Asthma Management Handbook

Providing information about the efficacy of complementary therapies

Recommendations

If patients are interested in using complementary therapies, provide reliable information about evidence for efficacy or lack of efficacy to help them make a well-informed decision. Explain that very few complementary therapies have been shown to be effective in asthma.

Table. Summary of efficacy evidence for complementary therapies Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/78

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Explain to patients that an AUST L label does not indicate that a product is effective.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Discussing complementary medicines with patients

For more information about discussing complementary medicines with patients and monitoring their effects, refer to National Asthma Council Australia’s information paper for health professionals Asthma and complementary therapies.1

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Regulation of complementary medicines and therapies (AUST L & AUST R)

Under the Therapeutic Goods Act 1989 (Commonwealth), all products in Australia for which therapeutic claims are made must be on the Australian Register of Therapeutic Goods and must carry either an Australian Listing (AUST L) or Australian Registration (AUST R) number on their label.

An AUST L number issued by the Therapeutic Goods Administration indicates that the product ingredients have been assessed for quality and safety, and have not been associated with major toxicity or side effects. AUST L listing does not indicate that a product is effective; AUST L numbered products do not undergo efficacy assessment.

An AUST R number indicates that a medicine is registered by the Therapeutic Goods Administration and has been assessed for safety, quality and effectiveness. Registered medicines include all prescription-only medicines and many over-the-counter medicines.

A ‘complementary medicine’ is defined in the Australian Therapeutic Goods Regulations 1990 as a therapeutic good consisting principally of one or more designated active ingredients (listed in Schedule 14 of the Regulations), each of which has a clearly established identity and traditional use.2 Complementary medicines regulated under the Therapeutic Goods Act 1989 include medicinal products containing herbs, vitamins, minerals, nutritional supplements, homoeopathic and certain aromatherapy preparations.2

State governments regulate practitioners of complementary therapies. This means that the laws differ between states.

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Efficacy of physical therapies and practices

Acupuncture

A systematic review reported that acupuncture had no statistically significant or clinically relevant effects, compared with sham acupuncture, and that the quality of evidence was generally poor.3 Other systematic reviews have concluded that clinical evidence does not support  the use of acupuncture in asthma,4 and that there is insufficient and poor quality evidence on which to judge efficacy.5

Buteyko technique (breathing exercise)

Buteyko breathing technique has been reported to improve quality of life in people with asthma and may reduce reliever requirement,6 but control groups in clinical trials have not been instructed to deliberately reduce reliever use (a component of Buteyko breathing technique). It has not been shown to improve objective measures of lung function.

Chiropractic

Chiropractic spinal manipulation has not been shown to improve asthma in sham manipulation-controlled randomised clinical trials.78

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Efficacy of ‘natural’ products and medicines

Caffeine

Caffeine improves lung function in people with asthma for up to 4 hours.9 The main implication of this finding is that drinking coffee before a spirometry test may give a misleading result.

A meta-analysis found that it was not possible to conclude whether caffeine improves asthma symptoms.9 Some small studies have reported that caffeine improves exercise-induced bronchoconstriction.1 The dose needed to improve symptoms may be so high that it is associated with intolerable adverse effects (e.g. agitation, tremor, gastrointestinal upset, increased heart rate and blood pressure).9

Cineole

Cineole (the main constituent of eucalyptus oil) may improve lung function, asthma symptoms, and quality of life when taken orally.10 However, there is insufficient evidence for its safety with systemic use.

Fish oil

Fish oil supplementation does not appear to improve asthma control.11

Herbal medicines

Overall, clinical trials have not clearly shown that herbal medicines benefit patients with asthma. Most clinical trials have involved small sample sizes, short duration, and poor methodology.12 Single studies of Boswellia, Mai-Men-Dong-Tang, Pycnogenol, Jia-Wei-Si-Jun-Zi-Tang and Tylophora indica have reported improved lung function, and a study of eucalyptol reported reduced daily oral steroid dosage.12 Overall, reported improvements in symptoms have not been strongly supported by objective changes.12

The Ephedra sinica (ma huang) plant, which contains ephedrine, has been used to treat asthma in traditional Chinese medicine.13 Ephedra is associated with clinical serious adverse effects, including heart attack, stroke, seizure, and death.14 The sale of Ephedra is prohibited in Australia.15

Ginkgo biloba has been reported to improve asthma symptoms, but has been associated with adverse effects including headache, nausea, dizziness, palpitations and allergic skin reactions.1

Homeopathy

Homeopathy has not been shown to improve asthma symptoms.16 Randomised placebo-controlled clinical trials have reported inconsistent effects on lung function.16 However, standardised homeopathy protocols used in randomised clinical trials are unlikely to be representative of homeopathic treatment used in practice,16 which is often individualised.

Magnesium (oral supplements)

Overall, evidence from randomised controlled clinical trials does not support routine use of long-term oral magnesium supplementation in the treatment of asthma.17

  • A placebo-controlled clinical trial reported improvements in lung function and quality of life, compared with baseline, in adults with asthma who took oral magnesium supplements for 6.5 months. The intervention group showed improvement in quality of life and asthma control compared with baseline, but the study did not report comparisons with placebo.18
  • Another small clinical trial in adults reported that magnesium supplementation was associated with improvement in symptom scores, compared with placebo.19
  • Another clinical trial in adults with asthma reported no benefit from 16 weeks’ oral magnesium supplementation, compared with placebo.20
  • A small clinical trial in children reported that 2 months’ treatment with oral magnesium was associated with reduced flare-ups compared with placebo, but did not affect lung function.21
  • Another small clinical trial in children reported that 12 weeks’ treatment with oral magnesium reduced reliever use, compared with placebo.22

Note: IV and nebulised magnesium sulfate may be used in the management of acute asthma.

Vitamin D

A single small randomised controlled trial in children with newly diagnosed asthma who were sensitised only to house dust mite, reported that Vitamin D supplementation reduced the risk of asthma flare-ups triggered by acute respiratory infections.23 There is not enough high-quality evidence to recommend this as a routine treatment in Australian children.

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Efficacy of ‘mind-and-body’ therapies

Relaxation techniques

Overall, relaxation techniques do not appear to be effective in the management of asthma.24

Meditation

Few well-designed studies have assessed meditation,24 and available clinical literature does not clearly separate its effects from those of other relaxation techniques.1 One randomised controlled trial reported that mindfulness meditation improved quality of life in adults, compared with asthma education.25

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Efficacy of dietary restrictions

A low-sodium diet does not appear to improve asthma control.26 Some small clinical trials have suggested that, in people with exercise-induced bronchoconstriction, a low-sodium diet might improve lung function after exercise, but the clinical importance of this is unknown.26

Overall, evidence from studies assessing links between the common food additive tartrazine (FSANZ number 102) does not show that tartrazine worsens asthma, or that avoiding tartrazine improves asthma for people without known sensitivity to tartrazine.27

There is not enough evidence to determine whether or not avoidance of monosodium glutamate (FSANZ number 621) affects asthma control.28

Eliminating dairy foods is not an effective strategy for improving asthma control in people without proven allergies to dairy foods, and could impair nutrition, growth or bone density.1 Food allergies rarely trigger asthma.29

Table. Effects of dietary strategies in asthma management Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/56

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References

  1. National Asthma Council Australia. Asthma and complementary therapies. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/asthma-complementary-therapies-hp
  2. Department of Health, Therapeutic Goods Administration. An overview of the regulation of complementary medicines in Australia. Therapeutic Goods Administration, Canberra, 2013. Available from: http://www.tga.gov.au/industry/cm-basics-regulation-overview.htm
  3. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database Syst Rev. 2003; Issue 3: CD000008. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000008.pub2/full
  4. Passalacqua G, Bousquet PJ, Carlsen KH, et al. ARIA update: I—Systematic review of complementary and alternative medicine for rhinitis and asthma. J Allergy Clin Immunol. 2006; 117: 1054-1062. Available from: http://www.jacionline.org/article/S0091-6749(05)04028-5/fulltext
  5. Suzuki M, Yokoyama Y, Yamazaki H. Research into acupuncture for respiratory disease in Japan: a systematic review. Acupunct Med. 2009; 27: 54-60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19502460
  6. Burgess J, Ekanayake B, Lowe A, et al. Systematic review of the effectiveness of breathing retraining in asthma management. Expert Rev Respir Med. 2011; 5: 789-807. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22082165
  7. Balon J, Aker PD, Crowther ER, et al. A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma. N Eng J Med. 1998; 339: 1013-1020. Available from: http://www.nejm.org/doi/full/10.1056/NEJM199810083391501#t=article
  8. Nielsen NH, Bronfort G, Bendix T, et al. Chronic asthma and chiropractic spinal manipulation: a randomized clinical trial. Clin Exp Allergy. 1995; 25: 80-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7728627
  9. Welsh EJ, Bara A, Barley E, Cates CJ. Caffeine for asthma. Cochrane Database Syst Rev. 2010; Issue 1: CD001112. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001112.pub2/full
  10. Worth H, Dethlefsen U. Patients with asthma benefit from concomitant therapy with cineole: a placebo-controlled, double-blind trial. J Asthma. 2012; 49: 849-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22978309
  11. Thien FC, De Luca S, Woods RK., Abramson MJ. Dietary marine fatty acids (fish oil) for asthma in adults and children. Cochrane Database Syst Rev. 2002; Issue 2: CD001283. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001283/full
  12. Clark CE, Arnold E, Lasserson TJ, Wu T. Herbal interventions for chronic asthma in adults and children: a systematic review and meta-analysis. Prim Care Respir J. 2010; 19: 307-14. Available from: http://www.nature.com/articles/pcrj201041
  13. National Drug Research Institute, Australian Institute of Criminology. National Amphetamine-Type Stimulant Strategy background paper: monograph series no. 69. Department of Health and Ageing, Canberra, 2007. Available from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/mono69
  14. Schulman S. Addressing the potential risks associated with ephedra use: a review of recent efforts. Public Health Rep. 2003; 118: 487-92. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497604/
  15. Standards Australia. Australia New Zealand Food Standards Code: Standard 1.4.4 – Prohibited and Restricted Plants and Fungi (F2011C00580). Department of Health and Ageing, Canberra, 2011. Available from: http://www.comlaw.gov.au/Details/f2011c00580
  16. McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database Syst Rev. 2004; Issue 1: CD000353. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000353.pub2/full
  17. Rowe BH, Camargo CA. The role of magnesium sulfate in the acute and chronic management of asthma. Curr Opin Pulm Med. 2008; 14: 70-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18043278
  18. Kazaks AG, Uriu-Adams JY, Albertson TE, et al. Effect of oral magnesium supplementation on measures of airway resistance and subjective assessment of asthma control and quality of life in men and women with mild to moderate asthma: a randomized placebo controlled trial. J Asthma. 2010; 47: 83-92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20100026
  19. Hill J, Micklewright A, Lewis S, Britton J. Investigation of the effect of short-term change in dietary magnesium intake in asthma. Eur Respir J. 1997; 10: 2225-9. Available from: http://erj.ersjournals.com/content/10/10/2225.abstract
  20. Fogarty A, Lewis SA, Scrivener SL, et al. Oral magnesium and vitamin C supplements in asthma: a parallel group randomized placebo-controlled trial. Clin Exp Allergy. 2003; 33: 1355-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14519140
  21. Gontijo-Amaral C, Ribeiro MA, Gontijo LS, et al. Oral magnesium supplementation in asthmatic children: a double-blind randomized placebo-controlled trial. Eur J Clin Nutr. 2007; 61: 54-60. Available from: http://www.nature.com/ejcn/journal/v61/n1/full/1602475a.html
  22. Bede O, Suranyi A, Pinter K, et al. Urinary magnesium excretion in asthmatic children receiving magnesium supplementation: a randomized, placebo-controlled, double-blind study. Magnes Res. 2003; 16: 262-70. Available from: http://www.jle.com/en/revues/bio_rech/mrh/e-docs/00/03/FD/CE/article.phtml
  23. Majak P, Olszowiec-Chlebna M, Smejda K, Stelmach I. Vitamin D supplementation in children may prevent asthma exacerbation triggered by acute respiratory infection. J Allergy Clin Immunol. 2011; 127: 1294-6. Available from: http://www.jacionline.org/article/S0091-6749(10)01957-3/fulltext
  24. Huntley A, White AR, Ernst E. Relaxation therapies for asthma: a systematic review. Thorax. 2002; 57: 127-131. Available from: http://thorax.bmj.com/content/57/2/127.full
  25. Pbert L, Madison JM, Druker S, et al. Effect of mindfulness training on asthma quality of life and lung function: a randomised controlled trial. Thorax. 2012; 67: 769-76. Available from: http://thorax.bmj.com/content/67/9/769.long
  26. Pogson Z, McKeever T. Dietary sodium manipulation and asthma. Cochrane Database Syst Rev. 2011; Issue 3: CD000436. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000436.pub3/full
  27. Ardern KD, Ram FS. Tartrazine exclusion for allergic asthma. Cochrane Database Syst Rev. 2001; Issue 4: CD000460. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000460/full
  28. Zhou Y, Yang M, Dong BR. Monosodium glutamate avoidance for chronic asthma in adults and children. Cochrane Database Syst Rev. 2012; 6: CD004357. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004357.pub4/full
  29. National Asthma Council Australia. Asthma and allergy. National Asthma Council Australia, Melbourne, 2012. Available from: http://www.nationalasthma.org.au/publication/asthma-allergy-hp