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Asthma is a lifelong diagnosis that has become epidemic as doctors routinely prescribe inhalers for prolonged viral infections.  Anyone who understands that steroid inhalers actually depress the immune response will share my dismay.  The following is a letter I wrote several concerned parents. 

Dear friends:

I looked up asthma to see why they diagnosed it so quickly with your son. Turns out we just had a new expert panel report this year that altered the 1991 report and made it pretty clear that we're going to see a great deal more asthma in the near future.

The complete report is available on: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm as the National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

I have taken the liberty of printing out a few pages and highlighting why I think your son has been diagnosed.

Page 8 of the report lists the current definition of asthma as a chronic inflammation disorder of the airways. As a diagnosis of exclusion, all that needs to be done to diagnose is not to find another cause. On page 22, another possible diagnosis of your son's condition could be "a recurrent cough not due to asthma." But because the preliminary results of studies show that the medication may positively alter the course of asthma, there is no downside for an MD to prescribe for asthma, and they would be liable if they did not.

I was under the impression that a saliva smear for eosinophils, one of the body's immune response cells, was standard for the diagnosis. It seems that the diagnosis has extended (descended?) to a simple trial with the albuterol. If it makes your breathing easier, you had asthma and you are now controlled.

On page 16, you see the indicators for asthma. Under these guidelines, when I had chronic bronchitis, I had asthma. Currently, because it is hard for me to breathe when I paint (airborne chemicals) or when I stand downwind of a campfire (smoke), I would be defined as having asthma. The questions on page 19 ask me if I have had shortness of breath in the last year (yes, after being in a closed room with paint), a bad cold go to my chest (yes, I have a three-year-old and work with sick people), coughing during a certain season (yes, when the pollen is really heavy), when exposed to certain things (pepper, dust, cement, etc.), and if I ever get short of breath after exercise (it depends on how fast I run). I am absolutely certain I could get an albuterol prescription tomorrow if I wanted it, and if I was short of breath from any of these things massively increasing the size of my airway would probably help me breathe easier. So I am afraid, under the same definition, my wife, my son, your son, and both of you have asthma. Given the definition, I can't think of many people who don't.

The report goes into a very helpful discussion of allergic response which made me think that this time of year is the time of year when things get moist and don't dry as fast with the cooler temperatures. We also start closing windows at night, so our exposure to inside dust mites and molds increases while our fresh air exposure decreases. In Oregon, the only way I could get a good night's rest was to have a hepa air filter in the room blowing on my face. Once it gets really cold and the furnace goes on, the humidity inside should drop again, making things less of a problem.

So I apologize for my confusion about asthma. It seems clear to me that the diagnosis of asthma is not what it once was, a distinct, life threatening illness. Instead, I can assure most of my patients (once in practice) that we all have at least "mild, intermittent asthma."

I hope your son is better.
J Allergy Clin Immunol. 2001 Feb;107(2):398-416. Related Articles, Links
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Advair: combination treatment with fluticasone propionate/salmeterol in the treatment of asthma.

Nelson HS.

National Jewish Medical and Research Center, Denver, Colo 80206, USA.

Several classes of medications are available for the treatment of asthma, and often they must be taken concurrently to achieve asthma control. Based on the understanding of asthma as an inflammatory disease, the National Heart Lung and Blood Institute guidelines provide a stepwise approach to pharmacologic therapy. Corticosteroid therapy, principally inhaled corticosteroid (ICS) therapy, is considered the most effective anti-inflammatory treatment. In cases of moderate-to-severe persistent asthma, the addition of a second long-term control medication to ICS therapy is one recommended treatment option. A combination-product inhaler (Advair, Seretide) was developed to treat both the inflammatory and bronchoconstrictive components of asthma by delivering a dose of the ICS, fluticasone propionate, and a dose of the long-acting beta2-adrenergic (LABA) bronchodilator, salmeterol. The Advair Diskus is available in 3 strengths of fluticasone propionate (100, 250, and 500 microg) and a fixed dose (50 microg) of salmeterol. Combination treatment with both ICS and LABA provides greater asthma control than increasing the ICS dose alone, while at the same time reducing the frequency and perhaps the severity of exacerbations. Furthermore, salmeterol added to ICS therapy provides superior asthma control compared with the addition of leukotriene modifiers or theophylline. The superior control is likely a consequence of the complementary actions of the drugs when taken together, including the activation of the glucocorticoid receptor by salmeterol. By combining anti-inflammatory treatment with a long-acting beta2-agonist in a single inhaler (1 inhalation twice daily), physicians can provide coverage for both the inflammatory and bronchoconstrictive aspects of asthma without introducing any new or unexpected adverse consequences. The most common drug-related adverse events were those known to be attributable to the constituent medications (ICS therapy and/or LABA therapy). Although the benefits of combined ICS plus LABA therapy can be achieved with separate inhalers, the convenience of the combination product may improve patient adherence and may therefore reduce the morbidity of asthma.

Publication Types:

* Review


PMID: 11174215 [PubMed - indexed for MEDLINE]
Oral Dis. 2005 Sep;11(5):303-8. Related Articles, Links
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Oral health in patients on inhaled corticosteroid treatment.

Komerik N, Akkaya A, Yildiz M, Buyukkaplan US, Kuru L.

Department of Oral Surgery, Faculty of Dentistry, Suleyman Demirel University, Isparta, Turkey. nkomerik@med.sdu.edu.tr

OBJECTIVE: The aim of this study was to investigate the effects of long-term inhaled corticosteroids on bone mineral density (BMD) of the mandible in relation with the tooth loss. DESIGN: Cross sectional analytic study. SUBJECTS AND METHODS: Patients (n = 30) with chronic obstructive pulmonary disease under inhaled corticosteroid therapy for at least 1 year were compared with sex- and age-matched healthy controls (n = 30). BMD of the mandible was measured by dual-energy X-ray absorptiometry. The clinical examination included recording the number of teeth present together with periodontal condition. Levels of serum osteocalcin, alkaline phosphatase, calcium, phosphorus and cortisol were also assessed. RESULTS: BMD of the mandible in patients on corticosteroid treatment was significantly lower than that in the control group (P = 0.001). Patients under treatment had more missing teeth than the control group but the difference did not reach statistical significance. The two groups exhibited similar clinical parameters of periodontal condition. Significantly lower levels of osteocalcin (P < 0.0001), calcium (P = 0.004) and cortisol (P = 0.03) were observed in the patients on corticosteroid treatment. CONCLUSION: Long-term use of inhaled corticosteroids may impair bone metabolism and lead to a marked decrease in the mandibular BMD.

PMID: 16120117 [PubMed - indexed for MEDLINE]
Ann Allergy Asthma Immunol. 2004 Feb;92(2):201-7; quiz 207-8, 267. Related Articles, Links

Impact of long-term inhaled corticosteroid therapy on bone mineral density: results of a meta-analysis.

Halpern MT, Schmier JK, Van Kerkhove MD, Watkins M, Kalberg CJ.

Exponent, Alexandria, Virginia, USA. mhalpern@exponent.com

BACKGROUND: The impact of long-term inhaled corticosteroid (ICS) therapy on bone mineral density (BMD) is poorly understood. OBJECTIVE: To evaluate the impact of long-term ICS use on BMD. METHODS: Random-effects meta-analysis. Published and unpublished literature were identified by searches of MEDLINE and EMBASE databases and consultation with experts. Studies reporting BMD among adult asthma and chronic obstructive pulmonary disease (COPD) patients using ICS and non-ICS controls were identified. Studies selected for review included at least 1 year of follow-up. Two independent reviewers evaluated studies; data from those meeting specified inclusion criteria were abstracted for inclusion in the meta-analysis. RESULTS: Fourteen (5.3%) of 266 reviewed studies met specified inclusion criteria. Sufficient data were available to perform meta-analysis on 3 measures for ICS-using patients (lumbar, femoral neck, and major trochanter BMD) and 1 measure (lumbar BMD) for non-ICS-using controls. Using current National Asthma Education and Prevention Program definitions, the majority of studies (12 of 14) included patients receiving moderate to high doses of ICSs. Among ICS users, annual changes from baseline in lumbar, femoral neck, and major trochanter BMD (-0.23%, -0.17%, and +1.46%, respectively) were not statistically significant. Mean changes in lumbar BMD were also not significantly different from controls (-0.02%). Further, annual changes in lumbar BMD were not statistically significant for subgroups of patients with asthma or COPD. CONCLUSIONS: Long-term use of ICSs in patients with asthma or COPD was not associated with significant changes in BMD.

Publication Types:

* Meta-Analysis


PMID: 14989387 [PubMed - indexed for MEDLINE]
Thorax. 2006 Jan 31; [Epub ahead of print] Related Articles, Links
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Adding salmeterol to an inhaled corticosteroid: long-term effects on bronchial inflammation in asthma.

Koopmans JG, Lutter R, Jansen HM, van der Zee JS.

Academic Medical Centre / University of Amsterdam, Netherlands.

Background: Adding the long-acting beta(2)-agonist salmeterol to inhaled corticosteroids leads to better symptomatic asthma control than increasing the dose of inhaled corticosteroids. However, little is known about the long-term effects of adding salmeterol on the asthmatic inflammatory process, control of which is considered important for the long-term outcome of asthma. Methods: After a 4-week fluticasone run-in period, we randomized 54 allergic asthmatics to receive 1 year of twice daily treatment with fluticasone 250 microg with or without salmeterol 50 microg, in a double-blind, parallel group design (total daily dose of fluticasone 500 microg in both treatment groups). Primary outcomes were sputum eosinophil numbers and eosinophil cationic protein concentrations. Secondary outcomes were neutrophil-associated sputum parameters and a respiratory-membrane permeability marker. Effects on allergen-induced changes were determined before and at the end of the randomized treatment period. Results: Adding salmeterol to fluticasone resulted in improved peak expiratory flows, symptom scores, rescue- medication-usage and bronchial hyperresponsiveness (p-values <0.05). We found no sustained effect on sputum cell differentials and cytokine concentrations, neither throughout the treatment period nor on changes induced by the end-of-treatment allergen challenge (p-values >0.05). However, adding salmeterol significantly reduced sputum ratios of alpha(2)-macroglobulin and albumin throughout the randomized treatment period (p=0.001). Conclusions: This study shows no sustained effect on (allergen-induced) cellular bronchial inflammation, but a significant improvement in size selectivity of plasma protein permeation across the respiratory membrane by adding salmeterol to fluticasone. Possibly, this phenomenon contributes to the improved clinical outcomes that result from adding a long-acting beta(2)-agonist to inhaled corticosteroids.

PMID: 16449264 [PubMed - as supplied by publisher]
Ann Allergy Asthma Immunol. 2004 Feb;92(2):250-4. Related Articles, Links

The effects of butterbur on the histamine and allergen cutaneous response.

Jackson CM, Lee DK, Lipworth BJ.

Tayside Centre for General Practice, University of Dundee, Dundee, Scotland.

BACKGROUND: Butterbur or Petasites hybridus is an herbal remedy that exhibits antihistamine and antileukotriene activity and has been shown to attenuate the response to adenosine monophosphate challenge in patients with allergic rhinitis and asthma. However, no data are available regarding its effects on the histamine and allergen cutaneous response. OBJECTIVE: To evaluate the effects of butterbur compared with fexofenadine and montelukast on the histamine and allergen wheal and flare cutaneous responses. METHODS: Atopic patients were randomized into a double-blind, double-dummy, crossover study to receive for 1 week butterbur, 50 mg twice daily (8 AM and 10 PM); fexofenadine, 180 mg once daily (10 PM), and placebo once daily (8 AM); montelukast, 10 mg once daily (10 PM), and placebo once daily (8 AM); or placebo twice daily (8 AM and 10 PM). Patients attended the department at 10 AM and had measurements of the cutaneous wheal and flare responses to histamine, allergen, and saline control at 10-minute intervals for 60 minutes. RESULTS: Twenty patients completed the study. The mean +/- SE histamine wheal and flare responses, respectively, were significantly attenuated (P < .05) by fexofenadine (9.4 +/- 1.8 mm2 and 13.5 +/- 3.2 mm2) compared with placebo (15.5 +/- 3.3 mm2 and 179.8 +/- 74.3 mm2) but not by butterbur (16.4 +/- 2.1 mm2 and 297.7 +/- 121.2 mm2) or montelukast (19 +/- 1.9 mm2 and 240.2 +/- 66.6 mm2). The allergen wheal and flare responses, respectively, were also significantly attenuated (P < .05) by fexofenadine (31.1 +/- 6.3 mm2 and 256.9 +/- 86.5 mm2) compared with placebo (65.4 +/- 15.2 mm2 and 1,014.5 +/- 250.0 mm2) but not by butterbur (50.4 +/- 9.2 mm2 and 1,110.3 +/- 256.1 mm2) or montelukast (58.8 +/- 9.1 mm2 and 1,463.6 +/- 295.6 mm2). CONCLUSIONS: Butterbur did not produce any significant effects on the histamine and allergen cutaneous response compared with placebo, whereas mediator antagonism with fexofenadine but not montelukast produced significant attenuation. This finding would suggest that butterbur may not be effective in allergic skin disease.

Publication Types:

* Clinical Trial
* Randomized Controlled Trial


PMID: 14989395 [PubMed - indexed for MEDLINE] Psychother Psychosom. 2005;74(3):165-72. Related Articles, Links
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Effect of self-hypnosis on hay fever symptoms - a randomised controlled intervention study.

Langewitz W, Izakovic J, Wyler J, Schindler C, Kiss A, Bircher AJ.

Division of Psychosomatic Medicine, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland. wlangewitz@uhbs.ch

BACKGROUND: Many people suffer from hay fever symptoms. Hypnosis has proved to be a useful adjunct in the treatment of conditions where allergic phenomena have an important role. METHODS: Randomised parallel group study over an observation period of two consecutive pollen seasons. Outcome data include nasal flow under hypnosis, pollinosis symptoms from diaries and retrospective assessments, restrictions in well-being and use of anti-allergic medication. We investigated 79 patients with a mean age of 34 years (range 19-54 years; 41 males), with moderate to severe allergic rhinitis to grass or birch pollen of at least 2 years duration and mild allergic asthma. The intervention consisted of teaching self-hypnosis during a mean of 2.4 sessions (SD 1.7; range 2-5 sessions) and continuation of standard anti-allergic pharmacological treatment. RESULTS: Of 79 randomised patients, 66 completed one, and 52 completed two seasons. Retrospective VAS scores yielded significant improvements in year 1 in patients who had learned self-hypnosis: pollinosis symptoms -29.2 (VAS score, range 0-100; SD 25.4; p < 0.001), restriction of well-being -26.2 (VAS score, range 0-100; SD 28.7; p < 0.001. In year 2, the control group improved significantly having learned self-hypnosis as well: pollinosis symptoms -24.8 (SD 29.1; p < 0.001), restriction of well-being -23.7 (SD 30.0; p < 0.001). Daily self-reports of subjects who learnt self-hypnosis do not show a significant improvement. The hazard ratio of reaching a critical flow of 70% in nasal provocation tests was 0.333 (95% CI 0.157-0.741) after having learnt and applied self-hypnosis.

Publication Types:

* Clinical Trial
* Randomized Controlled Trial


PMID: 15832067 [PubMed - indexed for MEDLINE]
J Am Osteopath Assoc. 2005 Jan;105(1):7-12. Related Articles, Links
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Effects of osteopathic manipulative treatment on pediatric patients with asthma: a randomized controlled trial.

Guiney PA, Chou R, Vianna A, Lovenheim J.

Family Practice Residency Program, Department of Family Practice, Peninsula Hospital Center, 51-15 Beach Channel Dr, Far Rockaway, NY 11691-1042, USA. pagdophc@netscape.net

Asthma is a common chronic condition that has long plagued the pediatric patient population. Asthma in children can cause excessive school absenteeism, hospitalizations, and even death. Osteopathic manipulative treatment (OMT) is an underutilized noninvasive treatment method for patients with asthma. The use of OMT may help decrease mortality and morbidity rates among this patient group. The authors conducted a randomized controlled trial attempting to demonstrate the therapeutic relevance of OMT in the pediatric asthma population. With a confidence level of 95%, results for the OMT group showed a statistically significant improvement of 7 L per minute to 9 L per minute for peak expiratory flow rates. These results suggest that OMT has a therapeutic effect among this patient population. The authors suggest that more clinical trials are required to better demonstrate the effectiveness of OMT in patients with asthma.

Publication Types:

* Clinical Trial
* Randomized Controlled Trial


PMID: 15710659 [PubMed - indexed for MEDLINE]
Br Homeopath J. 2001 Apr;90(2):73-8. Related Articles, Links

Prophylactic and acute treatment with the homeopathic medicine, Betula 30c for birch pollen allergy: a double-blind, randomized, placebo-controlled study of consistency of VAS responses.

Aabel S.

Institute of General Practice and Community Medicine, Department of General Practice, University of Oslo, Norway. siri.aabel@samfunnsmed.uio.no

A study of the consistency of responses by allergic patients in repeated studies of the homeopathic remedy Betula 30c or placebo against birch pollen allergy, was made. A randomized, double-blind, placebo-controlled trial was performed including participants with a known allergy to birch pollen. Allergy symptoms were assessed on a visual analogue scale (VAS) by patients or parents each day during a 20-day period during two different pollen seasons. The work was carried out in Oslo, Norway during May 1995, 1996 and 1997. There were 51 patients ranging in age from 7 to 50y. The homeopathic remedy Betula 30c or placebo was given as tablets, both as a prophylactic agent, once a week for 4 weeks before the pollen season started, and as an acute remedy during the pollen season. The mean value of the symptom scores on the visual analogue scale, for all registration days from each patient was the main outcome. The patient groups that received either placebo or Betula 30c for two successive years showed a consistent response (r=0.75, P=0.01 and r=0.70, P=0.003, respectively). No such correlation was found in the two groups that changed remedy from one year to another (either from placebo to Betula or vice versa). Subjective assessment of allergic symptoms to birch pollen differed more from one year to another when different regimens (placebo or homeopathic) had been administered these two seasons, than when the same treatment had been given.

Publication Types:

* Clinical Trial
* Randomized Controlled Trial


PMID: 11341460 [PubMed - indexed for MEDLINE]

 (207) 623-1681 Maloney Medical, 4 Drew St., Augusta ME 04330 docleroymaloney@hotmail.com 
"If you get hit by a bus, go see your MD.  If you just feel like you were, it's time to see me."  

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