber officinale, Glycyrrhiza uralensis, Ziziphus jujuba

Shin-yi-san Xiao-qing-long-tang Cang-er-san Ge-gen-tang

175 618 (20.1) 171 677 (19.6) 167 465 (19.2) 88 668 (10.1)

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Kung et al. ively ingested (10). Children with AR were the common population treated by CHM. The safety of long-term CHM treatments to this population needs to be more concerned by the medical policy makers. In conclusion, CHM for AR is indeed a common treatment in Taiwan. The therapeutic eect and the mechanism of Chinese herbal drugs or formulae in treating AR found in this study needs to be elucidated. Acknowledgments
This study is based on a portion of data from the National Health Insurance Research Database provided by the Bureau of National Health Insurance, Department of Health and managed by National Health Research Institutes in Taiwan. The interpretation and conclusions contained herein do not represent those of Bureau of National Health Insurance, Department of Health or National Health Research Institutes.

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