Let's Talk About Dosage: Granules

Dosing your formulas correctly is one of the most important factors in generating consistently good clinical outcomes. A perfect pattern diagnosis with the exact combination of herbs to treat it can fall desperately short of effective if the dose of each ingredient or the whole formula is off. So how do you decide what is an appropriate dose for any individual herb or even the total dosage of herbs for a patient? There are different things to consider when building a formula from granule herbs versus from bulk herbs, so let’s look at a couple of important factors for granule herbs:

1.) There is not a consistent relationship between weight and volume for granules produced by different manufacturers

Infosheet showing the weight to spoon conversion box

Our pharmacy uses a variety of different granule companies who have various manufacturing practices that result in granules that have variable weight and volume relationships (i.e. some grains of granules from one company could be bigger, or heavier, or both than some others). What that means practically is that there is no consistent weight to volume relationship for any formula that is filled in a pharmacy that uses granules from multiple manufacturers, and so, at Root & Branch we measure out the dosage for every bag of herbs and count the number of level spoons that it takes to hit that dosage weight. Using that method, we make sure that patients have a reasonable idea of how much herb to take in an easy way (using those little plastic spoons which, in our clinic, are about 1/2 teaspoon). But you can imagine that a "level spoon" is not as exact a measurement as weighing something in grams and varies sometimes widely from person to person by what they consider to be a "level" spoon. Fortunately, that difference results in a fairly consistent 0.5 spoon margin of error for any dosing done using spoons instead of the much more exact method of weighing the dosage. If having the truly exact weight for every dose is important for a super sensitive patient or for some pediatric clients, then the patient should use a scale to weigh their dose. But for the vast majority of users, spoons work just fine, as long as they check the dosage on the bag they got from us and use that conversion from grams to spoons that we include with every formula we fill. 

A lot of this confusion comes from the idea that there is a single weight to volume relationship as in 1 level spoon = 1 gram of granules, which is definitely not true universally and is only sort of true for the granules produced by the same company (that is, 1 level spoon of evergreen ci shi might weigh 1.25g while 1 level spoon of bai zhu might be 1g). To illustrate that variation, consider the following example: Evergreen herbs could give you a spoon for their herbs and say that 1 level spoon of evergreen brand herbs weighs one gram (which it mostly does), but that same evergreen spoon of Treasures of the East granules might in fact weigh 1.5g and if you mix ingredients from evergreen and ToE, that level spoon might weigh 1.25g. Hence the confusion, and why we weigh each bag's dose.

Also, it’s worth noting that even from bag to bag of the same formula, the weight to spoon ratio could vary. Let me say first that most of the time the weight and number of spoons for the same formula remains the same from bag to bag, but sometimes the granule lot or manufacturer can change between one order and the next, which could result in a change in the number of spoons written. Often that variation is just 0.5 level spoons but can be as much as 2 spoons depending on total dosage, granule density, and specific herb choice. It's why we include paperwork with every order and we have a stamp on every bag of herbs that shows the conversion from weight to volume (spoons) for that specific bag of herbs.

What matters most in our pharmacy then, is that when you build your formula, you use the input boxes to tell us how many grams, how many times per day, and for how many days, and then we will build that formula, weigh out that dosage in a spoon equivalent and note in on the paperwork and on the bag of herbs so that the patient knows how many spoons to take for that bag of herbs. So long as your inputs about grams, times per day, and total days are how you want it, we'll do the work of making sure the patient knows how many scoops that information is equivalent to.

2.) Dosing Individual Herbs Should Begin with Time-Tested Formulations

One of the many reasons that Chinese medicine is a powerful diagnostic and treatment framework is rooted in the medicine’s age. It’s not only that people have been practicing versions of Chinese medicine for thousands of years but that in all of that time, the medicine has been consistently peer-reviewed. Hundreds of commentaries on classic texts and then commentaries on the commentaries have been written over the centuries. So start your dosing with the tried and true dosages. Use the Bensky or the Chen Materia Medica as a starting point and then make your modifications.

If you are using Root and Branch’s HerbaScript system, you can actually write your granule formula using bulk ratios and the system will automatically do the math to determine how many grams of granules you will need for each ingredient. No more need to do the math yourself.

3.) Standard Granules Dose for Adults in the United States is 12 to 18 grams per day

I know you’ve heard a lot about the concentrated potency of granule herbs. They’re 5:1 ratios you might have heard. Wow! so potent!. Well, sort of. Firstly, the exact ratios for each individual herb will vary based on the specifics of that botanical. Some herbs cannot be concentrated to that level without damaging their components with heat or pressure (think bo he or sha ren). Some do not truly dissolve or even fully extract in a solo setting (think long gu or mu li). So the 5:1 becomes a standard number you read about, and it’s mostly true, but not always so.

Next, what does that concentration really mean? I would challenge you to take 5 grams of bulk jing jie and decoct it and drink it side by side with 1g of jing jie granules (from any manufacturer). They are not the same. Not even close. Hands down. NOT. THE. SAME. And not because the granules are more potent. Nope. Bulk wins EVERY TIME. With some of the most bitter herbs like huang lian or long dan cao, you can get a close approximation of bitterness but any of the other more nuanced flavors of the herb are undetectable in the granule. This test alone should give anyone pause who thinks that the concentration ratios reflect a similar concentration in nature and flavor. Go ahead and try it with any herb you can think of…

So if usual bulk dosage per day looks like 40-65g and a usual granule dosage per day looks like 12-18g per day, then your across-the-board ratio is more like 3.5:1. Use that ratio in your side-by-side taste test and you will get closer to the truth, but not always. It’s better to think of dosing granules as their own entity then thinking about what is a conversion dose from bulk herbs. They are made from the same botanicals, but they are NOT variations of the same thing.

Of course, you need to modify this dosage for people who are particularly slim bodied or people with larger builds; for people who are digestively sensitive; for adolescents and small children; for acute vs chronic disease. There are a lot of reasons why the dosage per day might less than 12-18g, but concentration ratio is not one of them.

4.) Think of Your Dosage in Terms of Ratios

9 parts chai hu to 6 parts huang qin to 6 parts ban xia to 3 parts ren shen. These are some of the dosages/ratios used in a standard version of Xiao Chai Hu Tang. If you were writing a bulk formula, you might use the numbers as grams per day for each herb, but as a granule formula, these numbers represent the relationships between the herbs in the formula. With that kind of a framework you can boost the parts of huang qin to 12 if there is more pronounced heat in the upper jiao. You could reduce the chai hu to 6 parts if you are worried about long term administration zapping the patient’s Yin while increasing the Ren Shen to tonify more heavily.

Write your granule formula in HerbaScript using these whole numbers, these ratios of one herb to another. Then tell the system that you want your patient to take 6g, 3 times per day and the software will build the exact number of grams of granules to dose the patient according to your parameters using the ratios you typed into the formula builder. No more fiddling with math and concentration ratios to try and build a custom formula. Let the tech help you work more efficiently!