William S. Silvers, M.D.

1. INTEGRATING COMPLEMENTARY MEDICINE (CAM) INTO ALLERGY AND ASTHMAWilliam S. Silvers, M.D.Clinical Professor of MedicineUniversity of Colorado Health Science Centerwww.AllergyAsthmaColorado.com

2. William S. Silvers, M.D. Financial: self-funded Research: only our own patient preferences Legal Consult/Expert Witness: none Organizational: Allergy Asthma Colorado PC Gifts: none Other: (someone’s gotta do this work w/o funding!)

4. What is CAM? NCCAM definition: …”a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”-

5. What is CAM? • COMPLEMENTARY medicine: • used together with conventional medicine. • Aromatherapy to help lessen a patient's discomfort post surgery (ALLERGY: eucalyptus in the steam) • ALTERNATIVE medicine: • used in place of conventional medicine. • Special diet to treat cancer instead of surgery, radiation, or chemotherapy. • (ALLERGY: acupuncture for asthma) • The list of what is considered to be CAM changes continually • New therapies that are proven to be safe and effective become adopted into conventional health care- NCCAM

6. What is CAM? • INTEGRATIVE medicine (NCCAM) • Combines mainstream medical therapies and CAM (“Complementary” WSS) therapies for which there is some high-quality scientific evidence of safety and effectiveness. • ALLERGY: • Yoga type breathing for asthma/VCD

7. Mind-Body Interventions • Uses a variety of techniques to enhance the mind’s capacity to affect bodily functions and symptoms • Meditation / prayer • Patient support groups • Cognitive-behavioral therapy • Mental healing • Art, music, dance • ALLERGY: Journaling for asthma • Stress/anxiety increase skin tests wheal response • stress and anxiety may enhance and prolong AR symptoms.

8. Biologically Based Therapies • Uses substances found in nature, such a herbs, foods, and vitamins • ALLERGY: Butterbur for AR, • FAHF-2 (Food Allergy Herbal Formula-2) for peanut induced anaphylaxis • Cold H2O fish for Omega-3 Fatty acids • Vitamin D for Asthma

9. Manipulative and Body-Based Methods • Based on manipulation and/or movement of one or more parts of the body • Allergy: Sinus accupressure? • ENERGY THERAPY Biofield therapies Bioelectromagnetic-based therapies

10. Energy Therapy • Biofield therapies • Affect energy fields that purportedly surround and penetrate the human body • Forms of energy therapy include applying pressure and/or manipulating the body by placing hands • Bioelectromagnetic-based therapies • Unconventional use of electromagnetic fields such as pulsed fields, magnetic fields, or alternating or direct current fields

17. Integrative MedicineAllergic Rhinitis Natural Medicines Comprehensive Database

18. NMCD- Natural Medicine Comprehensive Databasewww.naturaldatabase.com

19. NMCD- Allergic Rhinitis

20. NMCD- Allergic Rhinitis-other Miscellaneous Capsaicin Cat's Claw (Uncaria guianensis, Uncaria tomentosa) Goldenseal (Hydrastis canadensis) Methylsulfonylmethane (MSM) Nasal irrigation

21. Integrative Medicine Allergic Rhinitis Natural Medicines Comprehensive Database • Botanicals/Supplements

22. Alternative Medicine Survey in a Private Allergy Asthma Practice-1998 • 1997- Eisenberg follow-up of 1993 NEJM • 113 Questionnaires- 81 Denver, 32 Vail • CAM discussed 18% of time w/ PCP or allergist • 64% wanted to discuss CAM • 16% saw CAM practitioners for gen’l health • 4% pts saw CAM for allergies/asthma • 10% PCPs regularly Rx CAM • Denver v. Vail clinics- similar results

23. CAM ?aire f/u 1998-2004 • Both study periods, similar majority wanted to discuss CAM (65%-69%) • Similar 18% each yr discussed CAM w PCP • Similar % pts sought CAM for gen’l med needs (16% v 19%) • INCREASE from 4%-10% of our pts saw a CAM for allergies/asthma • Similar 62% wanted to pursue combo traditional w/CAM w/i our practice • (27% did not know/doc’s choice)

24. CAM f/u ?aire 1998-2004 • More pts seeking chiropractic (36% v 52%) • Acupuncture 1st CAM (48%) in 2004 surpassing vitamin/mineral Tx in 1998 • IMPRESSED- CONCERNED re: 10% of OUR patients seeking CAM from outside our ofc • Further INTEGRATIVE Allergy approach- evidence-based. Environ, diet, exercise, supplements, Breath relaxation- communication

25. CAM ?aire f/u: 2010 (N=100) • In contrast to previous interest (65%+), only 44% wished to discuss CAM for allergies/asthma • a decrease to 8% had PCPs who regularly recommend CAM

26. Immune Impact of Specific Herbs & Vitamins • Vit D: shift Th1 to Th2, no effect MS, IBD • Vit E: inhib prolif mast cc, eos in mucosa • Vit A: hi levels shift Th1 to Th2 • Vit C: antioxid, most evid no effect on asthma • Magnolol: plant polyphenol , immun effects • Quercetin: flavinoid, raspberries to apples • Antiasthma herbal medicine intervent (ASHMI) FAHF-2 Resveratol: grape skin extracts, red wine. Ma Huang: ephedrine, banned 2004, CV effects

27. INTEGRATIVE Medicine: Immune Enhancement • Echinacea • Adults: 200 mg three times a day for three weeks, then stop for one week and resume if still symptomatic • Eucalyptus oil • For URI, oil can be added to a warm bath to help relieve nasal congestion

28. Diet Supplement & Health Education Act (DSHEA): Herbal Medicine DSHEA 1994: requires NO proof of efficacy or safety, FDA must prove product is unsafe • Lack of standardization of active ingredients • FDA establishes good manufacturing practice regulations but no formal regulatory oversight (contrast Germany, UK, Fr, Canada) • Unanswered Questions that remain: • bioavailability, dosage, interlot variability, contaminants, adverse drug interactions

29. Butterbur • Common use: allergic rhinitis, asthma, migraine headache • Caution: cross reactivity w/ Ragweed family, crysanthemums, daisies, etc • Hepatotoxic due to pyrrolizidine alkaloids

30. Echinacea • Common use: URI • May increaseAR/C in patients with allergy to ragweed, chrysanthemums, marigolds, and daisies • NEJM 2005- no benefit with “colds”

31. Eucalyptus oil • Common use: Asthma -> decongestant/expectorant • Oral use may cause dyspnea, wheezing, cough, drowsiness • Caution: patients with seizure disorder, heart disease, and acute intermittent porphyria • Contamination with bacteria may worsen rhinoconjuctivitis and asthma

32. Ephedra (ma huaung) • Common use: asthma, weight loss, and energy enhancement • Hypertension, insomnia, arrhythmia, tremor, headache, seizure, cerbrovascular event, myocardial infarction

33. Evening primrose • Common use: eczema, asthma, menopausal symptoms • Contact dermatitis with use of oil on skin • Cross reactivity with plants in the same family

34. Chamomile tea • Common use: “calming” tea, relief of sore throat • Worsening allergic rhinitis reported with allergy to plants in the same family (Echinacea, daisy, marigold)

35. Butterbur • Common use: allergic rhinitis, asthma, headache, pain • Caution: cross-reactivity w/ ragweed family,

36. Feverfew • Common use: migraine headache, and rheumatoid arthritis • Cross reactivity in patients allergic to chrysathemums, daisies, marigolds, or ragweed • Atopic dermatitis reported with contact to skin • Mouth inflammation, ulcers, lip edema, tongue irritation, loss of taste • Long-term users may experience withdrawal symptoms including rebound headache, anxiety, difficulty sleeping, muscle stiffness, and joint pain

37. St. John’s Wort • Common uses: depression, anxiety, insomnia, migraines, IBS, sciatica • GI disturbances, fatigue, dizziness, dry mouth, photosensitivity • Should not be used with SSRIs • Inducer of cytochrome P-450 leading to altered metabolism of drugs co-administered with herbal supplement

38. Symbiotics – Clostrum Nature’s Way – Flax seed Oil Super Cignan NeilMed Sinus Rinse Emer’gen- C Mixed Berry Enzymatic Therapy – acidophilis pearls Clear Mountain Air – Ding Chuan Wan Natural Factors – Learning Factors Daily Nutrient Boost Smoothie Mix Garden of Life – Primal Defense Garden of Life – Perfect Food Super Green Formula Garden of Life – Q-Zyme CAM use in practice: Case #1 A comprehensive evaluation was conducted and a thorough review of herbals and supplements included:

39. Clear Mountain Air Teapills (Ding Chuan Wan)[MW3317] Regular Price: $13.00 Our Price:$11.70 Also known as: Calm Wheezing Pills Packaging: 200 pills Recommended Dosage: 8 teapills, 3 times per day Traditionally used for cough with chest tightness or wheezing with thick yellow phlegm.  Clears heat, resolves phlegm, stops cough, sinks the qi. THIS PRODUCT CONTAINS EPHEDRINE GROUP ALKALOIDS IN THE FORM OF HERBAL EXTRACTS. WE ARE UNABLE TO SHIP THIS PRODUCT TO CALIFORNIA ADDRESSES. WARNING: NOT FOR USE BY INDIVIDUALS UNDER THE AGE OF 18 YEARS. DO NOT USE IF PREGNANT OR NURSING. Consult a physician or licensed qualified health care professional before using this product if you have, or have a family history of, heart disease, thyroid disease, diabetes, high blood pressure, depression or other psychiatric condition, glaucoma, difficulty in urinating, prostate enlargement, or seizure disorder, or if you are using a monoamine oxidase inhibitor (MAOI) or any other dietary supplement, prescription drug, or over-the-counter drug containing ephedrine, pseudoephedrine, or phenylpropanolamine (ingredients found in certain allergy, asthma, cough or cold, and weight control products). Do not exceed recommended serving. Exceeding recommended serving may cause serious adverse health effects, including heart attack and stroke. Discontinue use and call a physician or licensed qualified health care professional immediately if you experience rapid heartbeat, dizziness, severe headache, shortness of breath, or other similar symptoms. Individuals who are sensitive to the effects of caffeine should consult a licensed health care professional before consuming this product. KEEP OUT OF REACH OF CHILDREN.

40. On-line Resources NCCAM: http://nccam.nih.gov/ Epocrates: http://epocrates.com PDR: http://pdr.net Natural Medicines Comprehensive Database: www.naturaldatabase.com /AAAAI.org NIH Office Dietary Supplements: http://ods.od.nih.gov/Health_Information/IBIDS.aspx FDA Patient Safety News: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm

42. J Allergy Clin ImmunolVol 123, 2, Feb 2009 • Clinical Reviews in Allergy and Immunology • CAM: Herbs, phytochemicals and vitamins and their immunologic effects, Mainardi et al • Efficacy and mechanisms of action of traditional Chinese medicines for treating asthma and allergy, Xiu-Min Li et al • CAM for the allergist-immunologist: Where do I start?, Engler et al • Role of CAM in the field of allergy and clinical immunology, Sampson • Letter to editor: CAM educ: Need for expanded educ resources for AAAAI mbrs, Engler, Silvers, Bielory • Prenatal probiotic admin can influence Bifidobacterium development in infants at hi risk of allergy, Lahtinen et

43. Food Allergy Herbal Formula-2 silences peanut-induced anaphylaxis for a prolonged post-treatement period via IFN-g-producing CD8+ cells, JACI 2009;123, 443-51 Srivastava, Qu, Zhang, Goldfarb, Sampson, Xiu-Min Li, MSSM, NY • 9 Herb formula • Pnut specif IgE decr 50% • IgG2a incr by 60% • TH2 cytokine by CD4+ T cells decr 75% • CD8+ T cell IFN-g prod incr by 85%. Neutraliz IFN-g and deplet CD8+ T cells decr FAHF-2 effic

46. Integrative Therapy • Environmental • Humidifier/dehumidifer, HEPA filters • Dust mite precautions, dander minimization • Nasal saline • Pharmaceuticals • Oral antihistamines • Topical nasal steroids, nasal antihistamines • Mucolytics • Immunotherapy

47. Integrative Summary Consultation • Environment: nasal saline, humidity, hepa • Nutritional Advice: • Avoidance Enhancement • Supplements: • Exercise: • Breathing Relaxation: • Mental-Emotional-Social-Spiritual Health- (takes time- for future visits, other providers?)

48. Integrative Summary Consultation • Environment: nasal saline, humidity, hepa • Nutritional Advice: • Avoidance Enhancement • Supplements: • Exercise: • Breathing Relaxation: • Mental-Emotional-Social-Spiritual Health- (takes time- for future visits, other providers?)

49. Integrative Therapy • Botanicals • Butterbur- leaf extract dose 8mg TID, whole root extract dose 50mg BID • Bioflavonoids- Quercetin- 1000-2000mg QD to TID • Stinging nettle (Urtica dioica)- 300mg BID • Supplements • Multivitamin, vitamin C, (vitamin E?) • Vitamin D- 2000+ IU QD • Probiotics- Lactobacillus GG- pregnancy/infants- 1-10 billion units TID to QID 2-4 weeks pre delivery and continue 3-6 months during breastfeeding. Culturelle now Every Day Health • Grape Seed Extract

50. Integrative Therapy • Nutrition • Yogurt, omega-3 fatty acids (cold H2O fish) • Biomechanical therapies • Diaphragmatic breathing • Steam inhalation (a little eucalyptus?)