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In
this Issue November 2003 
| 1. | Its use aids in diagnosing and monitoring an important chronic condition. |
| 2. | It can be made part of a series of consultations for asthma. |
| 3. | It is cost effective for the GP (i.e. over time the machine can be paid for and a small profit can be made from pre- and post-bronchodilator spirometry). |
| 4. | It is not hard to do nor difficult, generally, to interpret. |
| 5. | It can be an important tool in patient education and can improve adherence: for example, the read-out shows patients the improvement in their lung function once preventer treatment has been commenced. |
Spirometry is an important component of the 3+Visit Plan for proactive asthma care. It provides excellent information for both diagnosis and monitoring. The National Asthma Council strongly recommends its use2 and the RACGP is currently considering the inclusion of spirometers in the list of Essential Practice Equipment for practice accreditation.
References
2. Asthma Management Handbook 2002. National Asthma Council, Melbourne, 2002.
Useful Resources
Dr John Fardy and a National Asthma Council specific panel will be conducting
two Spirometry Workshops at the IPCRG 2nd World Conference on Respiratory
Disease in Primary Care 'The Way Forward'.
For the full program please go to
Community
Pharmacy and the IPCRG 2nd World Conference
| For the forthcoming IPCRG 2nd World Conference on
Respiratory Disease in Primary Care 'The Way Forward', all health
professionals are extended a very warm invitation to attend. For those of you who have not had the opportunity to review the program yet, the National Asthma Council committee members with a strong pharmacy interest have highlighted sessions on the program that cover therapies, new guidelines and medications as well as medication review for consideration as follows: |
 |
- Friday 20 February
Complementary Therapies
Prof Marc Cohen and Dr Mike Thomas
COPD: Guidelines
Prof Onno van Schayck
Australian ‘COPDX’
Prof Justin Beilby - Saturday 21 February
Paediatric Asthma
Dr Kerry Hancock and Dr Mark Levy
New medications – asthma, COPD & antibiotics
Prof David Price and Dr Chris Hogan
Smoking cessation
Prof Nick Zwar and Assoc Prof Susan Sawyer
- Sunday 22 February
Medication Review Panel
Dr Jenny Gowan, Assoc Prof Ian Charlton and Mrs Luisa Hogan (Australia)
These are just a few of the excellent sessions planned for IPCRG and are a must for community pharmacy. For the full program please go to
Device Training CD Rom now also on Video
The Lung Health Promotion Centre's "How to Correctly Use Inhaled
Respiratory Medication Devices" CD Rom has proven to be so popular that a
companion video has now been produced suitable for patient education and loan.
While compatible with any computer, the interactive CD Rom was not suitable for
patients who did not have access to a computer. The video version has an new,
appropriate introduction and does not attract nor cover CPD points allocation,
which is not relevant to patients.
Using verbal instructions, checklists
and non-verbal demonstrations the video covers the use of the six inhaler types
currently available as shown on the CD Rom.
Both the CD Rom and the
video of "How to Correctly Use Inhaled Respiratory Medication Devices" are
priced at $69.30. For information on how to order go to
Lung Health Promotion Centre (www.lunghealth.org/resources.htm#devices)
Asthma and Complementary Therapies
| Complementary medicines include: plant or herbal products;
vitamins; mineral supplements; traditional Chinese medicines;
naturopathic and/or homeopathic remedies; nutritional supplements;
and some aromatherapy products. These products are increasingly being used by people to complement and, in some cases, replace their mainstream medications1. As complementary medicines are often promoted as ‘natural’, many people don’t treat them as medicines. However, complementary medicines need to be used with care to ensure safety and efficacy. The growing interest in and acceptance of
complementary health care in Australia also
involves asthma medications and management. |
Complementary therapies for asthma - what advice should we give our patients?
Dr Chris Luttrell, general practitioner, Launceston, Tasmania; member, National Asthma Council General Practitioners’ Asthma Group
Increasingly, Australians are turning to complementary therapies as a means
of health maintenance. As their treating medical practitioners we must remain
open to change and encourage communication in order to assist them in their
choices.
Acupuncture, homeopathy, naturopathy, manual therapies,
traditional Chinese medicine, Buteyko breathing technique, herbal medicine.
These and many others can be seen as either complementary or alternative.
‘Complementary’ meaning their use is in addition to, and hopefully in
conjunction with, treatment by trained medical doctors. ‘Alternative’ meaning
their use is in place of, and to the exclusion of, treatment by trained medical
doctors.
Increasingly, patients are turning to these therapies,
reflecting increasing consumer preferences for non-pharmaceutical therapy. This
may reflect our increasingly diverse cultural background, a perception that
natural products are safe and that side-effects do not occur, or that patients
prefer the empowerment of using complementary therapies when they feel
traditional orthodox medicine has failed them for some reason.
While the majority of our patients use complementary therapies at some time,
many choose not to tell us. Or is it that we chose not to ask the question for
fear of the perception of personal failure if our patients have gone elsewhere?
If our patients are going to use complementary therapies, common sense would
have us preferring to know of their choice so that we can not only discuss their
reasons for doing so, but to allow us to assist them in monitoring for any
change in their asthma control.
Planning with our patients before they
change their asthma management should occur whether the change is in prescribed
drug therapy, or the addition of a complementary therapy.
Complementary Options
The list of complementary disciplines is extensive. Some require extensive
tertiary training; some practitioners have no training whatever. This may be the
ultimate game of caveat emptor. Professionally organised groups include those
practising acupuncture, chiropractic, herbal medicine, homeopathy, osteopathy,
naturopathy and traditional Chinese medicine. Other therapies include the
Alexander technique, aromatherapy, Ayurvedic medicine, Bach flower remedies,
hypnotherapy, reflexology, shiatsu, and the less mainstream Bowen therapy,
crystal therapy, kinesiology and radionics.
Our push for evidence-based medicine in general practice moves in a
divergent way to the process practised by most complementary practitioners,
where use of treatment modalities is primarily driven by anecdotal experience
gathered over time rather than conventional double-blind, placebo-controlled
crossover trials. In an ideal world, complementary therapies would be examined
in the same manner as, for example, drug therapies, but who is to fund the tens
of millions required for the study!
Finding suitable control groups is
not always easy. You cannot copyright a manual therapy technique, a herb or a
site for acupuncture. You cannot stop people learning a breathing technique.
Orthodox research is primarily pharmaceutical company sponsored and attempts to
prove that a copyrightable drug is better than the opposition’s. As more and
more doctors are using complementary alternatives as part of their management
armamentarium, should we not take on the responsibility to fund and research
these complementary therapies in conjunction with their practising
professionals?
Scientific Evidence
Evidence regarding the clinical effectiveness of most complementary
therapies, and associated risk factors, is extremely limited. The Cochrane
Review1 has considered many areas of
complementary management of chronic asthma, and in all cases has reached the
conclusion that there is limited evidence to make a recommendation based on the
selection criteria used by the review. Even traditional therapies such as
acupuncture have limited trials (only 7 trials involving 174 people met the
Cochrane inclusion criteria).
Our patients do not read the Cochrane
Review. They talk to friends and neighbours and hear stories from the media.
They feel more comfortable with therapies that have stood the test of time, such
as traditional Chinese medicine or the use of herbs (thyme, white horehound,
grindelia, euphorbia, passionflower and mullein). They are willing to try any
therapy, especially if a small group of patients gets a dramatic result, an
outcome not so different to that of our traditional therapies for asthma such as
sodium cromoglycate/nedocromil sodium or montelukast sodium.
Patients’ expectations of complementary therapies do not need to be
statistically significant or have a certain p-value. Often they are happy just
feeling better, even if there is not measurable change in outcomes, such as
improvement in peak flow measurements or spirometry. The best ‘local’ example of
this is the Buteyko Breathing Technique. There have now been two published
randomised controlled trials, the first a group taught in the standard Buteyko
manner from Brisbane2
and the second a trial of Buteyko Breathing
Technique taught by video3.
While neither group showed increase in
measurable parameters (FEV1 or peak
flows), they demonstrated a trend towards lowering inhaled steroid use and had a
statistically significant reduction in bronchodilator usage and improvement in
quality of life scores. Should we not consider this an improvement? Or was it
that the patients were being over-medicated by the orthodox practitioner who had
not back-titrated their prescribed drug therapy?
While the evidence may
not convince us to recommend this method to all asthmatics, if our patients ask
if the Buteyko Breathing Method is worth considering, how should we respond? We
must look at the parameters by which our patients judge their asthma control. We
must understand that both our patients and their complementary practitioners
rely on symptoms and quality of life scores to manage their patients, not peak
flows and FEV1. I am sure there are many
of us who manage our patients with asthma by exactly the same parameters.
What advice should we give patients?
1. Think yourself lucky if your patient trusts you enough to tell you they
wish to try another therapy.
2. Talk openly about their reason for their choice and what benefit they
hope to get from it.
3. Discuss with the patient that any change should
be considered a trial to attempt better control / reduced drug usage in the same
way you would trial a new medication regimen.
4. Consider open
discussion with the therapist of their choice, just as you would with a
physiotherapist or psychologist. Use their language so both practitioners can
understand monitoring of the disease.
5. Consider methods for
self-assessment of improvement in asthma control for some weeks before, during
and after the trial of complementary therapy
- Night-time waking.
- Early morning bronchoconstriction.
- Exercise tolerance.
- Use of bronchodilator.
- Reduction in preventer use
- Days missed from school / work.
6. Contract with the patient to formally assess their asthma control before, during and after the trial of complementary therapy.
- Quality of life symptom scores
- Peak expiratory flow rates
- Spirometry
7. Agree with the patient that should there be an improvement in asthma
control, a reduction in the use of prescription medication will be attempted.
Should
we accept the challenge?
Research into ‘complementary’ therapies for asthma is already progressing in
general practice. The roles of diet, environment, smoking, introduction of foods
to infants and the use of probiotics in the prevention of the development of
asthma are being researched. Most non-doctor practitioners would advise pregnant
women to cease smoking. Is this not a complementary therapy for asthma that has
a research base? Most non-doctor practitioners would recommend the avoidance of
antibiotics. Is this not a complementary therapy for asthma that has a research
base, not only from the aspect that gastrointestinal microflora may possibly
promote an anti-allergenic process, but that allowing the natural T-cell
response to infection may reduce IgE mediated allergy triggering?
Doctors have access to funding from the Divisions, RACGP and research grants
that most complementary practitioners cannot hope to achieve. Should we accept
the challenge of working with complementary practitioners to coordinate suitably
designed trials to assess the use of non-drug therapy in the management of
asthma? Many of us practise managements without, or even contravening,
research-based evidence. Are we not all complementary practitioners?
References
1. The Cochrane Library, Issue 2, 2001 prepared and published by Update Software Ltd. Cochrane Collaboration site: wwwsom.fmc.flinders.edu.au/FUSA/COCHRANE/Default.html; Cochrane Consumer site: www.cochraneconsumer.com
2. Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques in asthma: a blinded randomised controlled trial. MJA 1998;169:575-578.
3. Opat AJ, Cohen MM, Bailey MJ, Abramson MJ. A clinical trial of the Buteyko Breathing Technique in asthma as taught by a video. J Asthma 2000; 37(7):557-564.
For the latest information on complementary therapies in primary care attend
at the IPCRG 2nd World Conference on Respiratory Disease in Primary Care 'The
Way Forward' session on 'Complementary Therapies' with Prof Marc Cohen and Dr
Mike Thomas. For the full program please go to
IPCRG Melbourne 2004
Conference Diary 2003/4
Submit brief conference/meeting details to the National Asthma Council for possible posting in our Conference Diary by email to nac@NationalAsthma.org.au.
| IPCRG 2nd World Conference Respiratory Disease in Primary Care 'The Way Forward' 19 - 22 February 2004 Hotel Sofitel, Melbourne, Australia |
|
| The 2004 Australian Asthma Conference ‘A Fresh Breath – looking to the future’ 22 - 25 February 2004 Hotel Sofitel, Melbourne, Australia. Australian Asthma Conference 2004 |
|
| The Thoracic Society of Australia and New Zealand 2004 Annual Scientific Meeting Sydney Convention Centre 19-24 March 2004 |
|
| Australian & New Zealand Society of Respiratory Science
2004 Annual Scientific Meeting Sydney Convention & Exhibition Centre, Darling Harbour 19 - 21 March 2004 |
|
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