complementary/alternative medicine in the treatment of asthma

Review articleSupported by an unrestricted grant from Astra Zeneca Pharmaceuticals

Complementary/alternative medicine in thetreatment of asthmaDonna Melissa Graham, MD* and Michael S Blaiss, MD†

Objective: This review will familiarize clinical allergists/immunologists with thecommon forms of complementary/alternative medicine (CAM) that are being usedfrequently by their patients. It reviews reasons that patients seek alternative health caretherapies and the most common illnesses that are treated with this form of medicine.Cultural differences in CAM are also reviewed. The article focuses on specific therapiesused to treat asthma and reviews the efficacy of these therapies based on the availablescientific literature. The reader will also learn about views of other physicians on CAMand how this topic is being addressed in US medical schools.Data sources: Computer-assisted MEDLINE searches for articles on “complemen-

tary/alternative medicine” or “herbal therapy” and “asthma” or “atopy.”Study selection: Pertinent abstracts and articles in the above areas were selected.

Articles selected for detailed review included review articles of the subjects alongwith randomized, double-blind placebo-controlled studies in animals and humans.Results: Complementary/alternative medicine is commonly used by patients with

chronic conditions including asthma. One-third of the US population has triedCAM. The literature supporting the efficacy of these therapies is lacking. Somereports elucidate the mechanism of action of certain herbal therapies that couldpossibly be helpful in the treatment of allergic diseases. There are, however, fewwell-controlled studies that support the efficacy of CAM in the treatment andclinical improvement of human subjects with asthma or atopic disorders.Conclusion: Available scientific evidence does not support a role for CAM in the

treatment of asthma. The studies in the literature often have significant design flawsthat weaken the conclusions such as insufficient numbers of patients, lack of propercontrols, and inadequate blinding. Further studies are needed to prove or disprovethe efficacy of CAM. Physicians often find CAM intimidating because they areunaware of the clinical evidence and feel uncomfortable advising their patients onits efficacy. There is definitely a need for more education among physicians in thisarea. It is also important that physicians inquire and discuss the use of CAM withtheir patients since the majority of patients are using some form of CAM.

Ann Allergy Asthma Immunol 2000;85:438–449.

INTRODUCTIONComplementary/alternative medicine(CAM) is increasing in popularityamong patients, especially in theUnited States. According to analysis of

the Robert Wood Johnson2 FoundationNational Access to Care Survey, 10%of Americans saw an alternative medi-cine provider in 1994.1 One-third of theUS population has tried CAM. In the

Australian population this number is50%2 whereas it is 25% in the UnitedKingdom.3 In 1990, 425 million visitswere made to practitioners of unconven-tional medicine. This number exceededthe 388 million visits made to primarycare physicians. Most of the visits weremade by non-African-Americans aged25 to 49 years who had relatively higherincome and education. Approximately$13.7 billion was spent on CAM in1990. Insurance providers did not reim-burse 75% of this money.4Patients report several common rea-

sons for seeking alternative healthcare. These include word-of-mouth(32%), fear of side effects from tradi-tional medications (21%), presence ofchronic medical problems (19%), dis-satisfaction with conventional medi-cine (14%), and desire for more per-sonalized treatment (9%).5 Eisenbergand colleagues in 1993 indicated thatapproximately one-third of Americansused at least one form of alternativetherapy. Only three of ten people inthis study actually informed their pri-mary care givers of their alternativetherapy use. Most of these patients us-ing CAM were affluent and well edu-cated.4Complementary/alternative medicine

refers to a large range of therapies out-side the domain of orthodox Westernmedicine (Table 1). Therapies in-cluded in this domain range from1000-year-old systems of medicine,such as traditional Chinese medicine(TCM) and Ayurvedic medicine, tohomeopathy, acupuncture, biofeed-back, chiropractic manipulation, herbalmedicine, high-dose antioxidant vita-mins and minerals, hypnosis, imagery,

* Fellow, Division of Clinical Immunology,Department of Pediatrics, University of Tennes-see, 50 North Dunlap, Room 301, West PatientTower, Memphis, Tennessee 38103; e-mail:[email protected].

† Clinical Professor of Pediatrics and Medi-cine, Division of Clinical Immunology, Univer-sity of Tennessee, Memphis, Tennessee.Received for publication December 29, 1999.Accepted for publication in revised form May

19, 2000.

438 ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY

lifestyle and diet, massage therapy, os-teopathy, prayer healing, relaxation,yoga, and self-help groups. Sikand andcolleagues assessed the attitudes, train-ing and practices regarding CAMamong fellows of the Michigan chapterof the American Academy of Pediatrics.Results indicated that 83.5% of thesepediatricians believe some of their pa-tients use some form of CAM. The topicof CAM is usually initiated by patientsrather than physicians (84.7%). Half ofthese physicians would consider refer-ring patients to other practitioners forCAM therapies. The most commontypes of CAM referrals made includedbiofeedback, self-help groups, relax-

ation, and hypnosis. Less than 10% referfor chiropractic manipulation, osteo-pathic manipulation, homeopathy, herbalmedicine, and prayer healing. The ma-jority (54%) of these pediatricians areinterested in CME courses in CAM.6Medical conditions commonly treatedwith CAM include chronic problems(headaches, backaches, pain manage-ment, and seizures), problems for whichtraditional therapies have failed, behav-ioral problems, psychiatric disorders(anxiety and depression), and neurologicdiseases listed below.

Chronic conditionBack painHeadachesPain managementSeizures

Behavioral problemsNightmaresADHD

Psychiatric disordersDepressionAnxiety

Neurologic diseases (eg, demyelinating)

The primary chronic condition forwhich individuals seek alternativetherapies is lower back pain, followedby allergies.7Complementary/alternative medicine

is used mostly for benign chronic con-ditions for which mainstream medicinecannot offer a reliable cure. Asthmasufferers are prime candidates forCAM. Ernst surveyed members of theUnited Kingdom National AsthmaCampaign in order to generate data onthe prevalence of CAM use amongasthmatics. The majority of the re-

sponders (60%) used CAM in a varietyof forms. The most commonly usedtherapies included breathing tech-niques (44%), homeopathy (17%), andherbalism (15%). Most of the patientsfound out about CAM by friends andrelatives (27%), media (16%), and thegeneral practitioner (13%). The major-ity of respondents found that CAM hadimproved their symptoms “to some ex-tent” or “to a slight extent.”7The use of CAM in regard to general

beliefs and philosophies, specific herbs,and therapies varies between cultures(Table 2). Traditional Chinese medicine(TCM) relies on maintaining harmonyand balance between two forces (yin andyang), and among five elements (fire,earth, metal, water, and wood). “Firegives rise to bitterness, earth to sweet-ness, metal to acridity, water to saltiness,and wood to sourness.” Each taste has aspecific action: bitter dries and drains,sweet tonifies and reduces pain, acriddisperses, salty nourishes kidneys, sournourishes yin, astringe prevents un-wanted loss of body fluids, and bland isdiuretic. Therapy for asthma and aller-gies is based mostly onma huang (Ephe-dra bush). Observations made in Chi-nese medicine point to a link betweenasthma and water imbalance or kidneydeficiency. So herbs felt to produce kid-ney reinforcement or contain tonifyingblends are used in asthma therapy.8In Japan, the Kampo medical system

is based on TCM. Combination productsare recommended. In India, asthma ther-apy involves Ayurvedic medicine, yoga,meditation, breathing exercises, andhomeopathy. Ayurvedic medicine rec-

Table 1. Therapies used inComplementary/Alternative Medicine(CAM)

List of CAM Therapies

Traditional Chinese medicineHomeopathyBiofeedbackHerbal medicineHypnosisLifestyle and diet changesOsteopathyRelaxationSelf-help groupsAromatherapyAyurvedic medicineAcupunctureChiropractic manipulationAntioxidant vitamins and mineralsImageryMassage therapyPrayer healingYogaReflexologyBreathing techniques

Table 2. Cultural Differences Regarding CAM

China (traditional Chinese medicine) Stresses harmony between yin and yang and balance among five elements (fire,earth, metal, water, and wood)

Japan (Kampo medical system) Based on TCM; combination products commonly usedIndia (Ayurvedic medicine) Recognizes five elements (fire, ether, water, air and earth); used in combination

with yoga, meditation, and homeopathyLatin America/Puerto Rico Believes cold is the main cause of bronchial asthma so therapies are based on

“hot” remedies such as oral infusions and syrupsHawaii Feel illness is due to loss in energy or balance so therapy aimed at restoring

balance; use religious ceremonies, seances, massage, and herbsIndustrialized countries Utilize a variety of CAM therapies: acupuncture, chiropractic manipulation, herbal

therapy, etc.

Abbreviations: CAM � complementary/alternative medicine and TCM � traditional Chinese medicine.

VOLUME 85, DECEMBER, 2000 439

ognizes five elements (fire, ether, wa-ter, air, and earth), which manifest inthe body as form (tridosha) or humors:pitta (fire or bile), vata (air or wind),and kapha (water or phlegm). As withTCM, taste indicates an herb’s proper-ties: sweet, sour, salty, pungent, bitter,or astringent.8Medicine in Latin America/Puerto

Rico believes that cold is the maincause of bronchial asthma; therefore,therapy results in “hot remedies.”Treatment consists of oral infusionsand syrups, camphor rub, Vicks Va-poRub, prayer, and the use of talis-mans.9 In Hawaiian medicine, illness isbelieved to be due to a loss in energyand balance. Treatment is used to returnthis energy and balance back to normal.Methods include religious ceremonies,seances, massage, and herbs.10Industrialized countries utilize a

wide variety of CAM therapies includ-ing acupuncture, acupressure, homeop-athy, chiropractic manipulation, oste-opathy, herbs, hypnotherapy, massage,reflexology, iridology, and magnetictherapy. In the United States, any ofthe above therapies are used, alongwith vitamins, magnesium, selenium,acetylcysteine, omega-3 fatty acids,gingkolides, and herbs. Western cul-tures use herbal products from localplants along with herbs from easterncultures.11

SPECIFIC THERAPY INASTHMAChiropractic ManipulationChiropractic care claims that most dis-eases can be managed by the manipu-lation of subluxations in the vertebralcolumn. Classic chiropractic theoryclaims that subluxations block the flowof “innate intelligence,” which affectsthe ribs and organs. Practitioners relyon vigorous manipulation techniques,such as high-velocity, low-amplitudethrusts using their hands or devices toreadjust vertebral subluxations and tohelp patients maintain more healthypostures.12 Randomized, controlled tri-als have shown that spinal manipula-tion relieves back pain and other mus-culoskeletal conditions.13,14 Many

chiropractors report benefit in patientswith asthma, as well.15,16 The theoreti-cal basis for expecting benefit fromspinal manipulation in persons withasthma assumes that correction of sub-luxation restores normal mechanicaland nerve function and aids in the res-olution of asthma.17,18 A recent ran-domized controlled trial of chiropracticspinal manipulation for children withmild or moderate asthma was con-ducted. This study looked at twogroups of children that received eitheractive or simulated manipulation overa 4-month period while participantscontinued their routine asthma medica-tions. The primary outcome measurewas the change from baseline in thepeak expiratory flow, measured in themorning, before the use of a broncho-dilator. Eighty children had data thatcould be evaluated. The results showedsmall increases (7 to 12 L/min) in peakexpiratory flow in the morning andevening in both groups. There werealso decreased symptoms and beta ag-onist use and increased quality of lifein both groups. There was no signifi-cant difference between the twogroups. In conclusion, any benefit wasnonspecific and was attributable to aplacebo effect or to being involved inan active study (the hawthorne ef-fect).19 Other controlled studies alsosuggest chiropractic manipulation of-fers no corrective benefit in asthma.20Previous trials in which there had beenevidence of benefit of chiropractictreatment of asthma were inadequatelycontrolled.16,21

ACUPUNCTUREAcupuncture has been used in asthmawith varying success. This Chinesepractice involves insertion of thin nee-dles into specific points on the body inorder to restore the balance of yin andyang energies, which is believed to beabnormal in illness. The mechanism ofaction of acupuncture is not clear. Onesuggested mechanism is through thestimulation of adrenocorticotropic hor-mone, vasoactive intestinal peptide(VIP), or endorphins, which leads toincreased secretion of adrenocorticoidsand increased steroid production. Va-

soactive intestinal peptide is a potentvasodilator and bronchodilator. The ef-fects of acupuncture are most evidentat one-half hour after stimulation ofspecific acupuncture loci on the tho-racic wall and along the “lung-chan-nel.” These immediate effects includedecreased airway resistance, decreasein sputum viscosity, analgesia, and im-proved sleep patterns.22Kleijnen et al reviewed 13 studies

on acupuncture in the treatment ofasthma considered to have adequatemethodologic criteria. The eight supe-rior studies of these 13 were of onlymediocre quality and the claims of ef-ficacy were not supported by actualfindings.23 Lane and Lane reported thatacute benefits were discernible in someof the studies they examined.24 Theefficacy of acupuncture for the treat-ment of asthma remains uncertain, andits superiority over conventional med-ical therapy has never been demon-strated. It is relatively safe but is notwithout risks. There has been a reportof an outbreak of hepatitis B from useof unsterile needles and a report of apneumothorax following placement ofneedles into points on the chest wall.25

HERBAL THERAPYHerbs are plants or plant parts used toflavor food, make medicine, and pro-duce fragrance. Herbal products existin various forms including capsules,teas, extracts, essential oils, and oint-ments. As many as 250,000 to 500,000plants exist worldwide, but only 5,000have been studied in regard to theirmedicinal properties. Herbs contain“naturally occurring chemicals thathave biological activity.”8 Herbalistsclaim that certain constituents have an-ti-allergic, antihistaminic, anti-asth-matic, and anti-inflammatory proper-ties (Table 3).

MA HUANGMa Huang is one of the most impor-tant anti-asthma herbs used in tradi-tional Chinese medicine (TCM). Itis derived from the stem of the Chineseplant Ephedra sinica. The active ingre-dients include L-ephedrine (80% to90%), L-Methylephedrine, L-norephed-


rine, D-pseudoephedrine, D-N-methylp-seudoephedrine, D-pseudoephedrine,L-norephedrine, and alkaloid.26 Ephed-rine acts as an adrenergic agonist onboth alpha- and beta-receptors leadingto vasoconstriction, mydriasis, andbronchial relaxation. Oral ephedrinewas once used to treat asthma in con-ventional Western medicine, beforethe appearance of inhaled beta2-agonists, such as albuterol.25 This herbis the most well studied herb in TCMand is also used in the treatment of hayfever, nasal congestion, tracheitis,cough, hemorrhage, and shock.27 Theusual treatment regimen for asthma in-cludes doses of 15, 25, or 30-mg tab-lets tid or a 30 mg/ampoule subcutane-ously or intramuscularly.26 Rhinitis istreated with a 1% nasal spray. MaHuang is used either alone or in com-bination with other herbs such as Mi-nor Blue Dragon, cough formulas, andcold formulas. Ephedrine is also a pop-ular dietary supplement promoted totreat obesity and fatigue in largeramounts that may exceed 100 mg perdose. It is thought to be relatively safein the amounts used to treat asthma butis more dangerous at the larger doses.28Adverse effects can include hyperten-sion, tachycardia, palpitations, ner-vousness, headache, insomnia, dizzi-ness, euphoria, nephrolithiasis, seizure,stroke, and fatal myocardial infarction.

ATROPA BELLADONNAThe second most important herb in thetreatment of asthma is Atropa bella-donna (deadly nightshade). Its active

ingredient is atropine. Atropine isfound along with other anticholinergicagents in all solanacious plants such asjimsonweed (Datura stramonium) andhenbane (Hyoscyamus niger). Atro-pine has anticholinergic and bron-chodilating properties. The bronchodi-lating atropinic drugs are liberated byburning the leaves of these plants.These plants were once burned in cig-arettes and referred to as “asthma cig-arettes.”28 These primitive “inhalers”were a popular treatment for asthmaand other respiratory conditions in Eu-rope and North America in the earlypart of the 20th century.29

GINKO BILOBAGinkgo biloba is used around theworld for a variety of illnesses. Someof the diseases it is promoted to treatinclude coronary artery disease, an-gina, hypercholesterolemia, and Par-kinson’s disease.26 It is used through-out Europe for asthma and circulatorydisorders. Traditional Chinese medi-cine claims that it is useful in expellingphlegm and controlling wheezing. It isused for cough and wheezing in com-bination with Ephedra sinica, apricotseed, and Morus alba root.30 The mainingredients are termed ginkgolides andinclude kaemferol-3-rhamnoglucoside,ginkgetin, isoginkgetine, and bilobetin,which vasodilates, lowers plasma cho-lesterol, and relaxes smooth muscle.26There are studies that indicate thatginkgolides act as platelet activatingfactor (PAF) antagonists. In a recentpaper regarding herbal treatment of

asthma, Bielory and Lupoli reviewedseveral controlled trials in animals thatresulted in ginkgolides inhibiting PAF-induced bronchoconstriction.31 Guinotand colleagues performed a random-ized, double-blind, crossover study ineight atopic asthmatics who received 3days of a ginkgolide or placebo withsubsequent allergen exposure that re-sulted in inhibition of early broncho-constriction and residual bronchial hy-perreactivity in the treatment group.These results indicate that PAF-acetherantagonists are efficacious in allergen-induced reactions in asthmatic humans.32Side effects include nausea, vomiting,diarrhea, salivation, anorexia, headache,dizziness, tinnitus, and hypersensitivityreactions.

LICORICELicorice is a root that is used as an anti-tussive and mucokinetic in cough, bron-chitis, and asthma. Traditional Chinesemedicine describes it as an herb thatstops coughing and wheezing while itmoistens the lungs. Active ingredientsinclude glycyrrhizin, a glycone gly-cyrrhetinic acid, 2-beta-glucoronosylglucoronicacid, isoliquiritigenin-4-glu-coside, licorice, tannic acids and sev-eral others. Glycyrrhetinic acid activityinhibits 11-beta-dehydrogenase andblocks conversion of cortisol to corti-sone hence prolonging the action ofcortisol.33 Licorice has also been re-ported to inhibit histamine-induced in-creased permeability of capillaries andinhibit PAF.31 Licorice also has chem-icals that are antitussive including

Table 3. Herbs Commonly Used in the Treatment of Asthma

Common Name Botanical Name Possible Therapeutic Properties

Ephedra (Ma-Huang) Ephedra sinica Main ingredient, ephedrine, acts as adrenergic agonist on both �- & �-receptors leading to vasoconstriction, mydriasis, and bronchial relaxation

Deadly nightshade Atropa belladonna Primary ingredient, atropine, is anticholinergicGinkgo Ginkgo biloba Primary ingredients, ginkgolides, act as platelet activating factor antagonistsLicorice Glycyrrhiza uvale Antitussive and mucokinetic; glycyrrhetinic acid inhibits 11-alpha-

dehydrogenase and blocks conversion of cortisol to cortisone henceprolonging the action of cortisol

Saiboku-to (combination of 10 herbs) Contains glycyrrhizin and magnol which are inhibitors of 11-alpha-dehydrogenase leading to increased cortisol levels

Tylophora Tylophora indica BronchodilatorColeus Coleus forskohlii Primary ingredient, forskolin, enters cells and stimulates adenylate cyclase to

produce 3�,5�-adenosine monophosphate leading to bronchodilation


18-beta-glycyrrhetic acid and terpe-noids.26 Some derivatives of licoricehave been shown to be as potent ascodeine in suppressing cough.34 Therehave been no controlled trials with lic-orice in asthmatic humans.

SAIBOKU-TOSaiboku-to is the most popular and well-studied anti-asthmatic herbal treatmentused in the Kampo medical system inJapan. In China, it is called chaipu-tang(CPT). Uses include steroid-dependentasthma where it is claimed to be steroid-sparing. It is a combination of two prep-arations of herbs, sho-saiko-to andhange-koboku-to and contains the 10 fol-lowing herbs: Glycyrrhiza glabra, Peril-lae frutescens, Magnolia officinalis,Zizyphus vulgaris, Scutellaria baicalen-sis, Bupleurum falcatum, Poria cocos,Pinellia ternata, Zingiber officinale, andPanax ginseng.35 Both glycyrrhizin andmagnol, a component of Magnolia offi-cianalis, are inhibitors of 11-beta-dehy-drogenase leading to increased cortisollevels. This activity may account for theclaimed steroid-sparing effect of Sai-boku-to. There have been two con-trolled studies in adult steroid-depen-dent asthmatics that have resulted inreduced steroid dose. Egashira et alstudied 64 steroid-dependent asthmat-ics in a randomized, controlled trialusing saiboku-to and placebo. Sai-boku-to allowed some patients to with-draw from steroids and was helpful inalleviating symptoms as shown by de-creased asthma scores. Two patientswere able to stop steroids and elevenreduced their dose by 50%.36 Nakajimaet al studied 40 steroid-dependent asth-matics treated with saiboku-to for 6 to24 months: 11% stopped using steroidsand 34% decreased their steroid dose.Saiboku-to also spared the down-regu-lation of glucocorticoid receptors andbeta-2-receptors by beta-2-agonists.37Other studies have shown suppressionof allergen-induced bronchial hyperre-activity and tracheal accumulation ofeosinophils in guinea pigs.38

TYLOPHORA INDICATylophora indica is an herb claimed tobe mucokinetic used commonly in the

Ayurvedic system of medicine, whichis practiced in India. It is used in Indiato treat asthma and other respiratorydisorders such as bronchitis and thecommon cold along with dysenteryand rheumatism. It is recognized asa bronchodilator.39 The active ingredientis tylophorine, an alkaloid. Gopalakrish-nan et al showed that tylophorine inhib-ited anaphylaxis and immunocyto-ad-herence in guinea pigs.40 Bielory andLupoli recently reviewed studies onthe effects of Tylophora indica in asth-matics. There have been three double-blind, placebo-controlled studies inasthmatics that showed a decrease inasthma symptoms in patients receivingtylophora. One study also showed anincrease in peak expiratory flow rateafter treatment with this Indian herb.31A trial conducted by Gupta et al, how-ever, showed no statistically signifi-cant change between treated asthmat-ics and the placebo group in regard toasthma signs and symptoms, drug use,forced expiratory volume in one sec-ond, and peak expiratory flow rate.41Side effects, which are more promi-nent when the leaves of this plant arechewed rather than alcohol extracts in-gested, include nausea, vomiting, andsore mouth.31

COLEUS FORSKOHLIIColeus forskohlii is another Indianherb used in the treatment of asthma. Itcontains forskolin (also called colfor-sin), and has bronchodilator effects. Itis claimed to enter cells and directlystimulate adenylate cyclase to producecyclic 3�, 5�-adenosine monophosphate.This could offer an advantage by bypass-ing beta-surface receptors and overcom-ing tachyphylaxis.27 Two groups of in-vestigators compared forskolin withfenoterol and placebo in asthmatic sub-jects in double-blind, controlled, cross-over studies. Bauer et al found relevantbronchodilation in the forskolin-treatedgroup that lasted more than one-halfhour but a greater dose was required thanwhen fenoterol was used.42 Kaik andWitte found that colforsin capsules in-creased specific airway conductance.43Both groups found fewer side effects in

the forskolin groups in regard to degreeof tremor and hypokalemia.

TRADITIONAL CHINESEMEDICINEThe efficacy of several traditional Chi-nese medicines in asthma was investi-gated in a two-part multicenter, double-blind, placebo-controlled study by Hsiehet al. Three herbal-based interventionswere explored: group A, Liu-Wei-Di-Huang Wan; group B, Shen-Ling-Bai-Shu-San; and group C, Jia-Wei-Si-Jun-Zi-Tang. Each intervention consisted ofa combination of herbal products.Three hundred and three asthmatic

children were evaluated in the first partof the study in regard to symptomscore, medication score, peak expira-tory flow (PEF), and changes in immu-noregulatory function. Improvementswere found in both the placebo andtreatment groups by symptom andmedication scores. Groups A and Cshowed significant increases in PEFvalues. In vitro studies in the secondpart of the study showed a decrease inhistamine release and enhanced pros-taglandin E2 production. In vivo stud-ies, then performed in guinea pigs,showed decreased leukotriene C4 pro-duction and enhanced PGE2 produc-tion. Hsieh concluded that herbal-based TCM showed some efficacy inasthma treatment, although there wasalso a significant placebo effectpresent.44

RISKS OF HERBAL THERAPYMany herbal agents can be safe whenused appropriately, but known and po-tential risks of such compounds do ex-ist. There is a misconception that herbsare safe because they come fromplants. The chemical makeup of flow-ering plants is sophisticated and manyare toxic. Much of their risk is relatedto the unknown. Contamination withmetals such as lead and mercury hasoccurred. Adulteration with drugs toimprove their activity has been re-ported. Common adulterants that havebeen found include steroids andNSAIDS. Other factors related to theunknown include inconsistent dosing,


drug interactions, and worsening of se-rious medical conditions.45There is no licensing body for the

practice of herbal medicine in the UnitedStates. Most herbs are marketed as di-etary supplements and are not regulatedby the FDA. There is no guarantee ofquality. Physicians and patients shouldrealize the risks involved in using theseherbal remedies.46

VITAMIN THERAPY ANDASTHMAThere has been a great deal of interestin vitamin therapy in the treatment ofasthma. Bielory and Gandhi reviewedstudies pertaining to vitamin C inasthma and allergy. They found a num-ber of studies that support the use ofvitamin C in asthma and allergy. Sig-nificant results included positive ef-fects on pulmonary function tests andbronchoprovocation challenges withmethacholine or histamine or allergen.There were also several studies thatshowed no improvement in these mea-sures.47Vitamin C has been shown to attenu-

ate exercise-induced bronchospasmin at least some patients. Cohen et alevaluated 20 asthmatics with exer-cise-induced asthma (EIA) and foundthat over half of these patients had adocumented protective effect on exer-cise-induced hyperreactive airways af-ter receiving ascorbic acid.48 Thesefindings agree with the observations ofSchachter and Schlesinger49 and Miricand Hakhiu.50 Vitamin C is the majorantioxidant substance present in theairway surface liquid of the lung,where it could be important in protect-ing against both endogenous and exog-enous oxidants.Soutar et al evaluated the relation-

ship between dietary levels of antioxi-dants and bronchial reactivity in agroup of asthmatics in rural Swedenusing a validated dietary questionnaireand methacholine challenge. The re-sults indicated that the lowest intakesof vitamin C, manganese, and magne-sium were associated with a greaterrisk of hyperreactivity.51

EDUCATION OF US MEDICALSTUDENTSIn surveys of physicians, many are in-terested in continuing medical educa-tion opportunities regarding comple-mentary/alternative medicine. Medicalschools are having to face the chal-lenge of teaching their students aboutthese therapies. Wetzel and colleaguessurveyed the 125 US medical schoolsto document the courses offered tomedical students. Replies were re-ceived from 117 (94%) of the schools.Of the schools that replied, 64% offerelective courses or include topics inrequired courses. The number of coursesreported was 123. Most of the courses(68%) are stand-alone electives. One-third are part of required courses andone course is part of an elective. TheFamily Medicine Department teaches31% of the courses and the InternalMedicine department offers 11%. For-mats include lectures, practitioner lec-tures/demonstrations and patient pre-sentations. Common topics consist ofchiropractic manipulation, acupunc-ture, homeopathy, herbal therapies,and mind-body techniques. The expe-rience of doctors-in-training in regardto complementary/alternative medi-cine is diverse and heterogeneous.52

CONCLUSIONAvailable scientific evidence does notsupport a role for CAM in the treat-ment of asthma. The studies in theliterature often have significant designflaws that weaken the conclusionssuch as insufficient numbers of pa-tients, lack of proper controls, andinadequate blinding. Subject groupsare often not well characterized inregard to asthma severity and use ofconventional medications. Further stud-ies are needed to prove or disprove theefficacy of CAM. More investigationinto promising herbal treatments is notonly important because of their in-creased usage, but could possibly lead todevelopment of new medications thatwould be beneficial in the treatment ofasthma and allergy.Physicians often find CAM intimi-

dating because they are unaware of theclinical evidence and feel uncomfort-

able advising their patients on its effi-cacy. There is definitely a need formore education among physicians. Itis important to realize that the major-ity of patients are using some form ofCAM. Physicians should inquire anddiscuss this issue in order to promotemore successful treatment of theirpatients.

REFERENCES1. Paramore L. Use of Alternative ther-apies-estimates from the 1994 Rob-ert-Woods-Johnson-Foundation Na-tional Access to Care Survey. J PainSymp Manag 1997;13(2):83–89.

2. MacLennan AH, Wilson DH, TaylorAW. Prevalence and cost of alterna-tive medicine in Australia. Lancet1996(347):569–573.

3. Fisher P, Ward A. Complementarymedicine in Europe. Br Med J1994(309):107–111.

4. Eisenberg DM, Kessler RC, FosterC, et al. Unconventional medicine inthe U.S. prevalence, costs, patternsof use. N Engl J Med 1993;328:246–252.

5. Spigelblatt LS. Alternativemedicine: should it be used by chil-dren? Curr Probl Pediatr 1995;25(6):180–188.

6. Sikand A, Laken M. Pediatricians’experience with and attitudes towardcomplementary/alternative medi-cine. Arch Pediatr Adolesc Med1998;152:1059–1064.

7. Ernst E. Complementary therapiesfor asthma: what patients use. JAsthma 1998;35(8):667–671.

8. Compilation BGG. Alternative med-icine: the definitive guide. Puyallup:Future Medicine Publishers, 1994:261.

9. Malka S, et al. International perspec-tives on controversial practices in al-lergic diseases: the South Americanexperience. Clin Rev Allergy Immu-nol 1996;14(3):271–287.

10. Hope BE, Massey DG, Fournier-Massey G. Hawaiian materia medicafor asthma. Hawaii Med J 1996;52(6):160–166.

11. Ziment I. Alternative therapies forasthma. Curr Opin Pulm Med 1997;3(1):61–71.


12. Ziment I. What else are your patientsusing to treat their asthma? J RespirDis 1999;20(1):58–64.

13. Shekelle PG, Adams AH, ChassinMR, et al. Spinal manipulation forlow-back pain. Ann Intern Med1992;117:590–598.

14. Wiles MR, Diakow P. Chiropracticand visceral disease: a brief survey. JCan Chiropractic Assoc 1982;26:65–68.

15. Arbiloff B. Bronchial asthma. J ClinChiropractic 1969;2:40–42.

16. Hvidd C. A comparison of the effectof chiropractic treatment on respira-tory function in patients with respi-ratory distress symptoms and pa-tients without. Bull EurChiropractors Union 1978;26:14–34.

17. Dhami MSI, DeBoer KE. Systemiceffects of spinal lesions. In: Halde-man S, ed. Principles and practice ofchiropractic. Norwalk: Appleton &Lange, 1992:115–135.

18. Janse J. Chiropractic management ofselected spino-visceral disorders. In:Hildebrandt R, ed. J Janse principlesand practice of chiropractic. 1976,National College of Chiropractic:Lombard, 1976:227–239.

19. Balon J, Aker P, Crowther E, et al. Acomparison of active and simulatedchiropractic manipulation as adjunc-tive treatment for childhood asthma.N Engl J Med 1998;339:1013–1020.

20. Nielsen NH, Bronfort G, Bendix T,et al. Chronic asthma and chiroprac-tic spinal manipulation: a random-ized clinical trial. Clin Exp Allergy1995;25:80–88.

21. Jamison JR, et al. Asthma in a chi-ropractic clinic: a pilot study. J AustChiropractors Assoc 1986;16:137–143.

22. But P, Chang C. Chinese herbalmedicine in the treatment of asthmaand allergies. Clin Rev Allergy Im-munol 1996;14(3):253–269.

23. Kleijnen J, ter Riet G, Knipschild P.Acupuncture and asthma: a reviewof controlled trials. Thorax 1991;46:799–802.

24. Lane DJ, Lane TV. Alternative andcomplementary medicine for asthma[Editorial]. Thorax 1991;46(11):787–797.

25. Langmack E. Alternative therapiesfor asthma. Curr Practice Med 1999;2(2):45–47.

26. Huang KC. The pharmacology ofChinese herbs. Boca Raton: CRCPress, 1993:229–232.

27. Duke JA. Handbook of medicinalherbs. Boca Raton: CRC Press,1985:354–355.

28. Ziment I. How your patients may beusing herbalism to treat their asthma.J Respir Dis 1998;19(12):1070–1081.

29. Ziment I. Unconventional therapy inasthma. Clin Rev Allergy Immunol1996;14(3):289–320.

30. Bensky D, Gamble A. Chineseherbal medicine: Materia medica.Seattle: Eastland Press, 1993:309.

31. Bielory L, Lupoli K. Herbal inter-ventions in asthma and allergy. JAsthma 1999;36(1):1–65.

32. Guinot P, Brambilla C, Ducheir J, etal. Effect of BN 52063, a specificPAF-acether antagonist, on bron-chial provocation tst to allergens inasthmatic patients. A preliminarystudy. Prostaglandins, 1987;34(5):723–731.

33. MacKenzie MA, Hoefnages WHL,Jansen RWMM, et al. The influenceof glycyrrhetinic acid on plasma cor-tisol and cortisone in healthy youngvolunteers. J Clin Endocrinol Metab1990;70:1637–1643.

34. Anderson DM, Smith WG. The an-titussive activity of glycyrrhetinicacid and its derivatives. J PharmPharmacol 1961;13:396–404.

35. Toda S, Kimura M, Ohnishi M, et al.Effects of the Chinese herbal medi-cine “saiboku-to” on histamine re-lease from and the degranulation ofmouse peritoneal mast cells inducedby compound 48/80. J Ethnopharma-col 1988;24(2–3):303–309.

36. Egashira Y, Hagano H. A multi-center clinical trial of TJ-96 in pa-tients with steroid dependent bron-chial asthma. Ann N Y Acad Sci1993;685:549–560.

37. Nakajima S, Tohda Y, Ohkawa K, etal. Effects of saiboku-to (TJ-96) onbronchial asthma. Ann N Y Acad Sci1993;685:549–560.

38. Toda M, Motojima S, Fukuda T, etal. Effect of an herbal preparationsaiboku-to (TJ-96) on antigen-in-

duced airway hyperresponsivenessand eosinophil infiltration in activelysensitized guinea pigs. Ann N YAcad Sci 1993;685:561–571.

39. Hackman RM, Stern JS, GershwinME. Complementary and alternativemedicine and asthma. Clin Rev Al-lergy Immunol 1996;14(3):321–336.

40. Gopalakrishnan C, Shankaranaray-anan D, Nazimudeen SK, et al. Ef-fect of tylophorine, a major alkaloidof Tylophora indica, on immuno-pathological and inflammatory reac-tion. Indian J Med Res 1980;71:940–981.

41. Gupta S, George P, Gupta V, et al.Tylophora indica in bronchial asth-ma-double blind study. Indian J MedRes 1979;69:981–989.

42. Bauer K, Dietersdorfer F, Sertl K, etal. Pharmacodynamic effects of in-haled dry powder formulations offenoterol and colforsin in asthma.Clin Pharmacol Ther 1993;53(1):76–83.

43. Kaik KG, Witte PU. Protective ef-fect of forskolin in acetylcholineprovocation in healthy probands.Comparison doses with fenoteroland placebo. Wien Med Wochenschr1986;136:637–641.

44. Hsieh KH. Evaluation of efficacy oftraditional Chinese medicines in thetreatment of childhood bronchialasthma: clinical trial, immunologicaltests and animal study. Pediatr Al-lergy Immunol 1996;7(3):130–140.

45. Ernst E. Harmless herbs? A reviewof the recent literature. Am J Med1998;104:170–178.

46. Stix G. Plant Matters. How do youregulate an herb? Sci Am 1998;278(2):30–31.

47. Bielory L, Gandhi R. Asthma andvitamin C. Ann Allergy 1994;73(2):89–96; quiz 96–100.

48. Cohen H, Neuman I, Nahum H.Blocking effect of vitamin C in ex-ercise-induced asthma. Arch PediatrAdolesc Med 1997;151:367–370.

49. Schachter E, Schlesinger A. The at-tenuation of exercise-induced bron-chospasm by ascorbic acid. Ann Al-lergy 1982;49:145–151.

50. Miric M, Hakhiu M. Effect of vita-min C on exercise-induced broncho-constriction. Plucne Bolesti 1991;43:94–97.


51. Soutar A, Seaton A, Brown K. Bron-chial reactivity and dietary antioxi-dants. Thorax 1997;52(2):166–167.

52. Wetzel M, Eisenberg D, Kaptchuk

T. Courses involving complemen-tary and alternative medicine at USmedical schools. JAMA 1998;280(9):784–787.

CME ExaminationNo 002–012Questions 1–20. DM Graham and MS Blaiss. Ann Allergy Asthma Immunol 2000;85:438–449.

CME Test Questions

1. What proportion of the U.S.population has tried someform of CAM?A. One fourthB. One halfC. One thirdD. One tenthE. One eighth

2. Common reasons for seekingalternative health care includeall of the following except:A. Word of mouthB. Presence of chronic medi-cal problems

C. Dissatisfaction with con-ventional medicine

D. Fear of side effects fromtraditional medications

E. Desire for less personalizedtreatment

3. According to this review, themost common types of CAMreferrals from pediatricianssurveyed included all of thefollowing except:A. biofeedbackB. self-help groupsC. chiropractic manipulationD. relaxationE. hypnosis

4. The most common conditionstreated with CAM include allof the following except:A. headachesB. skin infectionsC. pain managementD. seizuresE. backaches

5. The primary condition forwhich individuals seek alter-native therapies is:

A. seizuresB. heart diseaseC. allergiesD. back painE. pain management

6. Members of the National AsthmaCampaign using CAM mostcommonly used the followingtherapy:A. Chiropractic manipulationB. HerbalismC. Magnetic therapyD. HomeopathyE. Breathing techniques

7. The following statement is nottrue in regard to chiropracticmanipulation in patients withchronic diseases:A. Classic chiropractic therapyclaims that subluxations blockthe flow of “innate intelli-gence” which affects the ribsand organs.

B. Randomized, controlled trialshave shown that spinal ma-nipulation relieves back painand other musculoskeletalconditions.

C. Theoretically, spinal manip-ulation in asthmatics cor-rects subluxation and re-stores normal mechanicaland nerve function and aidsin resolution of asthma.

D. Chiropractic manipulationshows increases in peak ex-piratory flow and decreasedsymptoms in a group ofasthmatic children comparedto a control group.

E. Benefit from chiropracticmanipulation in asthma isnonspecific and attributableto a placebo effect.

8. Possible mechanisms of actionfor acupuncture include all ofthe following except:A. Blocking of the “lung chan-nel”

B. Stimulation of steroid pro-duction

C. Stimulation of vasoactiveintestinal peptide

D. Stimulation of endorphinsE. Stimulation of adrenocorti-cotropic hormone

9. According to this review, themost important anti-asthmaherb used in Traditional Chi-nese medicine (TCM) is whichof the following:A. Atropa belladonnaB. Ma HuangC. Ginkgo bilobaD. LicoriceE. Saiboku-tu

10. According to this review, themechanism of action of Ginkgobiloba is which of the follow-ing:A. anticholinergicandbronchodi-lating

B. platelet activating factor an-tagonist

C. adrenergic agonist on al-pha- and beta-receptors

D. inhibition of 11-beta-dehy-drogenase

E. stimulation of adenylatecyclase

11. According to this review, themechanism of action of MaHuang is which of the follow-ing:A. Anticholinergic and bron-chodilating

B. platelet activating factorantagonist

Request for reprints should be addressed to:Michael S Blaiss, MD300 Walnut Bend Road SouthCordova, TN 38018




E. stimulation of adenylate cy-clase

12. According to this review, themechanism of action of Co-leus forskohlii is which of thefollowing:A. anticholinergic and broncho-dilating





13. According to this review, themechanism of action of lico-rice is which of the following:A. Anticholinergic and bron-chodilating





14. According to this review, themechanism of action of At-ropa belladonna is which ofthe following:A. anticholinergic and bron-chodilating





15. According to this review,Saiboku-to contains glycyrrhi-zin which has the followingactivity:A. Anticholinergic and bron-chodilating





16. According to this review, lowdietary levels of all of the fol-lowing were associated withincreased bronchial reactivityexcept:A. Vitamin CB. ManganeseC. MagnesiumD. Vitamin E

17. According to this review, thefollowing statements are trueabout herbal therapy except:A. Most herbs are marketed asdietary supplements.

B. Adulterants such as ste-roids and NSAIDS arecommon.

C. Contamination with metalssuch as lead and mercuryhas occurred.

D. Herbal therapy is associ-ated with inconsistent dos-ing, drug interactions, andworsening of serious med-ical conditions.

E. There is a licensing bodyfor the practice of herbalmedicine in the UnitedStates.

18. According to this review, vita-min C has been shown to beassociated with all of the fol-lowing except:A. Improvement in nocturnalcough related to asthma

B. Improvement in pulmonaryfunction tests

C. Positive effects on bron-choprovocation challengeswith methacholine

D. Positive effects on bron-choprovocation challengeswith histamine and allergen

E. Attenuation of exercise in-duced bronchospasm

19. According to this review, mostof the courses offered to USmedical students regardingCAM are in the form of whichof the following formats:A. Required coursesB. Stand-alone electivesC. Included as topic within anelective

D. Standardized topics acrossthe US

E. Interactive courses20. According to this review, the

following statements regard-ing CAM studies in the litera-ture are true except:A. Most studies have inade-quate numbers of patients.

B. Most studies lack propercontrols.

C. Most studies have inade-quate blinding.

D. Study groups are not wellcharacterized in regard toasthma severity.

E. Study groups are usuallywell characterized in re-gard to use of conventionalmedications.


Instructions for Category I CME Credit

Certification. As an organizationaccredited for continuing medical ed-ucation, the American College ofAllergy, Asthma, & Immunology(ACAAI) certifies that when theCME material is used as directed itmeets the criteria for two hours’credit in Category I of the AmericanCollege of Allergy, Asthma, & Im-munology CME Award and the Phy-sician’s Recognition Award of theAmerican Medical Association.Instructions. Category I credit can

be earned by reading the text material,taking the CME examination and re-cording the answers on the perforatedanswer sheet entitled, “Continuing

Medical Education,” which can befound after the examination.Please record your ACAAI identifi-

cation number and the quiz identifica-tion number in the spaces and scanningtargets provided on the answer sheet.Your ACAAI identification numbercan be found on your ACAAI mem-bership card, nonmembers of the Col-lege will be assigned an ACAAI iden-tification number and this should beleft blank on the answer sheet. Thequiz identification number can befound at the beginning of the CMEexamination.Use a No. 2 or soft lead pencil for

marking the answer sheet. You may

erase but do so completely in order toprevent computer reading errors. YourACAAI identification number and quizidentification number will be used torecord your credit hours earned on theCME transcript system. No records ofindividual performance will be main-tained.Tear out the perforated answer sheet

and print your name and address in thespaces provided. Return it within onemonth after the Annals is received tothe American College of Allergy,Asthma, & Immunology, 85 West Al-gonquin Rd, Suite 550, ArlingtonHeights, IL 60005. Answers will bepublished in the next issue of the An-nals of Allergy, Asthma, & Immunology.

Answers to CME examination—Annals of Allergy,Asthma & Immunology (Identification No. 2000-011)Thompson A K: Quality of Life in patients with allergicrhinitis. Ann Allergy Asthma Immunol 2000;85:338–348.1. c2. e3. e4. b5. a

6. b7. e8. e9. c10. c

11. e12. a13. e14. b15. d

16. d17. b18. a19. e20. a, b, c

VOLUME 85, SEPTEMBER, 2000 449

complementary/alternative medicine in the treatment of asthma

Documents