cu Paul Reller L.Ac.

Asthma and COPD: Manage or Cure?

Paul Reller, L.Ac.

Current medical management of asthma and COPD involves use of medications that combine corticosteroid with beta-2-adrenergic agonists (e.g. Advair), with medications that inhibit inflammatory mediators, such as the leukotriene receptor antagonists (e.g. Singulair). Many patients are paying attention to the FDA warnings and the warnings from medical researchers concerning chronic use of these medications and are seeking healthy alternatives and Complementary Medicine strategies to decrease the use of these medications and perhaps, like many patients have discovered, be able to live without asthma and/or COPD. Every patient with these problems sees that symptoms are much less frequent when one's health improves, yet specific information on improving the immune system and health of the bronchioles, respiratory membranes and nervous system responses is not easy to come by. Once one understands what needs to be done, choices in a healthy therapeutic routine are clear.

The choices with treatment in Complementary Medicine are not concerned with choosing between the asthma drugs and acupuncture/herbal medicine. These therapies can be used together to both manage symptoms and correct the underlying causes of asthma and COPD. Asthma medications insure that the patient avoids sometimes frightening episodes of breathlessness. The goal is to improve health and manage symptoms with an array of proven therapies so that the patient is confident that drug dependance can be reduced without problems, and then to improve health further so that the asthma or COPD is cured. This course of therapy is not undertaken lightly, and depends upon a good understanding of the disease, therapies and issues involved.

Can Complementary Medicine Increase the Effectiveness of Standard Medications for Control of Symptoms?

Combination drug therapies give greater results in controlling symptoms of asthma and COPD, even though the underlying health may not be improving. Complementary Medicine not only addresses the underlying health of the patient to improve the condition and eventually decrease the dependancy on symptom controlling drugs, but for many, may be an effective and safe addition to the symptom controlling regimen.

Studies cited by the manufacturer of a standard beta-adrenergic agonist (racemic albuterol) inhaler show that patients acquired tolerance to, and decreased effect by an average of one third, after 6 weeks of use. The study shows that there was a 22% average improvement in bronchodilation at first with the albuterol inhaler, which decreased to an average of 14.6% at the end of 6 weeks. If 14.6% effect or less of bronchodilation is occuring, acupuncture and herbal formulas, which are proven effective, could improve the symptom relief dramatically.

These studies also showed that there was a reversal of effectiveness of the beta-adrenergic agonist inhaler after 2 uses per day for 80% of the patients studied. If you are a patient that needs multiple dosing, you might consider adding Complimentary Medicine to your regimen.

The serious health problem of adrenal suppression and adrenal fatique with chronic overuse of combination corticosteroid inhalers has led to drug warnings, and the subsequent development of a new type of inhaler. Ciclesonide glucocorticoid, or Alvesco, was developed to insure that greater than 50% of the inhaled dose was delivered to the lung tissue rather than the systemic circulation, which effects that adrenal hypothalamic endocrine system, and suppresses natural cortisol levels. The drug makers bioengineered a drug with smaller airborne particles and a conversion to active des-ciclesonide in the broncial tissues with esterase activity. They also increased lipid conjugation and plasma protein binding, as well as P450 detoxification catabolism in the liver to decrease the threat of adrenal suppression in patients that used asthma inhalers chronically, or more than twice per day. The patient may choose to switch to this inhaler. Sometimes the prescribing doctor will add this inhaler to the albuterol protocol, but this appears to be a mistake with misunderstanding of the drug, and hence increase overuse and accumulation of corticosteroid and adrenal suppression may occur with this protocol. Adrenal suppression, even in mild circumstance, may lead to decreased cortisol levels, which affect the body's ability to fight infection, control inflammatory increases, and affect the sleep quality and general energy patterns.

Examining the Risk vs Benefit of Standard Medication

The following information is not meant to alarm or to suggest that asthma medications are unsafe, but awareness of the risk facts are needed when looking at your overall health and making the decision to decrease risk and adverse effects by adopting healthy strategies of complimentary medicine. The effects of long-term use of these medications are not always apparent. A story in the Money and Policy section of the New York Times, Dec. 5, 2008, illustrates the current debate and is available by clicking on the link at the end of this article.

Many medical groups and businesses have downplayed the risks of asthma medications, and pharmaceutical companies have produced new studies that downplay the risks. The fact that patients feel no immediate ill effects of these medications when starting use serves to help promote this downplaying of risk, but many researchers have become alarmed in recent years. The usual advice when faced with the recent proof of increased risk is that there is no alternative to these medications and so the risk is worth it, but when the facts are examined about alternative and complimentary treatment, many M.D.'s say that this may be worth trying. Many patients, too, have doubts about pharmaceutical manipulation of studies today and are increasingly wary of long-term risks.

Warnings and risks of chronic use of asthma medications have increased in recent years. In November of 2005, the FDA requested that a warning be included on products with beta-2-adrenergic agonists stating "may increase the chance of severe asthma episodes and death when these episodes occur". Researchers at Stanford and Cornell universities concluded that 80% of asthma deaths were caused by the combo-inhalers Advair, Serevent and Foradil, a combination of steroid and adrenergic agonist, although this was disputed by the manufacturer. Researchers found that these drugs may worsen bronchial inflammation and hyper-responsiveness. In 2004, the FDA issued a warning the albuterol sulfate contained in many asthma medications can produce "clinically significant cardiovascular effects" such as high blood pressure, racing pulse, and ECG changes affecting arrhythmias, and warned that beta-adrenergic agonists may "produce significant hypokalemia (potassium deficiency) which has the potential to produce adverse cardiovascular effects". FDA black box warnings have been required for Advair, Serevent, Symbicort, Foradil, Brovana and others. Clinical study of Brovana, a beta-adrenergic agonist, showed that increases in blood sugar of up to 1.2mg/dL were seen at both 2 and 6 hours after eating. A 2 year study showed a dose-related increase in uterine and cervical cancer and polyps in mice with high dose. In March of 2008, the FDA issued a stronger warning that recent clinical studies showed more serious risk for pediatric patients taking beta-adrenergic agonists, or bronchodilators. The FDA has issued warnings on asthma/CPOD medications that labeling makes unsubstantiated effectiveness claims and omits material facts.

Side effects in clinical study of these common asthma medication combinations include headaches, muscle and bone pain, soreness of the sinus and throat membranes, increased incidence of fungal infections in the mouth and ears, stomach ache, insomnia, tiredness, dizziness, increased blood acidity, etc. In 2008, Merck updated its labeling information of Singulair (anti-leukotrienic drugs) to include warnings of depression, anxiousness, tremor and suicidial thinking and behavior because of an FDA warning that resarch was strong linking these problems with chronic use of Singulair and investigation was ongoing.

The key question in evaluating long-term risk versus benefit is not whether we may be one of the unlucky few who face serious consequences, but rather, if these medications can cause such significant harm, what are they doing to my general health. To improve your general health and prevent future health problems, you can start understanding how asthma and COPD works and what healthy measures you can start taking to decrease chemical dependancy and to give your body the best shot at a cure.

Understanding the Mechanisms of Asthma and COPD

Asthma is not a simple problem. Many things may cause the alarming symptoms of subjective shortness of breath (dyspnea), airway constriction (wheezing) and inexplicable chronic coughing episodes. Asthma may be part of chronic obstructive pulmonary disease, or COPD, or it may be a separate problem. COPD is a progressively worsening problem of decreased expiration with the feeling of shortness of breath that causes a deficiency of oxygen and increase in carbon dioxide in the blood. COPD may be seen with or without chronic cough, and may eventually involve emphysema.

Asthma may involve acquired allergies and hyperresponsiveness to smoke, mold, mildew, dust, pet hair, pollen, chemicals in the environment, pollution, etc. Asthma episodes may be induced by cold, exercise, emotion, aspirin, Beta-blocking medications, such as blood pressure drugs, viral illnesses, or problems with inflammatory mediators and the immune system. Asthma involves not only problems with the immune response and allergic reaction, but also with the nervous system and autonomic regulation. The autonomic nervous system, a system of balance between the sympathetic and parasympathetic responses, may acquire problems due to variety of health issues, including chronic pain, anxiety, depression and hormonal imbalances.

Some basic ways to decrease exposure to common allergens include avoiding dust mites, pet dander, fungi, mold and pollens. This could include shaking the bedding out each day outside of the bedroom and dusting surfaces daily. Spraying pillows with a light lemon water mist and exposing them to the sunlight periodically may help. Using a non-electrostatic air filter in the bedroom may help, as well as vacuums designed to eliminate dust mites. Clearing common pollen plants and trees from the yard may be advisable. Getting rid of any old or unecessary carpeting, fixing roof leaks and old water pipes, fixing shower stalls, and having the air tested for mold and fungi if you are suspicious is advisable (refer to the California Home Performance Program to seek out contractors offering The Healthy House Inspection for about $100).

Ozone sources may have to be avoided, such as photochemicals, electrostatic air filters, and as much as possible, carbon monoxide from engines and hydrocarbons from rotting materials. In addition, some people may need to avoid cold drinks and frozen foods, as well as abrupt changes in climate by dressing appropriately in cold weather and planning vacations with care. For many, exercise routines may need to avoid abrupt heavy exercise and exposure to cool dry air with exercise. Swimming may be better than running. Routine low impact exercise should be performed rather than infrequent heavy exercise routines.

Dietary changes and Asthma

Asthmatic patients with potential allergies should consider a dual strategy when it comes to dietary changes. One, decrease or avoid foods that may trigger or worsen the asthma or allergy: and Two, increase foods that will help the body to deal with inflammatory regulation and antioxidants.

The most studied triggers in asthmatic patients in our common diet are sulfites, preservatives, glutens, chocolate, shellfish and dairy. Of these, the sulfites are the most important for most patients. This includes aged cheeses and meats, many wines and beers, cola drinks, olives, pickles, packaged food with sulfite preservatives, dried fruits, shellfish, dried fish, and some prepared restaurant foods such as guacamole, salad bars, cole slaw and potato salad. In fact, large commercial supermarkets sometimes spray the vegetables and fruit with sulfite preservative. Foods with benzoic acid preservatives should also be avoided, especially those with artificial colors, yellow dye #5 being the worst, vanillin, monosodium glutamate, BHT-BHA, benzoates, benzyldehyde amd eucapytol. Commercial pastries, peanuts, soy, alfalfa, beets, pork, turkey and white, brown and beet sugar should be decreased or avoided if possible.

Foods to increase in the diet include fresh, whole organic foods, fresh dandelion greens, burdock, garlic, onions, berries, unprocessed oils such as toasted walnut, avocado, pumpkin seed, sesame seed, and fresh ocean fish. The diet should be relatively high in healthy proteins and low in simple carbohydrates. Fresh herbs in cooking are a good idea, as well as watercress. For asthma with with phlegm or mucus that is clear of white, and cool extremities, fresh ginger, mustard greens, basil marjoram, garlic walnut, almond, molasses and anise are recommended. For asthma with much mucus or phlegm, or difficulty breathing when lying down, consume lemon, lime, raw honey, horseradish mustard, aduki beans and slippery elm tea. For asthma with heat flush accompanying difficult breathing and occasional yellow mucus or phlegm, dry stools or darker urine, consume apricots, limes, lemons, daikon radish and nettle leaf. For asthma with low energy and lassitude, shortness of breath, difficult breathing with exertion, consume whole or steel cut oats, barley, buckwheat, rice, black beans, walnuts, figs and perhaps regular small doses of Chinese ginseng.

Some common medications that may trigger or worsen asthma include aspirin, NSAIDS (ibuprofen, advil, naprosen etc.) and beta-blockers such as atenolol. Chronic use of antihistamines, steroids and medications for controlling stomach acidity may also worsen your condition. Complementary medicine may help reduce chronic drug dependancy in these cases.

The Link between Acid Reflux and Asthma

Acid Reflux, or Gastroesophageal Reflux (GERD), are often seen in the same patient. 77% of asthmatics complain of heartburn and 41% complain of reflux associated symptoms. Study of this phenomena has led to greater understanding of both GERD and asthma mechanisms. Acid stress from GERD may initiate asthmatic inflammatory processes, and nocturnal acid reflux may result in stomach acids that stay in the esophagus with likely spillover into the aerodigestive tract and pharyngeal area that are related to asthmatic symptoms and sleep apnea. Upper airway occlusion may in fact create intr-thoracic pressure that induces the acid reflux. This type of acid reflux may have nothing to do with the typical heartburn, and typical medications may not help.

The result of this esophageal acidity and spillover is heightened bronchial reactivity, neurogenic inflammation and acid-induced bronchoconstriction. Studies have found nitric oxide containing neurons, indicating inflamed nerve endings that may trigger asthmatic symptoms, in both the lung and esophagus. Nerve signals from the irritated esophagus were shown to produce substance-P and neurokinin-A release in the lungs, both potent stimulators of the asthmatic responses. One study even showed that esophageal acid exposure could result in decreased blood flow to the coronary artery, causing chest pain.

82% of asthmatics showed abnormal esophageal acid contact times on 24 hour tests, and it is estimated that 24% of patients with asthma that is difficult to control have clinically silent GERD. This association of GERD with asthma is not new. Sir William Osier found that GERD was a potential asthma trigger around 1900. The fear in modern medicine is that asthma medications may potentiate GERD. It was found that theophylline increases gastric acid secretion and lowers esophageal sphincter pressure in a dose-dependant manner, and oral corticosteroids increase esophageal acid times. (Refer to Chest 2002, vol. 121 pp 625-634; Lazenby et al).

Clearly, this shows that present medication management of asthma and GERD may be worsening the clinical condition with chronic use while relieving symptoms. A more holistic and safer approach, with less dosage of both asthma medications and stomach acid medications is warranted. This is where Complementary Medicine comes into play.

The link between Food Allergies, Eczema and Asthma

The National Institute of Allergy and Infectious Diseases, an offshoot of the NIH, convened an Expert Panel on Food Allergy Research in 2006. Dr. Stephen Galli of Stanford co-chaired this committee with Dr. Dean Metcalfe of the NIH. The findings showed that food allergies were frequently accompanied by other allergic diseases, namely asthma and eczema. The prevalence of food allergies appears to be increasing, with greater than 4% of the adult population, and 8% of the children under 4 years of age now affected by serious food allergies. Food allergies account for greater than 50% of emergency room visits for anaphylactic shock in the United States. The asthmatic patients with allergic triggers may be well advised to effect dietary changes, improve gastrointestinal health, and improve the immune health with holistic medicine. The NIAID study found that probiotic regimens and certain Chinese herbal medicines were effective in animal studies in reducing certain immune reactions, and may suppress the adaptive immune responses in a modulatory fashion.

The physiological link between allergic asthma and food allergies concerns the type of immune response. Studies have shown that over 60% of the CD4+ leukocytes in the lungs of patients with moderate to severe asthma are not typical helper T-cells, but natural killer T-cells that are activated by antigens/allergens with specific types of lipid and glycolipid components. Most allergens are water soluble, so this finding narrows the suspects in this allergic link to glycolipid pollens (such as cypress tree pollens) and lipid-carbohydrate complexes in foods. This would suggest that the increase consumption in transfats and simple sugars, especially high-fructose corn syrup, presents excess challenge to our immune system, and the development of hyperallergic responses. This would explain the unusual increase in incidence of allergic response to one of our most common fat-carbohydrate combination foods, the peanut, which is not really a nut.

Allergic responses are still not understood fully, and various thresholds of allergen intake trigger allergic responses. Even allergy testing may not reveal fully the extent of foods that you have developed hypersensitivity to. IgE response levels to specific foods in testing predict the likelihood of allergic reaction, but not the severity of that reaction. A simpler approach is to keep a journal and note connections between asthmatic episodes, other allergic responses, and the specific foods that you eat. Avoidance of common allergens for periods of time should be tried and noted in the journal to determine a cause effect relationship. Common allergens include glutens, shellfish, peanuts and dairy. Commercial baked goods often use high gluten flours and should especially be avoided. Endotoxins are found to be a prevalent allergen in asthma eczema, especially in a subset of children that were not exposed to animals at an early age. Not only pets can carry these endotoxins, but meat itself may carry endotoxins, and meat that is less cooked can present as a food allergen. Ground beef and prepared luncheon meats and hotdogs were found to have higher levels in general of these endotoxins. Decreasing meat consumption, or buying local organic meats from smaller cleaner producers may reduce your allergic reactions.

In 2010, much attention is now being directed to the subject of food allergies and the industry built up around the overblown fear of food allergies. As expected, as the public becomes aware of the prevalence of food allergies, which are difficult to understand and detect, there is much fear that food allergies may be responsible for a variety of individual health problems, and consequently, an industry has grown around these fears. The intelligent patient counters this by educating themselves. The key points to understand in allergic and hypersensitivity immune dysfunctions is that they are hard to objectively diagnose, vary intensely in the degree of reactivity, and most importantly, the food is not the problem, but rather the individual immune function. In fact, even patients with extreme allergic and hypersensitivity reactions may eventually consume these foods that cause the reactions without problems once the immune system is, in a sense, reprogrammed. Glutens and gliadins are posing problematic reactivity in a high percentage of people in industrialized countries now, according to the World Health Organization, but these are still healthy food nutrients. The problem is that the commercial use of high gluten flours has stimulated strong antibody responses and negatively impacted the health of the intestinal membranes. Most patients with gluten and gliadin sensitivity, though, will not respond significantly to these nutrients after 6 months of avoidance and restoration of the health of the intestinal tract and immune function. After health is restored, and the immune reaction is quieted, most people will be able to eat these foods without problems. The glutens and gliadins are not the focus, but rather the health of the immune system and gastrointestinal tract. Of course, resuming consumption of high gluten flours in commercial food products will probably again trigger an exagerrated antibody response.

Standard medicine does not have effective holistic therapy to correct this immune function and intestinal health. Many medical doctors are now utilizing tests for allergies, such as blood tests and skin prick challenges, that give some pertinent data, but are not conclusive. The advice to the patient is often to avoid a lot of healthy foods, and the fear of foods generated can be a problem for one's health that is greater than the allergies. The patient can seek help with Complementary Medicine to correct the underlying health problems as they avoid the foods that they may be allergic to, and eventually resume consumption of a variety of healthy foods in their diet. Patients that choose the common path in standard medicine, which generally supports steroid and antihistamine medications with chronic use, avoidance of many foods, and often even the cynical advice to avoid herbal therapy, often find themselves with a deteriorating health problem, even as the harsh medications relieve some of the symptoms. There is a healthier approach that restores health, and Complementary Medicine improves its approach each year with new research.

Herbal products

A variety of herbal formulas are prescribed in the treatment of asthma and CPOPD, depending upon the individual and the needs of the case. Some herbs are very effective to calm bronchospasm and constriction. Ephedra is still the most effective bronchodilator in the world and is used in small doses infrequently for safety and effectiveness, and in formulas that modify its effects. Substitutes for ephedra are also very effective and frequently used since the controversies concerning overuse of ephedra in so many diet products, sports supplements and phen-fen causing health problems. In addition, a variety of formulas successfully both calm asthmatic triggers and aid the immune responses. Studies comparing simple herbal formulas to the most common pharmacueutical products showed that herbal formulas could perform better than the pharmaceuticals. Researchers at Stanford, Mount Sinai and other prestigious universities conducted rigorous studies that surprised the medical profession. A knowledgeable herbalist is the key. In severe cases, the herbal protocol needs to be adjusted in response to changes in symptoms and course of the disease. The goal of herbal therapy is not just a suppression of symptoms, so symptoms may change and vary during the course of the therapy. Monitoring of these changes and effective response by the herbalist is often important.

One of the heavily researched formulas of Chinese herbs was called MSSM-02, or the second in the common formulas heavily researched in the treatment of allergic asthma. This formula consists of Ling zhi (reishi mushroom), gan cao (licoric root), ku shen (sophorae flavascentis root), su zi (perilla seed), ting li zi (lepidii seed), xing ren (the inner core of the prune pit), huang qin (scutellaria baicalensis), dang gui, bai shao (peony root), ge gen (kudzu), jie geng (balloon flower root, or platycodi), zhen zhu mu (mother of pearl powder), da zao (jujube fruit), and sheng jiang (fresh ginger). Documentation of the effectiveness is found below in a link to the NIH PubMed database of health science published studies.

Combining acupuncture, diet and lifestyle changes and herbal medicine offers a complete and effective package for both managing and curing asthma and COPD. Persistence and consistency in the treatment usually results in eventually being able to bring these problems down to a mild case that no longer requires regular treatment or products.

Information Resources

The information below represents just a small portion of the sound research information now available to the public concerning asthmatic therapies and herbal medicine. The research oriented Licensed Acupuncturist accesses this information to better guide therapy.

  1. Current debate illustrated in a New York Times article of Dec. 5, 2008, Warnings Given on Four Popular Asthma Drugs, but Debate Remains http://www.nytimes.com/2008/12/06/health/policy/06allergy.html?em If you have trouble accessing this database by clicking on this address, try searching for the article on Google.
  2. Report of the NIH expert panel on food allergy research 2006: http://www3.niaid.nih.gov/topics/foodAllergy/PDF/FoodAllergyExpertReport.pdf If you have trouble accessing this database by clicking on this address, try searching for the article on Google.
  3. Study in 2004 at Mount Sinai School of Medicine in New York found that a commonly used Chinese herbal formula, termed MSSM-02, was effective in treating allergic asthma and had beneficial immunoregulatory or modulatory actions that posed less chance of side effects than comparable pharmaceuticals: http://www.ncbi.nlm.nih.gov/pubmed/15330010.
  4. Study in 2007 at the National Taiwan University found that the Chinese herb Ganoderma tsugae (Ling zhi, or Reishi mushroom) exerted potent anti-inflammatory effects on asthmatic airway reponses and attenuated the immune reaction specifically without overall immune suppression seen in pharmaceuticals such as prednisone: http://www.ncbi.nlm.nih.gov/pubmed/17191006.
  5. A 2005 double-blinded placebo-controlled study conducted by Mount Sinai School of Medicine in New York jointly with Weifang Asthma Hospital and School of Medicine in China, found that a combination of Ling zhi (Reishi mushroom), Ku shen (Sophora bark) and Gan cao (licorice root) performed almost as well as prednisone in a large scale human study, and was found to be as effective as corticosteroid therapy to control asthma symptoms and cough after 2 weeks of therapy: http://www.nutricology.com/In-Focus-Newsletter-August-2006-Chinese-Herbs-sp-37.html.
  6. Safety and efficacy trials of the 3-herb formula, Lingzhi, Kushen and Gancao cited above were tested for safety and efficacy in 2009 in a randomized, placebo-controlled, dose escalation phase 1 trial and found to demonstrate safety and tolerability over a prolonged period of use: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830609/.
  7. Study in 2008 at the Fudan University, Shanghai, China, found that the Chinese herb Epimedium (Yin yang huo) was effective in alleviating the attack stages of asthmatic inflammation by decreasing the gene expression of the inflammatory chemokine RANTES and MCP-3 in lung tissue: http://www.ncbi.nlm.nih.gov/pubmed/18476425.
  8. Study in 2010 at the Federal University of Sao Paulo, Brazil, found that electroacupuncture could be an important complementary treatment for asthma, balancing the Th1/Th2 T-cell responses, increasing IL-1 and IFN-gamma, while decreasing IL-4, IL-10, Nitric oxide, and Leukotriene B4. Previous study had shown that eosinophil infiltration into the lung tissue was decreased with use of electroacupuncture: http:/www.ncbi.nlm.nih.gov/pubmed/20231101.

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.