Alternative medicine for allergy and asthma.

Orthodox medical approaches to asthma and allergic respiratory diseases are provided in guidelines developed by professional societies and national or state organizations that represent organized medicine. Alternative therapies may include such orthodox medical therapies as obsolescent formerly used agents, unusual but accepted agents, and agents that are in favor for orthodox therapy in other countries. However, the current growth of complementary and alternative medicine is based on the use of nonorthodox remedies that are becoming increasingly popular with patients and that should be familiar to physicians. Asthma and allergies are frequently treated with such remedies by patients, either as part of self-therapy or on the advice of a complementary and alternative medicine practitioner. The most popular alternative medical treatments are herbs (Western and Asiatic), acupuncture, various types of body manipulation, psychologic therapies, homeopathy, and unusual allergy therapies. There is little evidence in favor of most of these unorthodox treatments, although they are very often reported on favorably by patients. The published evidence that might support some alternative medical practices is reviewed so as to help physicians select alternatives that could appropriately be integrated into orthodox practice.

Recent advances in alternative therapies.

Complementary and alternative medicine (CAM) is becoming more popular, and CAM remedies are used instead of, or integrated with, orthodox allopathic therapies by many patients with asthma. Although most CAM remedies may have no discernible effects when analyzed by conventional medical techniques, some double-blind controlled studies do suggest that a meaningful benefit can be obtained with acupunture and homeopathic management in asthma. Herbal medicine is more popular, despite little evidence that the vast majority of herbs for asthma have any useful effects other than a nonspecific expectorant action. Dietary adjustment may benefit a small percentage of patients with asthma, but extreme measures are very rarely indicated. Formal pyschologic approaches can help some patients by reducing anxiety. Although most CAM approaches are harmless, the lack of benefit of many remedies and the potential harm from some of them must be recognized.

Alternative therapies for asthma.

Many traditional drugs and techniques are gaining popularity in the treatment of asthma, although scientific proof of their value is usually inadequate. Alternative remedies, including herbs and nonmedication management techniques, have not been shown to be useful primary measures, but they still appeal to patients who feel unsatisfied with orthodox medicines. Dietary modification may be worth considering; evidence suggests that salt reduction and magnesium supplementation have value in reducing asthmatic symptoms. The evidence on the role of steroid-sparing agents is not encouraging, but administering steroids once a day in the mid-afternoon may provide benefit. New aerosol techniques are appearing, but judgement is needed to select the best device for each medication as well as for each patient.

Controversies in the management of asthma.

The debate persists on the relative role of beta 2-agonists, corticosteroids, and other antiasthmatic drugs, in part because asthma can be so difficult to control. Exploration of the concerns about therapy is followed by practical recommendations.

Psychotropic drugs in terminal care.

Respiratory patients require psychotropic drug administration to treat pain, cough and respiratory distress or to treat insomnia, anxiety, depression or psychosis. Terminal patients require thoughtful and compassionate use of these drugs, even when there is an expectation that such therapy may lead to an earlier death. Most psychotropic agents can be used safely in patients with respiratory disease, and careful use of selected drugs should always be employed if indicated for treating distressful conditions that may be benefitted. Guidelines to appropriate choices and doses are provided.

History of the treatment of chronic bronchitis.

Although chronic bronchitis was first named and described in 1808, the disease has been known since earliest time, and numerous drugs have been utilized in its therapy. The basic historic theories of human function have readily been applied to bronchitis; thus in Greek medicine, the disease was appreciated as one of excess phlegm. Early remedies included garlic, pepper, cinnamon, and turpentine, whereas later therapies of choice emphasized coffee, ipecac, and potassium nitrate. Most of the favored bronchodilator drugs of today are derived from the traditional folk remedies, ephedrine, atropine, and theophylline. The most interesting historical drugs, however, are those that have given rise to modern mucokinetic agents such as bromhexine and iodides.

Pharmacologic therapy of obstructive airway disease.

The pharmacologic treatment of chronic obstructive pulmonary disease (COPD) differs from that of asthma in several respects. Oral therapy should be the keystone, using a long-acting theophylline or a beta 2-sympathomimetic agent. The addition of a metered dose inhalant aerosol provides additive benefit with low toxicity; either a sympathomimetic agent or ipratropium or both should be used. The antiinflammatory aerosols, cromolyn, and steroid drugs are usually of no value, and oral steroids are only indicated if there is an asthmatic component. Mucokinetic agents and antibiotics should be used selectively. The numerous other drugs that may be required by a COPD patient must be prescribed with consideration to the potential for adverse physiologic effects and untoward drug interactions.

Chest diseases: inhaled treatment of asthma.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in chest diseases. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in chest diseases that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Chest Diseases of the California Medical Association, and the summaries were prepared under its direction.

Risk/benefit ratio of long-term treatment with beta 2-adrenoceptor agonists.

Optimal control of chronic obstructive airway disorders is usually achieved with therapy based on beta 2-adrenoceptor agonist administration. Aerosols are highly effective, have few side effects, allow for fine adjustment of dosage to titrate symptoms, and result in reduction in hyperreactivity. Equivalent bronchodilating doses of oral agents cause side effects that limit acceptability. With oral agents, cardiohemodynamic disturbances are usually minor, while tremor and restlessness diminish with continued drug use. In chronic regimens, an aerosol beta 2-adrenergic agent should be chosen whose overall incidence of side effects is less than 5%, and an oral agent that produces no more than a 10% incidence of tremor. Suboptimal oral dosages in combination with maximal dosages of beta 2-agonist aerosol, with or without other bronchodilator drugs, are advisable for chronic therapy. An optimal risk/benefit ratio with broxaterol therapy will probably be achieved by using an aerosol-oral combination. Thus, broxaterol, a new beta 2-agent, should be studied further to determine its value in chronic bronchospastic disorders.