Q: I don't want to constantly take drugs for my asthma. Which alternative asthma therapies work?
A: I strongly believe in minimizing the use of medications for asthma -- including over-the-counter, "natural" (herbal) and prescription drugs.
There are many ways to improve your asthma control without drugs. The most important is often overlooked by primary care physicians, and that is prevention. To prevent asthma, you must first learn what triggers your brochospasm and airway inflammation. Since airway inflammation is often caused by allergies, even in elderly adults, the first logical step is to determine to which indoor allergens you have become sensitized, and then do everything that you can to minimize inhaling those antigens.
Everyone with asthma has twitchy airways which narrow when irritants are inhaled. This means that you should work to avoid inhaling smoke (cigarette, cigar, pipe, fireplace, etc), dust, chemicals, and fumes. Everyone with asthma also has some degree of exercise-induced bronchospasm, due to airway cooling and drying. Therefore, you should try to exercise in a warm, moist environment whenever possible. If you must exercise in cold, dry air, either use a moisture retaining mask or scarf and breathe through your nose, or premedicate to prevent EIB.
If all of the above fails to control your asthma symptoms, then use a daily asthma controller medication at the lowest dose necessary to keep in the "green zone." Work with an asthma expert to determine the safest controller that works for you.
Non-drug, "alternative" or complementary medicine approaches MAY also be helpful, but have not been proven effective in scientific studies. There is no conspiracy by the AMA, FDA, or allopathic physicians to prevent patients from using these approaches. The vast majority of physicians would eagerly recommend any drug-free approach that was proven to work in a randomized clinical trial.
The alternative approaches that I think have the best potential are found in the $10 paperback book Reversing Asthma by Richard Firshein, DO, and the $15 book "Asthma Free in 21 Days" by Kathryn Shafer, Ph.D.. But please don't try these methods while your asthma is out of control. Use proven prescription medications to reduce your airway inflammation to get back into control, then work with your doctor to gingerly reduce your controller medications while you try each new approach. The wise patient will objectively measure the effectiveness of any new asthma treatment by using a written daily diary of symptoms and peak flow.
Q: I have recurrent sinusitis and post nasal drainage. What non-drug methods can I use to help this condition?
A: Methods to wash out your nose and clear your sinuses, from free to $130
You are not alone, since more than half of those with asthma also suffer from sinusitis, usually following a cold. Treatment of rhino-sinusitis often improves asthma control. Be sure to avoid smoke, dust, and allergens, which often cause rhinitis and sinusitis.
Nasal lavage (saline rinse, sinus irrigation) with a salt water solution (normal saline) one or twice a day is a great drug-free way to treat rhinitis and sinusitis. I do it myself whenever I get acute sinusitis (thankfully only once or twice a year). There are several methods available to wash "the debris" out of your nasal cavaties. For each method, you start with a cup of salt water that is just the right concentration of salt, so that it doesn't sting. Use one-half teaspoon of table salt dissolved in a cup (8 ounces) of warm water (not cold and not hot).
1. The "tool free" method is to merely pour some of the salt water into your cupped hand, snort it up and blow it out. Since this can get a little messy, it's best done over a sink.
2. A more "delicate" method, uses an inexpensive Neti-Pot, a small ceramic pot shaped like Aladdin's lamp. You put the salt water in the pot, stick the spout into one nostril, and tilt your head to one side so that the salt water flows into the upper nostril and drains out the lower nostril into the sink. I bought one on ebay.com for $16 but they are also available from netipot.org and nutraceutic.com
3. Doctor Grossan invented a method of shooting the saline solution into the nose. He makes and sells a $18 "sinus irrigator" tip to be placed on the business end of a WaterPik (about $65 retail), available from sinus-relief.com. I recommend that you also read his excellent book “The Sinus Cure.”
4. The "Rino-Flow" uses a special nebulizer to produce a mist from the saline solution. This plastic nebulizer differs from the nebulizers used to treat asthma, in that it produces a coarse mist (larger particles) which are deposited mainly in the nasal passages, instead of the fine mist produced by asthma inhalers, which is designed to get deep into the small airways of the lungs. It also has a top cover which comfortably fits into one nostril and directs the mist upwards. It takes about 5 minutes for a complete treatment. I like using the Rino-Flow when I get acute sinusitis, but it was given to me by respironics.com and usually sells for $130 for the compressor with two nebulizers and a videotape.
The traditional medical treatment of sinusitis is a decongestant (pills like Sudafed, or a nasal spray like Afrin for only the first 3 days), plus 10-14 days of antibiotics. Antihistamines usually don’t help, but some doctors recommend nasal corticosteroid sprays.
Q: Nothing seems to control my asthma very well. Will Omalizumab help?
A: Monthly anti-IgE shots are not a miracle cure for asthma.
It sounds like a wonderful idea: Since immunoglobulin E (IgE) plays a central role in the allergic response of persons with asthma and hayfever, "knocking it out of action" should help those with asthma and hayfever. Following this line of reasoning, the Genentech scientists in South San Francisco, who can genetically engineer almost any protein in the body, started the development of an anti-IgE medication over ten years ago. The resulting recombinant human monoclonal antibody #E25 (now called Omalizumab) has now been tested on over 1500 patients, but has not yet been approved by the FDA for sale in the U.S.
Around 1993, preliminary (Phase 1) studies showed that #E25 when given intravenously or subcutaneously (injected just below the skin) attached to IgE proteins in blood within hours, inactivating about 95 percent of them so that IgE no longer participated in an allergic reaction. The human body is continually producing more IgE, so the drug effect lasts for about two weeks. These Phase 1 studies also demonstrated that anti IgE shots were relatively safe, at least when taken for a few months.
Omalizumab was then given to 240 patients with hayfever, during the hayfever season. It dramatically dropped their blood levels of IgE, but didn't reduce their skin test reactions to ragweed antigen, and didn't help their hayfever symptoms. The authors concluded that the amount of drug given was too low. The study subjects probably would have felt much better that Spring if they had continued taking their non-sedating antihistamines and anti-inflammatory nose sprays (the standard therapy for hayfever).
In the Phase 2 study of anti-IgE, in 317 adult patients with asthma from 27 communities, the amount of drug was increased (titrated), according to the total amount of IgE measured in each patient's blood (which ranged from 40 to 5000 ng/ml). The anti-IgE shot was given every two weeks for 5 months. Improvement in asthma control was assessed primarily by a reduction in the number of asthma symptoms reported each day by the study participants. The average symptom score when the patients started the study was 4.0 on a scale where 1=no symptoms and 7=severe symptoms. After 3 months of therapy, those who received the anti-IgE injections had an average symptom score of 2.8 compared to 3.1 for those who got a shot of salt water (placebo) every two weeks. The difference between the real drug and the placebo was "significant" according to the statistical tests, but clearly unimpressive from the standpoint of most of the patients. About half of the patients who got the anti-IgE were able to reduce their need for inhaled or oral corticosteroids -- compared to one-third of those who got the placebo shots; so the anti-IgE therapy did have a "steroid sparing" effect. About 10 percent of those receiving anti-IgE got hives (an itchy rash) within an hour of receiving the injection and were successfully treated with Benadryl, but no one got hives with subsequent injections. No other side effects due to the anti-IgE therapy were noted during the study. The potential hazards of long-term (>1 year) anti-IgE therapy are not yet known.
Preliminary results from two large (Phase 3) studies of anti-IgE therapy for patients with moderate or severe asthma who require daily inhaled corticosteroids were reported recently. One study included 525 adults (half with severe asthma) and the other included 334 children (9 percent with severe asthma). The number of asthma attacks was cut in half and the amount of inhaled corticosteroids needed to maintain asthma control was also reduced in those taking the anti-IgE therapy. The results seem better than from the Phase II studies, but the details have not yet been published. No predictors of good response to Omalizumab therapy have emerged from these studies.
In summary, Omalizumab shots may reduce asthma and allergic rhinitis (hayfever) symptoms in some patients who have elevated IgE levels in their blood, and may reduce the need for prednisone to control asthma in some of these patients, but will require a visit to an allergist or pulmonary doctor every two weeks, and is likely to be expensive.
Q: I wheeze whenever I take pain medication; Why?
A: NSAIDs and aspirin cause bronchospasm in about 10 percent of people with asthma
Patients with aspirin-induced asthma (AIA) should avoid aspirin and other non-steroidal anti-inflammatory drugs [NSAIDs], including ibuprofen (Advil) and naproxen (Aleve). Acetaminophen (Tylenol) is an alternative for relief of minor pain, although asthmatic responses to high doses of acetaminophen have been reported in about 5 percent of adults with AIA. Patients with conditions such as heart disease or rheumatoid arthritis, who would greatly benefit from aspirin, should ask an allergist about aspirin desensitization therapy, which is very effective in allowing them to tolerate this useful medication.
The new NSAIDs called COX-2 inhibitors include celecoxib (Celebrex), and rofecoxib (Vioxx). Although they reduce the risk of gastrointestinal side-effects (such as GI bleeding), when compared to the older NSAIDs and aspirin, they do not have a reduced risk of bronchospasm for those who experience this after taking other NSAIDs.
An objective method to see if you are one of the 10 percent of asthmatics who get worse after taking an NSAID is to measure your own peak flow (PEF) response every 20 minutes for a couple of hours after you take one. Only do this if you have taken them before and didn't feel any symptoms and discuss it with your doctor. If your PEF doesn't fall more than 10 percent during the 2 hours, then you probably are not one of the unlucky one in ten.
If you do have bronchospasm due to NSAIDs or aspirin, the leukotriene antagonists (LTAs, like Singulair) may prevent this reaction. Discuss this possibility with your doctor.
Q: Why do I have leg cramps, shakiness, palpitations, nervousness, or insomnia?
A: These are side-effects of bronchodilators, like the salmeterol in Advair.
Shakiness is a common side-effect of all bronchodilators, but the long-acting bronchodilators (LABs) like Serevent (salmeterol) and Foradil (formoterol) cause it for 8-12 hours. Taking a short-acting bronchodilator (such as albuterol, Proventil, Ventolin, or Maxair) on top of the long-acting one doubles the chance (or doubles the intensity) of a side-effect. If you need to take a rescue inhaler more than twice a week, contact your doctor, because you probably need a higher daily dose of your asthma controller medication, at least for awhile. Salmeterol (50 mg) is the second ingredient in Advair, and currently ranks second only to albuterol for the largest number of asthma prescriptions written per year in the U.S.
Bronchodilators are in the same family of drugs as caffeine (a xanthine) and act similarly to adrenaline: they speed your heart rate and narrow blood vessels in your arms and legs (increasing the blood pressure), besides relaxing the muscles surrounding your airways (the desired effect). The adrenaline-like drug found in over-the-counter (non-prescription) bronchodilators is worse in this regard when compared to prescription asthma rescue inhalers (beta agonists). L-albuterol (Xopenex) is less likely than standard albuterol to cause cardiac (pulse and blood pressure) side-effects, and less likely to cause shakiness and headache. The primary disadvantage of Xopenex is that it comes as a liquid, so you have to use it in a compressor driven nebulizer.
Leg cramps, palpitations, and low potassium. A surprising number of patients with asthma who are given Advair or Serevent experience leg cramps, which is associated with low intra-cellular potassium levels. Also, about one in every five older persons taking salmeterol experience arrhythmias (felt as palpitations) -- twice the rate of those on placebo in clinical studies. These arrhythmias are probably due to the cardiac stimulant effect of bronchodilators, low potassium levels, and the low oxygen levels and stress which occur during an asthma attack.
The primary action of LABs isn't like a diuretic acting on the kidneys to reduce blood potassium levels. Instead, they cause a shift in the concentration gradient across cell walls in muscles -- both skeletal muscles, like in your legs (calves), and cardiac smooth muscles. So despite a normal blood level of potassium, the level inside muscle cells becomes abnormally low.
If your doctor determines that your symptoms are indeed a bronchodilator side-effect, then you will probably be told to take dry powder fluticasone without the Serevent in Advair. An asthma controller medication, such as monteleukast or a higher dose of an inhaled corticosteroid, may be added in place of the long-acting bronchodilator.
Salmeterol (Serevent) should not be used by itself as an asthma controller. The results from two related multicenter trials, SOCS and SLIC, were published recently (JAMA, May 23, 2001; vol 285, pages 2583-2603). The important conclusions were that in adult patients with persistent asthma, using an inhaled corticosteroid (ICS), may improve asthma control by adding salmeterol, and may reduce their ICS dose, but cannot be switched to salmeterol by itself (monotherapy) without risking the loss of asthma control. One-fourth of the patients switched from ICS plus salmeterol to salmeterol alone experienced an asthma exacerbation within the next six weeks, and the number of allergy cells (eosinophils) in their sputum increased.
Q: I take 500mcg of fluticasone twice a day, but worry about the side effects.
A: Stepping-down ICS therapy is an appropriate goal, but may take months.
Inhaled corticosteroids (ICSs) are the most asthma effective controller therapy for most people. They have been proven to reduce airway inflammation, improve lung function, reduce airway twitchiness, improve asthma control, reduce asthma exacerbations, reduce hospitalizations, and reduce the risk of death from asthma. So what are the disadvantages of these wonderful medications, other than their cost? Probably none if you are taking a low dose most of the time. A low dose is less than about 250 micrograms per day of fluticasone (or equivalent). After needing a higher dose for a few months to gain control of their asthma (get back into the green zone), many people can be "stepped down" to a low dose of ICS and retain asthma control (if they really take it every day).
If a moderate daily dose of ICS is needed for asthma control (about 500 mcg per day of fluticasone), long-term side-effects occur in less than 5 percent of the patients who take them. The risk of side-effects is higher in infants and small children. When a moderate ICS dose won't control asthma, most experts now recommend adding a long-acting bronchodilator inhaler (salmeterol or formoterol), or a leukotriene modifier (monteleukast) rather than doubling the dose of ICS. The risk of corticosteroid side-effects when taking a high dose of ICS for years may be about 10 percent, but this risk is much lower than taking more than 20mg of prednisone per day (as a pill).
You and your doctor are justifiably concerned about the long-term side-effects of high-dose inhaled corticosteroids (1000mcg per day), but treatment of moderate to severe persistent asthma is always a balancing act. Asthma controller medications must be increased to regain control, and then stepped-down once you are back in the green zone for a few months. At the same time, everything possible should be done to minimize your exposures to allergens to which you are skin-test positive, as well as dust, smoke, and chemicals. Avoid respiratory viruses, treat GERD, sinusitis, and rhinitis to minimize your need for high dose corticosteroids. Other asthma controller medications with fewer side-effects should also be tried, but don't work for everyone.
Thrush. Advair contains a strong inhaled corticosteroid (ICS) called fluticasone, one of the most effective asthma controllers. A common side effect of all ICS inhalers is a yeast infection of the throat, called thrush (caused by candida). Thrush may look like white plaques or spots at the back of your throat or coating your tongue, and may cause a sore throat and deepening of your voice (hoarseness). The very fine particles of medication created by Advair's dry powder inhaler reduce, but do not eliminate the risk of thrush when compared to the older "wet" mist created by traditional metered dose inhalers (MDIs).
Thrush results from the ICS being deposited in your throat (or the vocal cords) and then creating an environment in which candida yeast like to grow. This yeast overgrowth is not dangerous, but is annoying and can and should be prevented or treated as follows:
1) Review your inhaler technique to make sure you are activating it at the beginning of a slow and deep inhalation.
2) Obtain a volume chamber or spacer to attach between the MDI and your mouth.
3) After inhalation, gargle and rinse your mouth thoroughly.
4) If the thrush persists, ask your doctor about rinsing with an antifungal agent like Nystatin until the yeast overgrowth resolves.
Q: Can asthma drugs affect an unborn child?
A: Many studies have shown absolutely no increase in the risk of congenital anomalies in children born to women with asthma.
The risk of asthma medications to the developing child is much less than the fetal risks due to low oxygen levels when the mother has an asthma attack. Therefore, maintaining good asthma control during pregnancy is important. As always, take enough but not too much medication. Poor control of asthma during pregnancy (lung function in the red zone) means that the child growing in the womb frequently experiences low levels of oxygen -- this is the greatest risk associated with asthma during pregnancy, and may cause retardation of fetal growth (low birth weight), and if severe: abortion or neonatal death. For this reason, oxygen therapy with pulse oximetry monitoring, as well as fetal monitoring are indicated during asthma attacks in pregnant women.
Some studies show that pregnant women with severe uncontrolled asthma who required daily oral prednisone were somewhat more likely than healthy women to develop preeclampsia, and have premature births, or low birth weight babies. These associations were not seen in women with mild asthma or asthma controlled with inhaled corticosteroids or any other asthma medications. The FDA gives ratings (safety grades) to each medication which indicate knowledge about the safety of taking that drug during pregnancy. Those with an A rating have been tested by good clinical trials (research studies) in pregnant women and found not to be associated with fetal abnormalities. Those with a B rating are probably safe, based on less than ideal evidence. Those with a C rating have not been tested for safety in pregnant humans, but animal studies showed no fetal abnormalities. No asthma medications have an A rating (probably because the expense and legal risk of such studies is larger than the expected increment in income that the drug companies would enjoy if the studies were done). Terbutaline, inhaled corticosteroids, and Atrovent are B rated. The inhaled bronchodilators Serevent and Albuterol are C rated.
When choosing amongst asthma medications during pregnancy, one should consider both effectiveness and safety. Although both Serevent and Atrovent are similar in that they are both relatively long-acting inhaled bronchodilator medications, they have different mechanisms of action, and while almost all persons with asthma respond well to Serevent, much fewer respond to Atrovent. Several studies support the safety of beclomethasone and budesonide (inhaled corticosteroids), rescue inhalers (albuterol), and cromolyn (Intal).
In summary, asthma control is very important during pregnancy, and outweighs almost all concerns about asthma medication side-effects. Avoid asthma triggers, step-up your asthma controller medication according to the written asthma action plan provided by your doctor when your peak flow falls into the yellow zone, and quickly seek medical attention when your peak flow falls into the red zone.
Q: Since I'm taking inhaled corticosteriods and sometimes bursts of prednisone, should I worry about osteoporosis?
A: Yes, you should certainly take active steps to prevent osteoporosis, especially if you are a woman over age 50. Persons with asthma who require a medium to high daily dose of an inhaled corticosteroid, or frequent prednisone to control their asthma should be concerned about osteoporosis. The frequent use of corticosteroids increases the risk of vertebral fractures by 5 times, and will double the risk of vertebral fractures. Half of post-menopausal women will experience a osteoporosis-related fracture even without steroid therapy, and the one-year mortality rate following a hip fracture is 25 percent. Search WebMD using the term osteoporisis for lots more information on the topic.
The treatments listed below are proven to reduce osteoporosis, fractures, and falls. All women with asthma should at least take calcium and Vitamin D supplements, since many have avoided dairy products -- because they were told that dairy products exacerbate or even cause asthma.
- Minimize the use of prednisone and high-dose ICS
- Supplement calcium 1200mg per day
- Supplement Vitamin D 800 IU per day
- Daily non-impact exercise
- Consider hormone replacement therapy if over age 50
- Ask your doctor about taking risedronate (Actonel)
- To detect glaucoma and cataracts, and to prevent falls, have your vision checked every 6 months.