Integrative medicine and allergic disease
اسلاید 1: www.tabaye.ir
اسلاید 2: Integrative medicine and allergic diseaseDenise M Kearney, MDCenter for Allergy, Asthma, and Immunology, Waterbury, CT
اسلاید 3: Denise M Kearney, M.D.Financial:SELF-FUNDEDResearch:only our own patient preferencesLegal Consult/Expert Witness:noneOrganizational: Center for Allergy, Asthma, and ImmunologyGifts:none
اسلاید 4: ObjectivesDefine CAMUnderstand the possible benefits and risks of CAMExamples of role/potential role of CAM in allergic rhinitis, atopic dermatitis, food allergy, and asthmaIdentify resources for CAM education
اسلاید 5: DefinitionComplementary and alternative medicine (CAM) is very broad and constantly changing. “NCCAM defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Complementary medicine“: alternative madicine together with conventional medicine, i.e. neti pot with nasal steroids for allergic rhinosinusitisAlternative medicine refers to use of alternative practices in place of conventional medicine.
اسلاید 6: Integrative MedicineIntegrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness. It is also called integrated medicine. ABIHM 2012 Mimi Guarini, MD “Integrative Medicine is the practice of medicinethat reaffirms the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.”
اسلاید 7: Fig 3Source: Journal of Allergy and Clinical Immunology 2009; 123:283-294.e10 (DOI:10.1016/j.jaci.2008.12.023 )Copyright © 2009 American Academy of Allergy, Asthma & Immunology Terms and Conditions
اسلاید 8: TraditionCAM has been developed over centuries in various cultures, based on teacher apprentice models, observations, and experiences i.e. TCM, ayurvedaWestern “allopathic” medicine is based on “scientific methods” and “evidence-based medicine”: Randomized controlled trials and meta-analyses/clinical reviews (Cochrane)
اسلاید 9: Stats on CAM use from this paperCAM Cost and Spending, 2007 (NCCAM from the NHIS 2007)In 2007, Almost 4/10 adults had used CAM in the past 12 months with the most commonly used therapies being “nonvitamin, nonmineral, natural products” (17.7% i.e. fish oil, echinacea, glucosamine, flaxseed, ginseng)In 2007, approximately 1/9 children used CAM in past 12 months most commonly nonvitamin, nonmineral “natural” productsIn 2007, U.S. adults spent $33.9 billion out-of-pocket on visits to CAM practitioners and purchases of CAM products, classes, and materials.Barnes et. Al. Nat Health Stat Rep. 2008.
اسلاید 10: National Health Information SurveyMost common used: nonvitamin, nonmineral natural products and deep breathing exercises (adult). Nonvitamin, nonmineral natural products and chiropractic or osteopathic manipulation (children)Allergists are more likely to use special diets, US population more likely to use prayer, herbal, chiropractic interventions*Source: Journal of Allergy and Clinical Immunology 2009; 123:283-294.e10 (DOI:10.1016/j.jaci.2008.12.023 )
اسلاید 11: Allergists are interested!Engler et. Al. The Journal of Allergy and Clinical Immunology Volume 123, Issue 2 , Pages 511-512, February 2009
اسلاید 12: Disadvantages to CAM“natural” does not equal safe, i.e. push for FDA regulation of “all natural” on food labelingNo FDA regulationRisk of contaminationAdverse effects and drug/supplement interactions, anaphylaxisLegal considerationsWe often do not use these options because the data is not there: there are no pharmaceutical co’s to fund vitamin and herb trials…role of NCCAM
اسلاید 13: Biologically based systems“Natural” productsDietary supplements, herbal medicines (botanicals), probioticsEvidence found in mummified prehistoric “ice man”, Middle Ages use2007 NHIS (National Health Interview Survey)17.7% American adultsMost popular form of CAMFish oil/omega 3 (adults)Echinacea (children)
اسلاید 14: How should we be using biologically based systems?Diagnosis: BronchitisTx: Take some “antibiotics”If we would not do this in the above example, why do we rationalize recommending some “probiotics”
اسلاید 15: BotanicalsDietary Supplement and Health Education Act (DSHEA): 1994 dietary supplements marketed without prior approval of efficacy and safety by the FDA. “structure and function” claims (no claims made regarding prevention or treatment of a specific disease) Labels also must state that the FDA has not evaluated the product for any claim. German commission E (1994): scientific “expertise” for the approval of substances and products previously used in traditional, folk and herbal medicine, became known beyond Germany for compiling and publishing 380 monographs evaluating the safety and efficacy of herbs for licensed medical prescribing in Germany: political issues implicated in criticisms (JAMA 1999)ABIHM 2012 course curriculum study guide
اسلاید 16: PitfallsActive part of plant: leaf versus root i.e. mullein: leaf for lung, flowers as ear drop in antimicrobialMost appropriate form: whole, fresh versus dried herb, tincture, tea, poultice, liquid extract/tincture, etc. It can be dried and placed into capsules. It can be sprayed onto inert powder or dried plant material, and then pressed into pill form. The liquid may be placed into capsules. Any of these processes can theoretically affect the bioavailability of the plant constituents. : ABHIM 2012 course curriculum study guide
اسلاید 17: Mind and Body medicineMeditation, yoga, acupuncture*, deep breathing exercises, guided imagery, hypnotherapy, progressive relaxation, qi gong*, tai chiCrossover to energy medicine, manipulative practices, whole systems practice (TCM)Popular in top 10 CAM practices reported by adults in NHIS (deep-breathing, meditation, yoga)
اسلاید 18: Other major categories of CAMManipulative and body based practices: Spinal manipulation, massage therapy: chiropractic, osteopathic physiciansMovement therapies: Feldenkrais method, Alexander technique, Pilates, Rolfing, TragerTraditional healers: Native AmericanEnergy medicines: magnet and light therapy, qi gong, Reiki, healing touch, halotherapyWhole medical systems: Ayurveda, traditional Chinese medicine, homeopathy, naturopathy
اسلاید 19: How do I use CAM?Tools in the toolboxAdjunctive to allopathic toolsInterested patientsAdditions to refractory conditions
اسلاید 20: J Allergy Clin Immunol Vol 123, 2, Feb 2009Clinical Reviews in Allergy and ImmunologyCAM: Herbs, phytochemicals and vitamins and their immunologic effects, Mainardi…Bielory et alEfficacy and mechanisms of action of traditional Chinese medicines for treating asthma and allergy, Xiu-Min Li et alCAM for the allergist-immunologist: Where do I start?, Engler et alRole of CAM in the field of allergy and clinical immunology, SampsonLetter to editor: CAM educ: Need for expanded educ resources for AAAAI mbrs, Engler, Silvers, BieloryPrenatal probiotic admin can influence Bifidobacterium development in infants at hi risk of allergy, Lahtinen et
اسلاید 21: EchinaceaSales represent 10% of the dietary supplement industryRecent study showing 10% of 59 commercially avail echinacea preparations contained no measurable amount of echinacea; 43% met quality standards (ConsumerLab)German Commission E approves E Pallida root and E Purpurea herb for chronic respiratory infections, influenza-like infections, lower urinary tract infections, topically for poorly healing wounds/chronic ulcerationsNatural Standard Professional Monograph. 2013Med Lett Drugs Ther 4-1-2002;44(1127):29-30
اسلاید 22: EchinaceaNatural Standard Evidence Table cites 12 systematic reviews/meta-analyses, 20 randomized controlled trials: many positive trials were published prior to 2001 but 3 recent higher quality studies have reported negative effects.Issues include preparation: E. purpurea vs angustifolia, dried herb and/or root, alcohol extract, multiple various doses, and specific use/timing i.e. prevention and/or treatment of URIOne trial showed significantly increased incidence of rash in children receiving echinacea versus placeboCaution again in those with allergies to Asteraceae familyChild Health Alert. 2004 Apr;22:1-2.
اسلاید 23: Probiotics: meta-analyses and systematic reviewsAtopic dermatitis: moderately severe disease more likely to benefitSystematic review of probiotics for treatment of eczema showed no significant evidence in sx scores in favor probiotics, no sig difference in eczema severity ratingSystemic review of probiotics prenatal and post natal efficacy in prevention versus treatment studiesCochrane study of probiotics in infants for prevention of allergic disease and food hypersensitivity* reduction in infant eczema; most significant benefits w L rhamnosus and high risk infants.Boyle et.al. Cochrane 2008 doi 10.1002/14651858.CD006135.pub2MIchail et.al. Ann all asthm immunol 2008. 101:508-16.Lee et.al. JACI 2008. 121:116-21.Osborn et.al. Cochrane 2007: 17: CD006475.
اسلاید 24: JACIMaternal probiotic supplementation during pregnancy and breast-feeding reduces the risk of eczema in the infant 2012. 130: 1355-60.Prenatal probiotic can influence Bifidobacterium microbiota development in infants at high risk of allergy 2009. 123:499-501Early probiotic supplementation for allergy prevention: Long-term outcomes 2012. 130:1209-11Pre and post nasal supplementation for high risk cohort with lactobac rhamnosus GG (Kalliomaki et. al.) and probiotic mixture (lactobaccilli, Bifidobacterium, propionibacterium Kuitunen et al) reduced eczema up to first 7 years of life; and igE associated disease in c/s delivered children respectivelyPost natal supplementation with L acidophilus versus placebo months 0-6 had increased sensitization @ first year; but no significant difference at 5 years of ageClinical and immunological effect of probiotic in childhood atopic dermatitis 2010. 125: AB93: Postnatal study (abstract 40 children) of 7 probiotic strain mixture versus placebo favorable SCORAD in probiotic group
اسلاید 25: Fish oilSmall pilot study of Fish oil supplementation for exercise induced bronchoconstriction improved pulmonary function, use of bronchodilator, and sputum and blood inflammatory markersSmall study using fish oil for mild asthma showed reduced neutrophil inflammatory markers and chemotaxis but no change in asthma severityChest. 2006 129: 39-49.Thorax. 1988 43:84-92.Acta Paediatr. 2009 98:1461-7.
اسلاید 26: Fish oilHigh risk pregnant mothers supplemented with omega 3 polyunsaturated fatty acids from week 25 to 3-4 months breast feeding resulting in significant decrease of food allergy (2 versus 15%) and“igE associated” eczema (8 versus 24%) during year one in offspringDouble blind randomized studies using fish oil versus olive or corn oil showed modest effects on atopic dermatitis with rationale of decreasing redness, scaling, and itching via reduction of inflammatory components of atopic dermBjorneboe et. Al. J Intern Med Suppl 1989.Soyland et. Al. Br J Dermatol 1994.
اسلاید 27: Vitamin DPubmed search: 66 reviews in past 5 years for vitamin D and “allergy” or synonym thereofAsthma: improved lung function, increased corticosteroid responsiveness in adultsDecreased wheeze in children ages 3 and 5 whose mothers were supplemented prenatallyDecreased allergic markers, responsiveness to methacholine and hospitalization in children (Costa Rica)Upper respiratory tract infections (recent URTI, rhinovirus associated wheeze): the jury is outEpipen prescriptions and food allergies: observationalUrticaria and/or atopic dermatitis: theoretical (cathelicidin) and anectodotal
اسلاید 28: Vitamin D ReferencesSutherland ER et.al. Am J Respir Crit Care Med. 2010 April 1; 181(7): 699–704. Published online 2010 January 14. doi: 10.1164/rccm.200911-1710OCCarmargo. Am J Clin Nutr. 2007;85:788–95. Devereux G, Litonjua AA, Turner SW, Craig LC, McNeill G, Martindale S, et al. Maternal vitamin D intake during pregnancy and early childhood wheezing. Am J Clin Nutr. 2007;85:853–9. Ginde AA, et.al. Arch Int Med. 2009;169:384-390 2. Jartti, et.al. AAAAI abstracts #171 2010.Hata TR et.al. J Allergy Clin Immunol 2008;122:928-30.Goetz D. Ann All,Asthma,Immunol 2009;103:A84-85
اسلاید 29: QuercitinAntioxidant flavonoid family present in fruits, vegetables, tea, wine, supplementsArtemesia abrotanum L.: possesses antiinflammatory, expectorant, spasmolytic, antiseptic, and antimicrobial activities: small study with nasal spray for allergic nasal sx showed positive results similar to antihistamine and chromoglicate medications.Remberg et.al. Phytomedicine 2004. 11:36-42.Natural Standard.
اسلاید 30: Stinging nettle:Urtica dioicaAllergic rhinitis: 600mg freeze dried nettle at the onset of symptoms for one week has been used, but only one study cited by most sourcesNettle is generally regarded as safe because the plant is also used as a green, leafy vegetable. Other than urticaria from contacting the stinging hairs (contain histamine, acetylcholine), gastrointestinal discomfort is the only reported adverse effect. Ironically histamine has been used as a local hormone to modulate immune responses and thus the paradoxical antihistamine effects of nettlesPlanta Med. 1990 56:44-47.Natural Standard.Alt Med Rev. 2007 12:280-84.Alt Med Rev. 2000 5:448-454.
اسلاید 31: ButterburPetasin exhibits antileukotriene and antihistamine activity2 studies showed decreased nasal response to AMP challenge comparable to fexofenadine (perennial AR) and over placebo (SAR grass pollen), one study showed SF-36 questionnaire/global impression improvement comparable to cetirazine (50mg qd to qid), one study showed no efficacy over placebo during grass pollen season in SARMigraine prophylaxisCaution should be exercised in patients with known allergy/hypersensitivity to Petasites hybridus or other plants from the Asteraceae/ Compositae family such as ragweed, marigolds, daisies, and chrysanthemums. Hepatotoxic due to pyrrolizidine alkaloids (raw unprocessed plants)Ann All Asthma Immunol. 2004 93: 56-60.BMJ. 2002 Jan 324:144-6Clin Exp Allergy. 2004 34: 646-9.CLin Exp Allergy. 2003. Jul 33: 882-6.
اسلاید 32: EucalyptusAsthma, decongestant/expectorantSmall trial showed reduction in oral steroid dosage for 12/16 200 mg 1.8 cineol (eucalyptol; suppress AA metabolism and cytokine production in monocytes) versus 4/16 placebo steroid dependent asthmaticsMost trial description, randomization, and blinding not well characterized; as well as multiple trials with combination formulations (camphor, menthol, juniper oil) with some positive results for respiratory infections, COPD, and bronchitisTopical use or inhalation use of eucalyptus oil at low concentrations may be safe, although significant and potentially lethal toxicity has been consistently reported with oral use, and may occur with inhalation as well. All routes of administration should be avoided in children. Natural Standard. Respir Med. 2003 97:250-256.
اسلاید 33: OthersBromelain: inhibition of kinins and activation of plasmin reducing edema and inflammation: allergic rhinitis, mucolytic agentSinusitis: mixed results and often used as adjunct to nasal decongestants and antibioticsN acetylcysteine: reduces viscosity of mucous: effective mucolytic agent for chronic bronchitis, cystic fibrosis, asthma, sinusitis, pneumoniaStudies since 1960’s with inhalational and oral NAC up to 600 mg bid chronic bronchitis, inhalational solution for asthmaVitamin C: For PARC: 2 week randomized trial of intranasal vitamin C solution improved nasal secretions, blockage, edema; little detail on selection of patients or dosage of vitamin C most studies for common cold and URTI showing mixed resultsAlt Med Rev. 2000 5:448-454.Natural Standard.Ear Nose Throat J. 1991 70:54-55.
اسلاید 34: Migraine HeadachesVitamin B complex, Vitamin B 2 riboflavin 400 mgFeverfew 125 mg dailyMagnesium work up to 300 mg dailyButterbur 25-75 mg twice dailyHeadache diary; avoid fermented foods like aged cheeses, cured meats, caffeine, chocolate if applicableNatural Standard
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اسلاید 36: YogaAsthma: Three RCTs and one NRCT suggested that yoga leads to a significantly greater reduction in spirometric measures, airway hyperresponsivity, dose of histamine needed to provoke a 20% reduction in forced expiratory volume in the first second, weekly number of asthma attacks, and need for drug treatment. Three RCTs showed no positive effects compared to various control interventions. Posadzki P, Ernst E. J Asthma. 2011 Aug;48(6):632-9.
اسلاید 37: YogaThe jury is out and studies done are generally of “low quality” in regards to blinding, placebo matched control groups: how does one placebo control and blind yoga????!!!To me, this is like stating: “Inhalers are effective asthma”: What kind of yoga are we doing????
اسلاید 38: Breath techniquesSystematic review of RCT’s (41) indicate beneficial effects for quality of life with yoga breathing, Buteyko breathing, and physiotherapist-led breathingCOPD: 16 studies of various breathing techniques including “pranayam yoga breathing” improved 6 minute distance walking with variable effect on dyspnea and well being; but not above that provided by whole body exercise training.*Holland AE et.al. Cochrane Database of Systemic Reviews 2012, DOI: 10.1002/14651858. Burgess et. Al. Expert Rev REspir Med 2011.
اسلاید 39: JournalingPatients (61) with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group.FEV1 improved from 63.9% to 76.3%These gains were beyond those attributable to the standard medical care that all participants were receiving. JAMA. 1999. 281:1304.
اسلاید 40: ResourcesNCCAM:NIH National Center for Complemenatary and Aleterntive Medicine: http://nccam.nih.gov/ Herbs at a glance: 40 of most commonly used herbs in dietary supplements http://nccam.nih.gov/sites/nccam.nih.gov/files/herbs/NIH_Herbs_at_a_Glance.pdf Natural StandardNatural Medicines Comprehensive DatabaseConsumerLab.com: provider of independent test results and information to help consumers and healthcare professionals identify the best quality health and nutrition products
اسلاید 41: NIH National Center for Complementary and Alternative Medicine
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اسلاید 44: Natural StandardThe only independent entity that evaluates all clinical studies on natural productsDatabases for specific medical conditions, Drug-CAM, CAM-CAM interaction checkers and safety pregnancy, lactation dataComplete information on specific brands used in studies if avaliable
اسلاید 45: Natural Medicines Comprehensive Database
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اسلاید 47: Consumer LabUse for biologically based systems: leading provider of independent test results and information to help consumers and healthcare professionals identify the best quality health and nutrition productsThe “Whistle blowers:” regular updates about warning, recalls, toxicities, tainting of nutritional products, unproven supplement claims; this is also provided by Natural Standard
اسلاید 48: Only 42% of adults who used CAM in past 12 mo disclosed this to an MD or DO; of those who had ever used CAM, 58% discussed CAM with any health care professional (HCP)Twice as many patients as HCP initiated the conversation!Those who did not discuss most likely due to HCP never asked or did not know you should; although a sad 12% chose not to discuss b/c HCP would have been dismissive or advised against use of CAM EDUCATION!!!!!AARP and National Center of Complementary and Alternative Medicine Survey Report. April 2011.
اسلاید 49: FeverfewEchinaceaButterburFish oilprobiotic
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