Complementary and Alternative and Medicine for Asthma

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Complementary and Alternative and Medicine for
Asthma

• Kathi J. Kemper, MD, MPH
• Caryl J Guth Chair for Holistic and Integrative
  Medicine
• Professor, Pediatrics
• Family and Community Medicine and
• Public Health Sciences

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

• Describe an integrative model of therapeutic
  options to treat asthma
• Compare and contrast two models for testing
  treatment effectiveness
• List three herbs or dietary supplements widely
  used to treat asthma/allergic conditions
• List two evidence-based sources of information to
  learn more about CAM for asthma/allergies

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Adolescent Asthma

• Irene Wong is 15 yo with moderately severe
  asthma. She had 1 ER visit last year. She is
  tired of taking medications and would like to try
  Traditional Chinese Medicine. She admits she
  stopped using her steroid inhaler about a month
  ago.

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Cultural cough remedy

• A mother from the Dominican Republic tells you
  that she prefers home remedies to medications,
  but she values your opinion. What do you think of
  the bottle of Bronquila she brought you? Is it
  safe? Will it interfere with cromolyn?

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Complementary, Alternative and Mainstream
Therapies
Alternative
Mainstream
Complementary
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CAM - Adult Epidemiology,

• In late 1990s, 42 of adult Americans had used
  CAM
• Only 40 talked with docs about CAM same for
  peds
• Numbers are increasing
• Highest use in white, affluent, educated chronic
  illness
• Eisenberg, JAMA, 1998

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CAM in kids

• ADHD 32 (Chan, 03)
• IBD 41 (Heuschkel, 2002)
• Cancer 65 (Friedman, 1997)
• Cystic fibrosis 66 (Stern, 92)

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Puerto Rican asthma remedies

• Interviews of 118 Puerto Rican children with
  asthma in Connecticut
• Maintain balance and harmony religious
  practices herbs
• Siete Jarabes sweet almond oil, castor oil,
  tolu, wild cherry, licorice, cocillana, honey
• Expectorants, emetics, cathartic, demulcents
• Pachter LM, et al. Arch Pediatr Adolesc Med,
• 1995149 982-88

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CAM in Asthma

• Asthma and allergies are both in top 10 ailments
  for which adults use CAM
• UK kids 33 had used CAM homeopathy (15),
  breathing exercises (15) herbs (6)
• Turkish asthmatics 49 used CAM quail eggs,
  herbs, wild honey (Orzhan, 2003)
• Australian asthmatic kids 50-55 Vitamins,
  Herbs, Massage, Diet, Relaxation (Andrews. 1998
  Shenfield, 2002)
• Brooklyn kids 80 diet (avoidance), massage,
  prayer (Dinkevich. Peds Res, 2003)
• Bronx kids rubbing ointments (Vicks), prayer,
  massage, syrups, teas, foodsd (Reznik, Peds Res,
  2003)
• Texas kids 81 used CAM prayer, herbal teas,
  vitamins, massage (Mazur. 2001)

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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
• Astin, JAMA, 11/98

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Does CAM work?
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Goals of Medicine

• Yang goals
• Cure disease
• Manage symptoms
• Prevent specific disease
• Yin goals
• Promote well-being
• Promote peace, harmony, meaning
• Support, hope, trust

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Goals of Asthma Therapy

• YANG
• Manage or relieve symptoms beta agonists
  steroids Mg
• Prevention immunizations breathing exercises
  fish oil vitamin C Vitamin B6 yoga
• Eliminate toxins fluids avoid ETS avoid
  allergens

• YIN
• Promote resilience/vitality diet, sleep,
  meditate, yoga
• Support feeling of presence/connection
  reassurance, touch follow-up
• Inner peace/harmony prayer, spiritual practice,
  meditation

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Models for Rx/ Rsch
QOL Well-being
Disease in Organ or Tissue
Symptoms
Treatment
A
Secondary
Primary
Person
Symptoms or Disease
QOL Well-being
B

• Treatment

Primary
Secondary
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Holistic

• Caring for whole person body, mind, emotions,
  spirit, relationships -- in the context of
  family, culture and community
• Patient centered care

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Dimensions of Well-Being

• Physiologic, eg. normal PEF
• Physical, eg. no cough uninterrupted sleep,
  sense of vitality
• Functional, eg. attends school/work daily
• Psychological, eg. competence, self-esteem
• Emotional, eg. no anxiety, depression
• Social, eg. friends, family
• Spiritual, eg. meaning
• Others..

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Integrative Therapeutics

• Considering a broad range of therapies, including
  the evidence of their benefits, risks,
  interactions, costs and selecting best in
  collaboration with patient/family.
• Which therapy are we asking about? Or is it a
  combination (much harder to study!)

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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,
  bee propolis, fish oil

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Coffee and Asthma

• NHANESII survey of adults Regular coffee
  drinkers had 0.71 risk of asthma compared with
  non-drinkers
• Italian studies showing significantly less asthma
  in 2 cup/day coffee drinkers
• Dose effect observed

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Herbs for Asthma

• Xanthines coffee, tea. Epidemiology links higher
  intake to lower prevalence of asthma and wheeze
  (Schwartz. Ann Epid, 1992)
• Adrenergic ephedra, coleus
• Anti-inflammatory licorice, onions, fish oil,
  Shinpi-to, Saiboku-to (Japanese aka TJ-96,
  anti-inflammatory, inhibits LT synthesis. Urata.
  Respir Med, 2002) Onion (Allium cepa) improved
  PFTs (Amla. Ind J Pharmacol, 1980)
• Ivy leaves (Hedera helix) in RCTs reduce airway
  resistance (Hofman. Phytomedicine, 2003)
• Anti-oxidant Ginkgo
• Solanum xanthocarpum acute improvement in PFTs
  for 6-8 hours (Govindan S. J Ethnopharm, 1999)

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Ephedra- product variability

• 20 products tested 10 evaluated for lot-lot
  variability
• 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

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Federal regulations food supplements

• 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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Do NOT use Patent Medicines

• Heavy metals - lead, mercury, cadmium
• Toxins - arsenic
• Pharmaceuticals - steroids, antibiotics,
  hypoglycemic agents, antihistamines, etc.
• In some studies, over 40 contaminated

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Vitamin C

• Antioxidant intake higher in non-asthmatics.
  (Bielory 1994 Fonastiere 2000) Daily use may
  decrease inflammation
• EIB? (Cohen Arch Pediatr Adolesc Med, 1997)
• Nigerian asthmatics, 1 gm daily helped. (Anah
  1980)
• Reduces reactivity to methacholine, effect
  blocked by indomethacin. (Mohsenin 1983)
• Block ozone-mediated exacerbations? (Grievink
  1999 Freed 1999)

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Vitamin C

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

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Vitamin B6 (pyridoxine) and Asthma

• db RCT of 76 asthmatic children
• Vitamin B6 50 -200 mg/daily for one month
• reduced frequency and severity of symptoms and
  need fewer meds
• Possibly more important in kids on theophylline

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Dietary supplements for asthma

• Magnesium Fish oils
• Bee propolis in RCT in patients on theophylline,
  marked reduction in nighttime symptoms and
  improved PFTs and decreased inflammatory
  cytokines (Khayyal. Fund Clin Pharmacol, 2003).
  BUT Bee pollen can cause anaphylaxis
• Cordyceps sinensis (Chinese fungus) affects Th1
  and Th2 cells

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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 Sources
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Lifestyle

• Nutrition
• Exercise
• Mind-Body Therapies
• Environment

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Nutrition

• Breastfeeding is protective
• Onion extracts reduce bronchospasm in guinea pigs
  and reduce inflammation in vitro

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FOOD and ASTHMA
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Omega 3 fatty acids

• Tend toward anti-inflammatory side of leukotriene
  production
• Reduced asthma symptoms with chronic intake of
  high fish diet (twice weekly for at least 9
  months)

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Environment

• No smoking
• Clean house
• Minimize exposure to sick kids
• Minimize exposure to allergens
• Air filters? Yes (McDonald. Chest, 2002) bed
  covers? No? (Woodcock. NEJM 2003) Vacuums?
  De-humidifiers?
• Minimize exposure to triggers such as sulfites,
  ozone, nitrogen dioxide, particulates (Tolbert PE
  Am J Epid, 2000 Gent, JAMA, 2003McConnell R. Am
  J Respir Crit Care Med, 2003)
• Advocacy 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 techniques? Reduce frequency and depth of
  breathing, record pulse and breath holding
  practice twice daily(Cooper. Thorax, 2003)

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Asthma Mind-Body therapies

• Hypnosis, yes
• Autogenic training, yes
• Biofeedback, yes
• Meditation, yes, e.g., Sahaja yoga improves ARQL,
  POMS, methacholine challenge (Manocha. Thorax,
  2002)
• STRESS MANAGEMENT YES or NO? Cost issues. Time.
  Self-efficacy (Frieri. Ann Allergy Asthma
  Immunol, 2003Huntley. Thorax, 2003 Hockemeyer
  J. Behav Med, 2002)

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Biomechanical

• Surgery
• Massage
• Cranial, spinal or joint adjustment

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Massage for pulmonary problems

• One of most common home remedies for asthmatics.
  Often combined with liniments (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?)
• CF (Hernandez-Rief, Soc Ped Psychol,199924(2)
  175-81)

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Chiropractic and Asthma

• Chiropractic is most common CAM therapy in US
• DCs licensed in all 50 states
• 2 RCTs show no benefit for asthma (Hondras.
  Cochrane Database Syst Rev, 2002)

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Asthma - surgery

• Early 20th century division of sympathetic and
  parasympathetic branches of pulmonary plexus
  abandoned with advent of better drugs

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Bioenergetic

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

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Acupuncture for ASTHMA

• Not sole therapy for asthma, even in China
• Effective? Controversy
• NOT for acute, rescue remedy
• MAY help with subjective dyspnea, sleep, overall
  well-being
• Safety
• IS acceptable for sick kids (Kemper. Pediatrics,
  2000 Kemper, et al. Clinc Pulm Med, 2003 in
  press)

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Therapeutic and Healing Touch

• No research (yet)
• Subjective improvement
• Case histories
• Not sole treatment!

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Prayer
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Homeopathy and ASTHMA

• One RCT homeopathy and 96 asthmatic kids showed
  NSD, ceiling effect?(White. Thorax, 2003 Linde.
  Cochrane Database Syst Rev, 2000)
• Benefits for allergies?
• Very safe as long as not used as rescue medicine
  for acute attacks

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Bioenergetic
Biochemical
Biomechanical
Lifestyle
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Goals of Medicine

• Yang goals
• Cure disease
• Manage symptoms
• Prevent specific disease
• Yin goals
• Promote well-being
• Promote peace, harmony, meaning
• Support, hope, trust

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Summary

• Healthy lifestyle, including diet rich in omega
  three fatty acids, fish, onions, anti-oxidants,
  magnesium and possibly caffeine
• Herbs may be useful, but not replacement for
  steroids
• Comforting therapies and stress reducers
  (massage, meditation) probably underutilized
• No evidence yet that chiropractic or homeopathy
  are worth professional intervention
• More research needed! (e.g., Healing Touch)

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Resources

• Bielory L, et al. J Asthma, 200340S 47-53
• Gardiner P and Kemper K. Herbs in Pediatric and
  Adolescent Medicine Peripheral Brain. Peds in
  Rev, 200021(2) 45-57
• Kemper KJ and Lester M. Alternative asthma
  therapies an evidence based review. Contemp
  Peds, 199916(3) 162-95
• Kemper KJ. ASTHMA chapter in The Holistic
  Pediatrician, 2nd edition. Quill, 2002
• Ziment I and Tashkin DP. J Allergy Clin Immunol,
  2000106(4)603-14