Introducing Yunnan Baiyao or Yunnan Paiyao
Herbology is one branch within the field of integrative, or complementary and alternative, veterinary medicine (CAVM). With the growing interest around integrating these techniques into daily practice, veterinary herbology is gaining attention. One patent Chinese herbal formula, called yunnan baiyao or yunnan paiyao, is commonly utilized to stop bleeding, promote wound healing and relieve pain (18,19,20,27).
Translated as "White Medicine from Yunnan Province" (3,9,12,27), it was developed in the
Yunnan Province of China over 80 years ago. A variety of anglicized spellings for this product exist, including:
-yun(n)an baiyao, yun(n)an bai yao, yu(n)nan bai-yao, yun nan bai yao, yun nan bai yao wan
-yun(n)an paiyao, yun(n)an pai yao
-yunnan paiyou, yunnan payao, yunnan piao, yunnan paiao
-hunnan pai yao
The exact herbal formula for yunnan baiyao is not completely clear. The formula is reported to be a 'highly guarded secret', but is variably labeled to contain some of the following, suspended in a potatostarch base (3,9,15,22,27,29,30):
-pseudoginseng/san qi/tien chi/tian qi/tian qi ginseng (Panax pseudoginseng, Panax notoginseng, Radix pseudoginseng,Radix notoginseng)
-chinese yam root/Shan Yao (Dioscorea opposita)
-wild yam root (rhizome)/Chuan Shan Long (Dioscorea hypolglauca, Dioscorea nipponica)
-sweet geranium (aerial parts)/Lao Guan Cao (Erodium stephanianum, Geranium hunbergii)
-galangal (lesser) rhizome/Gao Liang Jiang (Alpinia officinarum)
-ox gall bladder/Bai Niu Dan
-borneol/Bing Pian
To the unaided eye, yunnan baiyao appears to be a uniform tan colored powder with a sweetly pungent odor. Microscopic examination reveals a granular nature to the powder, with brown or reddish particulate matter included (15). A 10 mg/ml water-based solution of yunnan baiyao yields a pH of 4.7, and biochemical tests have revealed high concentrations of polysaccharides (starch 97.4%) and elemental calcium (1%) in the yunnan baiyao powder (14,15).
How does Yunnan Baiyao affect hemostasis?
Normal hemostasis requires platelet function to form an initial platelet plug (primary
hemostasis), and functional coagulation factors (intrinsic and extrinsic coagulation athways) forming fibrin to stabilize the platelet plug (11). The platelet function, and therefore the ability of the body to perform primary hemostasis, is evaluated clinically by analyzing platelet numbers, platelet aggregation and the buccal mucosal bleeding time (BMBT), also known as template bleeding time (TBT). The efficacy of the coagulation factors, and therefore the intrinsic and extrinsic coagulation pathways, is evaluated by activated coagulation time (ACT), activated partial thromboplastin time (APTT) and prothrombin time (PT). The role of these normal mechanisms is important to prevent excessive blood loss and the subsequent consequences (23,24,26).
Historically, when faced with significant ongoing blood loss, equine practitioners have resorted to intravenous formaldehyde in non-sedated and anesthetized horses (7,16). This technique is not proven to have significant effects on coagulation variables and is associated with dose-dependent side effects in standing, awake horses (21). Regional injection of formalin has been used to stop bleeding and cause sloughing of large, vascular lesions in horses (8). This technique has also been reported to cause significant side effects (4). Therefore, other clinically simple, inexpensive and effective options to minimize blood loss would be ideal.
Herbal therapies can be used to augment hemostasis when necessary. Yunnan baiyao is one
Chinese herbal formula reported to stop bleeding or minimize blood loss in a variety of species (3,6,18,20), including humans. This herbal formula was even carried historically by foreign soldiers as a traumatic hemostatic agent (12,15). In the author's experience, use of yunnan baiyao has allowed patients to return home earlier than without any hemostatic therapies. Preoperative use of yunnan baiyao may decrease the need and the cost for blood products. This would decrease the potential difficulties and sideeffects of blood replacement and minimize the physiological stresses associated with blood loss (23,24).
Many studies have confirmed the positive hemostatic effects of yunnan baiyao. A variety of traditional mechanisms for the positive hemostatic actions of yunnan baiyao have been proposed, including shortened bleeding times (5,13,14), an increased permeability of platelet membranes resulting in a release of platelet constituents (1,2), and shortened clotting times (10,13,14). Primary hemostasis of small vessels involves platelet function, not the coagulation factor cascade, in the formation of the platelet plug. In vitro rat platelets have been shown to degranulate in a dose-related fashion in the presence of filtered extracts of yunnan baiyao, perhaps by increasing the permeability of the platelet membrane (1,2). This action during platelet release has long been recognized as one of the mechanisms of action of platelet function inducing blood coagulation (11). Clinically,
(buccal or template) bleeding times are an indicator of platelet function in the role of primary hemostasis.
The effect of yunnan baiyao on the platelet function decreased the time needed for primary hemostasis, as indicated by the shortened bleeding times from incised liver lobes after in vivo, topical administration of yunnan baiyao in pentobarbitone anesthetized rats (13). Preoperative, oral administration of yunnan baiyao to rats also resulted in decreased bleeding times from incised liver lobes within 1 hour of administration and these effects lasted for a minimum of four hours (14). Another study demonstrated that preoperative, oral administration of yunnan baiyao caused a significant decrease in the template
bleeding time in healthy ponies under halothane anesthesia (5). This confirms that the positive hemostatic action of yunnan baiyao occurs, in part, via an effect on the platelets (primary hemostasis).
The formation of fibrin involves the cascade of coagulation factors and mediators, allowing
the platelet plug (formed during primary hemostasis) to be stabilized. The clotting time allows practitioners to easily assess the function of the intrinsic and common pathways of the coagulation cascade. In vitro clotting test using bovine blood demonstrated a reduction in clotting time associated with the use of yunnan baiyao (10). Topical administration of yunnan baiyao decreased the in vitro clotting times in blood taken from pentobarbitone anesthetized rabbits and awake humans (13). A dose- related shortening of in vivo clotting time was seen within 30 minutes after preoperative, oral administration in pentobarbitone anesthetized rabbits, and these effects lasted for a minimum of fourhours (14). In addition to augmenting primary hemostasis, the hemostatic effects of yunnan baiyao may be related to pathways of the coagulation cascade, as indicated by shortened clotting times in these
studies.
Other proposed mechanisms for the hemostatic effects of yunnan baiyao include peripheral
vasoconstriction (13,14), a particle/precipitant effect of the polysaccharide base (13,14), or a calcium mediated effect (13). The high levels of starch and calcium may partially account for the hemostatic effects of yunnan baiyao, especially when applied topically. To simulate this action of yunnan baiyao, the effect of starch and starch plus calcium solutions were tested on bleeding times and clotting times in two studies. Neither topically administered starch (13), nor orally administered starch (14), at an equivalent dose (by weight), caused a decrease in bleeding times in rats. Topically administered starch plus calcium did shorten the bleeding time in rats (13). In the same study, topically administered yunnan baiyao
caused a greater shortening in bleeding time (in vivo) compared to topical administration of starch plus calcium (13). Also, yunnan baiyao significantly shortened the in vitro clotting time in rabbit blood and human blood when compared to starch or starch plus calcium (13). Therefore, it is unlikely that the high levels of starch and calcium, contained in commercially available yunnan baiyao, significantly account for the hemostatic actions when administered orally or topically.
Yunnan baiyao is also thought to have antimicrobial and anti-inflammatory properties
(9,20,25,27), although these claims are debated (15). Arasaponin A/B and dencichine, reported to be in the primary components of yunnan baiyao, have anti-inflammatory effects according to one study (28).
However, clinical trials evaluating the analgesic effects of this herbal formula have not been published in the Western literature. Another study showed in vitro cytotoxic effects of some of the saponin extracts of yunnan baiyao, leading to the possibility of anti-neoplastic effects (16). Anti-neoplastic effects have not been evaluated in vivo, to the author's knowledge.
In terms of Traditional Chinese Medicine (TCM), yunnan baiyao stops bleeding by removing or dispersing stagnant blood, which blocks vessels and obstructs the normal path of blood flow. It also tonifies, invigorates and regulates blood via the Liver (9,22,19).
The positive hemostatic effects of yunnan baiyao are well documented, and although the exact mechanism remains unclear, an augmented platelet effect seems to play a role. The oral and/or topical (in vivo) administration of yunnan baiyao to rats, rabbits and horses has not been associated with adverse side effects in studies (5,14). However, long-term effects of chronic yunnan baiyao use have not been described in Western medical terms (18,19). Chronic use of yunnan baiyao is not recommended, as it could exhaust the Fire and/or Yin of the individual. The author has used longer term, pulsed therapy (ie 1 week on, 1 week off; 4 days on, 3 days off; dosing M-W-F only, etc.) when necessary, especially if no
other viable options are feasible. Mild to moderate elevations in liver enzymes (ALP, ALT, AST) have been anecdotally reported with long term use of yunnan baiyao. However, these patients often have received multiple other traditional or non-traditional therapies, or have diagnoses that in and of themselves can be associated with elevations in liver enzymes.
How is Yunnan Baiyao used?
Yunnan baiyao has been used clinically, both orally and topically, in everything from birds to
elephants. It has been useful for (but not limited to) internal and external bleeding tumors, sheared nails/hooves, surgical bleeds, epistaxis/nasal procedures, gastrointestinal hemorrhage, abdominal trauma, disseminated intravascular coagulation (DIC), avian bumblefoot, VWD and/or thrombocytopenic patients, aural hematomas, oral/dental surgery and spays in estrus.
As with many herbal therapies, dose ranges of yunnan baiyao are poorly defined and widely
variable. Dosing is often 'to effect' and may vary depending on the cause of the bleeding. The following dose recommendations have been gathered from a variety of sources, including VIN postings, the CAVM list discussions, textbooks and continuing education talks:
Dog: open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
one (250 mg) capsule per 10 kg, once to twice a day
one capsule per 5 kg daily, given as divided doses, if possible
- tsp per 5-7 kg, OR 60-75 mg/kg, at least once a day
75-100 mg/kg daily, given as divided doses
30 = 2 capsules P.O. three times a day
Cat: open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
- -1 capsule P.O. twice a day, adjusting appropriately
Horse (500kg): open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
1 bottle (4 gm), or 16 capsules, P.O. three times a day as an oral slurry in water
2 bottles P.O. twice a day for six days, then 1 bottle twice a day for six days
Birds (400-1000gm):open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
one (250 mg) capsule dissolved in water, given by oral gavage, once a day
How do I get Yunnan Baiyao?
Yunnan baiyao is a widely available herb, via mail order or in local Asian markets and health
food/co-op stores. When purchasing Chinese herbal formulas, it is important to buy from reputable retailers; the quality and contents of herbal formulas can vary greatly and heavy metal contamination is a very real possibility.
Yunnan baiyao is an inexpensive herb. It is available in foil sheets of 16 gelatin capsules (250mg each), with 5 sheets in a box. This box costs less than US$10 from most retailers. It is also available in 4 gm bottles of loose powder, which are equivalent to one foil sheet of 16 capsules (9,12,22). Each 4 gm bottle or each foil sheet of 16 capsules comes with one small, red 'safety pill' which is about the size of a peppercorn. This very potent form of yunnan baiyao, called Bao Xian Zi [or 'insurance pill for a serious or emergency case' (12)] is equivalent to one 4 gm bottle or 16 capsules of yunnan baiyao. It is unclear as to whether the ingredients of this 'safety pill' are exactly the same as the yunnan baiyao capsules. One
reference notes that the components are different, but does not state what those components are (12). Research on the Bao Xian Zi is not documented in the Western literature (searches via PubMed, Medline, etc).
Summary
Yunnan baiyao is an inexpensive, patent Chinese herb known for its positive hemostatic effects in the face of active hemorrhage. A variety of traditional mechanisms for the action of yunnan baiyao have been proposed, including shortened bleeding time, shortened clotting times, reduced capillary permeability, peripheral vasoconstriction, an increased permeability of platelet membranes resulting in a release of platelet constituents, a calcium mediated effect, or a particle/precipitant effect. Most studies seem to indicate an enhanced platelet (primary hemostasis) or coagulation factor effect. Some of these mechanisms and the contents of yunnan baiyao are defined by research, but many open questions remain regarding its use in companion animals. Preoperative use of yunnan baiyao may decrease the need and the cost for blood products. This could decrease the potential difficulties and side effects of blood replacement and minimize the physiological stresses to the patient and the veterinary staff associated with blood loss.
References:
1. Chew EC (1977a) Effects of yunnan bai yao on blood platelets: an ultrastructural study. Comparative
East and West 5:2, 169-175
2. Chew EC (1977b) Yunnan bai yao -induced platelet release in suspensions of washed platelets.
Comparative Medicine East and West 5:3-4, 271-274
3. Fratkin J (1992) Chinese Herbal Patient Formulas: a practical guide (5th printing). Shya Publications, Boulder CO, USA; 33
4. Frees KE, Gaughan EM, Lillich JD et al. (2001) Severe complication after administration of formalin for treatment of progressive ethmoidal hematoma in a horse. J of the Amer Vet Med Assoc 219:7, 950-952
5. Graham L, Farnsworth K, Cary J (2002) The effect of yunnan baiyao on the template bleeding times and activated clotting times in healthy ponies under halothane anesthesia. Journal of Veterinary
Emergency and Critical Care 12:4; 279; 2002 (abstract only)
6. Hsu K (1974) Common Chinese Herbal Drugs (2nd edn). Commercial Press, Hong Kong, 98-100
7. Jones W (1998) IV Formalin to control hemorrhage. J Eq Vet Sci 18, 581
8. Marriot MR, Dart AJ, Hodgson DR. (1999) Treatment of progressive ethmoidal haematoma using intralesional injections of formalin in three horses. Aust Vet J 77, 371-373
9. Maclean W, Tayler K (2000) The Clinical Manual of Chinese Herbal Patent Medicines. Pangolin
Press, Donnelly, NSW, Australia; 262-3
10. Monke DR (2000) Evaluating the efficacy of yunnan paiyao. The Meridian-Newsletter of the American Academy of Veterinary Acupuncture 2:4, 6
11. Mustard JF, Packham MH (1970) Factors influencing platelet function: Adhesion, release and aggregation. Pharm Rev 22, 97
12. Naesser MA (1990) Outline Guide to Chinese Herbal Patent Medicines in Pill Form. Boston Chinese
Medicine, Boston, MA, USA; 244-5
13. Ogle CW, Soter D, Ma JCN (1976) The haemostatic effects of the chinese herbal drug yunnan bai yao: a pilot study. Amer J Chin Med 4:2, 147-152
14. Ogle CW, Soter D, Cho CH (1977) The haemostatic effects of orally administered yunnan bai yao in rats and rabbits. Comparative Medicine East and West 5:2, 155-160
15. Polesuk J, Ameodeo JM, Ma TS (1973) Microchemical Investigation of Medicinal Plants. X. Analysis of the Chinese Herbal Drug Yunnan Bai Yao. Mikrochim Acta 4, 507-517
16. Ravikumar PR, Hammesfahr P, Sih CJ (1979) Cytotoxic saponins from the Chinese herbal drug Yunnan Bai Yao. Journal of Pharm Sci 68:7, 900-3
17. Roberts SJ (1943) The effects of various intravenous injections on the horse. Amer J Vet Res 4, 226-239
18. Schoen A (2001) Principles of Veterinary Acupuncture; 2nd edition, Mosby, Philadelphia, PA, USA
19. Schoen A, Wynn S (2000) Complementary and Alternative Veterinary Medicine (1st edn). Mosby, Saint Louis, MO, USA; 655, 668
20. Schwartz C (1994) Chinese Herbology in Veterinary Medicine. In: Veterinary Acupuncture (1st edn). Schoen A (ed). Mosby, Saint Louis, MO, USA; 695, 697
21. Taylor EL, Sellon DC, Wardrop J et al. (2000) Effects of intravenous administration of formaldehyde on platelet and coagulation variables in healthy horses. Amer J of Vet Res 61:10, 1191-1196
22. Tierra M (1998) The Way of Chinese Herbs. Pocket Books-Simon & Schuster, 363
23. Trim CM, Eaton SA, Parks AH (1997) Severe nasal hemorrhage in an anesthetized horse. J Amer Vet Med Assoc 210:9, 1324-1327
24. Wagner AE, Dunlop CI (1993) Anesthetic and medical management of acute hemorrhage during surgery. J Amer Vet Med Assoc 203:1, 40-45
25. Wang (1994) Histological study on repairing experimental pulp chamber floor perforations with yunnan bai-yao in the dog. Zhongguo Zhong Xi Yi Jie He Za Zhi 14:6, 357-359 (abstract only in English)
26. Wilson DV, Rondenay Y, Shance PM (2003) The cardiopulmonary effects of severe blood loss in anesthetized horses. Vet Anaesth Analg 30:2, 80-86
27. Wynn SG, Marsden S (2003) Manual of Natural Veterinary Medicine-Science and Tradition. Mosby, Saint Louis, MO, USA; 181, 219, 276, 285-6, 416, 428, 437
28 Yang T (1986) Anti-inflammatory effects of the saponins in yunnan bai-yao. Zhonong Yao Tong Bao 11:2, 47-50 (abstract only in English)
29 Yunnan Baiyao (package insert); produced by Yunnan Paiyao Group Co, Ltd.; exported by Yunnan Medicines and Health Products Import and Export Corp, China
30. Yunnan Paiyao herbal supplement (package label); Camellia Brand manfuctured by Yunnan Paiyao Group Co, Ltd, Kunming, China; distributed by Solstice Medicine Company, Los Angeles, CA; www.sosusaco.com
What is the dose of Yunnan Baiyao?
(Compiled from Yunnan baiyao-where's the clinical evidence?' c. 2006 presented at the 2006 SAVMA
Symposium; Lynelle Graham, DVM, MS, Diplomate ACVA; University of Minnesota College of Veterinary
Medicine, Department of Veterinary Clinical Sciences)
A variety of traditional mechanisms for the action of yunnan baiyao have been proposed,
including shortened shortened bleeding time, shortened clotting time, reduced capillary permeability, peripheral vasoconstriction, an increased permeability of platelet membranes resulting in a release of platelet constituents, a calcium mediated effect, or a particle/precipitant effect. Most studies seem to indicate an enhanced platelet (primary hemostasis) or coagulation factor effect. Yunnan baiyao has been used clinically, both orally and topically, in everything from birds to elephants. It has been useful for (but not limited to) internal and external bleeding tumors, sheared nails/hooves, surgical bleeds, epistaxis/nasal procedures, gastrointestinal hemorrhage, abdominal trauma,
disseminated intravascular coagulation (DIC), avian bumblefoot, VWD and/or thrombocytopenic patients, aural hematomas, oral/dental surgery and spays in estrus.
As with many herbal therapies, dose ranges of yunnan baiyao are poorly defined and widely
variable. Dosing is often 'to effect' and may vary depending on the cause of the bleeding. The following dose recommendations have been gathered from a variety of sources, including VIN postings, the CAVM list discussions, textbooks and continuing education talks:
Dog: open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
one (250 mg) capsule per 10 kg, once to twice a day
one capsule per 5 kg daily, given as divided doses, if possible
- tsp per 5-7 kg, OR 60-75 mg/kg, at least once a day
75-100 mg/kg daily, given as divided doses
30 = 2 capsules P.O. three times a day
Cat: open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
- -1 capsule P.O. twice a day, adjusting appropriately
Horse: open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
1 bottle (4 gm) P.O. three times a day with water
2 bottles P.O. twice a day for six days, then 1 bottle twice a day for six days
Birds (400-1000gm) open capsule and sprinkle on superficial wounds, bleeding tumors, etc.
one (250 mg) capsule dissolved in water, given by oral gavage, once a day