Asthma Complementary Therapies

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Asthma- Complementary Therapies

• Kathi J. Kemper, MD, MPH
• Caryl J Guth Chair for Holistic and Integrative
  Medicine
• Professor, Pediatrics
• Wake Forest University School of Medicine
• Instructor, Harvard Medical School

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By the end of this talk, participants will be
able to

• Describe an integrative model of therapeutic
  options for asthma
• Describe the safety and effectiveness of herbs,
  dietary supplements and other complementary
  therapies for asthma
• List two evidence-based sources of information
  about CAM for asthma

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Asthma CAM Case

• Amy Wong is 15 yo who is tired of taking meds and
  would like to try alternative medicine. She
  admits she stopped using her steroid inhaler
  about a month ago. She wants to know about
  Traditional Chinese Medicine (herbs such as
  ephedra and acupuncture). Or breathing exercises,
  or meditation. Shes not really sure.

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CAM in Pediatric Asthma

• Brooklyn 80, diet (avoidance), massage, prayer
  (Dinkevich. Peds Res, 2003)
• Bronx gt 70, rubbing ointments (Vicks), prayer,
  massage, syrups, teas, foods (Reznik, Peds Res,
  2003)
• Texas 81 , prayer, herbal teas, vitamins,
  massage (Mazur. 2001)
• CAM most common in those with more serious
  illness, females, higher SES and education
  ethnic groups other than African American Whites
  most like to tell MD (Rivera, Ann Pharmacother,
  2004)

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Why do patients choose CAM?

• Values (natural, organic, humanistic), cultural
  factors, and view of life (empowerment,
  egalitarian) MUCH MORE than
• Dissatisfaction with mainstream care
• Side effects from mainstream care
• Wanting to know theyd tried everything
• Astin, JAMA, 11/98

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Integrative Approach to Therapeutic Options for
Asthma

• Biochemical
• Lifestyle
• Biomechanical
• Bioenergetic

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Biochemical

• Medications (not for this lecture!)
• Dietary Supplements herbs, vitamins, minerals,
  fish oil
• Anti-inflammatory
• Bronchodilator / Smooth muscle relaxation
• Demulcents
• Others

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US FDA regulations DS

• 1. Supplements can be marketed without testing
  efficacy.
• 2. Safety need not be proved before marketing.
  Burden is on FDA to prove product is unsafe.
• 3. Standards not required for manufacture.
• 4. Structure/function product claims allowed.
• 5. Label claims do not require extensive
  evidence.
• 6. FDA approval not needed for marketing claims.

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AVOID Patent Medicines

• Heavy metals - lead, mercury, cadmium
• Toxins - arsenic
• Pharmaceuticals - steroids, antibiotics,
  hypoglycemic agents, antihistamines, etc.
• gt 30 - 40 contaminated

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Anti-inflammatory herbs and supplements - Overview

• Fish oil
• Licorice
• Vitamin C
• Butterbur

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Omega 3 fatty acids fish oil!

• Tend anti-inflammatory side of leukotriene
  production fish oil better than flax oil,
  walnuts or algae
• Reduced asthma symptoms with fish twice weekly
  for at least 9 months
• Less asthma (OR0.2) in kids if moms eat fatty
  fish monthly during pregnancy (Salam. J Asthma,
  2005)
• RCT 5.2 gms EPADHA, helped with EIB and reduce
  bronchodilator use (Michelborough. Chest, 2006)
• GRAS if less than 3 grams daily side effects
  mostly GI and esthetic no mercury concern

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Licorice root

• Traditional use for coughs in TCM
• Glycyrrhizin inhibits 11-beta-hydroxoysteroid
  dehydrogenase
• Approved by German Commission E
• Chronic use -gt edema and hypertension
• Contraindicated in DM, HBP, Liver, renal disease,
  hypokalemia pregnancy
• Use for lt 6 weeks
• No trials in kids or adults with asthma!
• NOT anise

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Vitamin C

• Antioxidant intake higher in non-asthmatics and
  higher FEV1. (Fonastiere 2000 Gilliland Am J
  Epid, 2003)
• Reduces reactivity to methacholine, effect
  blocked by indomethacin. (Mohsenin 1983)
• 1 gram daily Vit C decreases EIB Spares steroid
  use in adults (Cohen Arch Pediatr Adolesc Med,
  1997 Anah 1980 Fogarty. Respir Med, 2006)
• Block ozone-mediated exacerbations (Grievink
  1999 Freed 1999)
• Cochrane review of 6 RCTs evidence insufficient
  to rec Vitamin C b/c most studies small and
  brief usual dose is 500-1000 mg/daily

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Vitamin C

• Intake (mg/day) saturation
• 60 30
• 100 72
• 200 86
• 400 91
• 1000 100

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Butterbur (Petasites hybridus)

• Active ingredients, petasins, inhibit leukotriene
  synthesis reduce histamine release RCTs for
  migraine and allergies
• Unsaturated pyrrolizidine alkaloids
  teratogenic, hepatotoxic (some UPA-free products
  are available)
• Typical dose 50 -100 mg bid qid with meals
  NOT standardized
• Two trials suggest benefits in patients on
  inhaled steroids (Danesch, 2004 Lee, 2004)

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Bronchodilators Coffee

• NHANESII Regular coffee drinkers had 0.71 risk
  of asthma compared with non-drinkers dose-effect
  observed (Schwartz. Ann Epid, 1992)
• Italian studies show significantly less asthma in
  2 cup/day coffee drinkers
• Mechanism? XANTHINES like theophylline

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Ephedra/ Ma huang product variability

• Contains L-ephedrine (80) D-pseudoephedrine
  less effective than terbutaline or albuterol
  more side effects
• 20 products tested
• 5/20 contained norpseudoephedrine, a class IV
  controlled substance
• Two contained 17 and 31 of listed alkaloids 6
  contained more than 100 of product label
• Lot to lot variability 44-1000
• Cardiac deaths from high doses limit use FDA
  limited sales

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Magnesium and Asthma

• Dietary magnesium intake is independently
  related to lung function and the occurrence of
  airway hyper-reactivity and self-reported
  wheezing in the general population.
• J Britton, et al. Lancet, 1994344357-62

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Magnesium

• Smooth muscle relaxant attenuates neutrophil
  respiratory burst and stabilizes mast cells
• Higher dietary intake linked to higher FEV1 and
  lower airway reactivity
• ED given iv or by nebulizer (Cochrane Database
  Systematic Review, 2005) most ED docs know it
  works, but lt 5 use it.
• ? Effect of long-term oral supplementation in
  children

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Magnesium Sources
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Demulcent herbs

• Coltsfoot (Tussilago farfara) NOT for long-term
  use b/c UPA
• Marshmallow (Althaea officinalis)
• Mullein no studies
• Slippery elm bark - safe
• Wild cherry safe, placebo?

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SUMMARY Herbs/ Supplements

• Eat fish, fruits, vegetables, beans, bran
• Consider coffee
• Avoid TCM pills, ephedra
• Avoid long-term use of any herbs
• Watch for future research

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Resources on Herbs and Supplements

• Natural Medicines Comprehensive Database
  http//www.naturaldatabase.com/
• Clinical Pulmonary Medicine, 2005 Kemper, Singla
  and Gardiner
• https//northwestahec.wfubmc.edu/learn/herbs_ce/?p
  ricing_tierspecialpricing_code2095

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Lifestyle

• Nutrition breastfeed, fish, onions, fruits,
  vegetables, beans less salt
• Exercise do it
• Environment clean it ,dont smoke
• Mind-Body Therapies manage stress

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Nutrition

• Breastfeeding is protective (Oddy, 2004)
• Onion extracts reduce bronchospasm in guinea pigs
  and reduce inflammation in vitro
• Decreasing salt may help with EIB (Mickleborough,
  2004)

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Environment

• No smoking active or passive
• Clean house (Morgan. NEJM, 2004 HELPS if you
  reduce dust-mite, cockroaches, indoor allergens)
• Minimize exposure to sick kids, allergens,
  triggers such as sulfites, ozone, CO, nitrogen
  dioxide, PM (Tolbert PE Am J Epid, 2000 Gent,
  JAMA, 2003McConnell R. Am J Respir Crit Care
  Med, 2003 Goldsobel, Pediatrics, 2004
  Gauderman, NEJM, 2004)
• Air filters? Yes (McDonald. Chest, 2002)
• Bed covers? No? (Woodcock. NEJM 2003)
• Advocate for clean air, less polluting vehicles

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Exercise

• Skiers and ice skaters have very high rates of
  EIB.
• They can still compete successfully in Olympics
• Keep moving!

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Breathing exercises

• Yoga. Pranayama.
• Inspiration to Expiration time 12. Eg. count to
  5 breathing in and count to 10 breathing out.
• Slow, deep breaths.
• Daily, paying attention
• Buteyko Breathing techniques

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Buteyko techniques

• Buteyko (Russian MD) belief that asthma patients
  over breathe
• Breathing Technique
• Trained teachers
• Nose breathing only watch self in mirror
  self-awareness
• Sustained shallow breathing, to feel air hungry
  for increasing amounts of time
• Increase control pauses at end of expiration
• Increase length of expiration past discomfort
  thru distraction
• Practice 20 minutes twice daily
• (Cooper. Thorax, 2003)

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Stress

• Physiology psycho-neuro-immunological effects
• Tends to increase inflammation, increase IgE
  production, imbalance inflammatory cytokines
• Tends to increase bronchoconstriction
• Diminishes expression of the glucocorticoid and
  beta(2)-adrenergic receptor genes in children
  with asthma (Miller. Proc Natl Acad Sci USA,
  2006)
• Adverse life events linked to more asthma acute
  stressful tasks worsen bronchoconstriction
• Therefore, MANAGE STRESS

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Mind-Body therapies

• Hypnosis, yes (Anbar, 2002, 2005)
• Autogenic training, yes (German)
• Biofeedback, yes (Lehrer. Chest, 2004, 2006)
• Meditation, yes, e.g., yoga improves ARQL, POMS,
  methacholine challenge (Manocha. Thorax, 2002)
• Journaling (Warner LJ. J. Pediatric Psychology,
  2005)
• STRESS MANAGEMENT Cost issues. Time.
  Self-efficacy (Frieri, 2003Huntley. Thorax,
  2003 Hockemeyer, 2002)

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Biomechanical

• Massage
• Cranial, spinal or joint adjustment no
  significant benefits in 3 RCTs

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Massage

• Very common home remedy for asthmatics. Often
  combined with rubs (Vicks Vapo-Rub) (Reznick.
  APAM, 2002)
• Asthma (Field. J Pediatr, 1998132(5)854-58)
• Reduce stress?
• Enhance social support
• Relaxation immunomodulator (Th1 vs Th2 balance?)

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Bioenergetic

• Acupuncture
• Healing Touch/TT/Reiki/Qi Gong
• Prayer/Spirituality
• Homeopathy

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Acupuncture for ASTHMA

• Not sole therapy for asthma in China
• Effective? Controversy
• MAY help with subjective dyspnea, breathlessness,
  sleep, overall well-being, QOL (Lewisth. Chest,
  2004 Wu HS, 2004 Maa SH. 2003)
• Safety
• Acceptable for sick kids (Kemper. Pediatrics,
  2000 Kemper, et al. Clinic Pulm Med, 2004)

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Therapeutic and Healing Touch

• Subjective improvement
• Case histories
• No RCTs
• Safe
• Not sole treatment!

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Homeopathy

• Positive case reports
• One RCT homeopathy and 96 asthmatic kids showed
  NSD, ceiling effect? (White. Thorax, 2003)
• Very safe as long as not used as rescue medicine
  for acute attacks

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Resources

• http//www.holistickids.org/teaching_toolbox/asthm
  a.html
• http//www.besthealth.com/IntegratedMedicine/
• http//www.naturaldatabase.com/
• http//naturalstandard.com

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Summary

• Healthy lifestyle, including diet rich in omega
  three fatty acids, fish, onions, anti-oxidants,
  magnesium, vitamin C, and possibly caffeine low
  salt
• Herbs are not replacement for steroids more
  research needed
• Clean environment no smoke
• Comforting therapies and stress management
  (massage, meditation) underutilized