Complementary and Alternative Medicine

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Summary of practice points

 Level of evidence
Ask about use of complementary medicines and advise patients about potential hazards. [√]
Warn patients that echinacea and royal jelly can precipitate life-threatening anaphylaxis in predisposed individuals with asthma IV
Encourage patients to choose TGA-assessed products in preference to unregulated products and make sure they understand that the Aust L code does not indicate that the product is effective. [√]
Monitor effects of complementary therapies as for conventional therapies. [√]
There is evidence for subjective improvements in asthma symptoms with some breathing techniques, but not for improvement in lung function. I
Current evidence does not support the use of manual therapies (chiropractic, osteopathy and related modalities) for patients with asthma. I
Current evidence does not support the use of acupuncture as a treatment for asthma. I
Physical training improves cardiopulmonary fitness but does not improve lung function or symptoms. I
Based on current evidence, health professionals can advise patients that homeopathy is ineffective. I
Although some traditional Chinese medicines might be beneficial in asthma, they cannot yet be recommended for clinical use based on current efficacy and safety data. I
Alternative diagnostic tests should not be used in the diagnosis of asthma and allergies. [√]
Note: various definitions of ‘complementary' and ‘alternative' medicine (CAM) are used in Australia and overseas. Here CAM refers to the wide range of medical and health care systems, practices and products that are not currently considered to be part of conventional medicine.1

Since this is a large and growing field, an exhaustive review of evidence is beyond the scope of this handbook.

For more information on CAM and asthma, see Information Resources.

Health care professionals treating patients with asthma need to be aware of the widespread use of complementary and alternative medicine (CAM). A recent large Australian survey estimated that 52% of Australians use complementary medicines and 27% consult CAM practitioners. Of those who use complementary medicines, 57% do not report this to their doctor, and 50% use complementary medicines and conventional medicines concurrently.2

Health professionals can increase patients' understanding of expected health effects of complementary medicine through a non-judgemental approach and an honest discussion of what is known about their effects and by avoiding a rigid dismissal of complementary therapy. When treating a patient with asthma:

  • always ask about use of complementary products when taking a medication history
  • consider potential effects on asthma and interactions between complementary medicines and prescribed conventional asthma medications
  • approach the issue of CAM in an open, sympathetic manner, acknowledging the patient's experience with complementary therapies and asthma control
  • be aware of potential hazards of CAM and advise patients about these (Table 1).

If introducing complementary therapies, any dose reduction in conventional therapy should be conducted under the supervision of a medical practitioner to avoid adverse outcomes.

Clinical evaluation and regulation of CAM

Practice points
  • Ask about use of complementary medicines and advise patients about potential hazards. [√]
  • Warn patients that echinacea and royal jelly can precipitate life-threatening anaphylaxis in predisposed individuals with asthma. (IV)
  • Encourage a good therapeutic partnership with the patient by approaching the issue in an open, sympathetic manner and avoiding a rigid dismissal of complementary therapy. [√]
  • Monitor effects of complementary therapies as for conventional therapies. [√]
  • Encourage patients to choose TGA-assessed products in preference to unregulated products and make sure they understand that the Aust L code does not indicate that the product is effective. [√]

Practice tip

  • Patients may not mention that they are using complementary therapies for asthma.
  • A non-judgemental, respectful attitude may encourage patients to discuss their use of complementary therapies.

Overall, there is less documented evidence for the effectiveness and safety of complementary therapies than for conventional therapies.

  • The majority of published studies have examined the complementary therapy as adjunctive therapies given in addition to patients' usual medical care (usually inhaled corticosteroids).
  • Clinical trials of complementary therapies have not always collected safety data (e.g. frequency of exacerbations, deaths), as is routinely done in registration trials of conventional drug therapies.
  • Some studies have not recorded lung function outcomes or measures of airway inflammation.

The placebo effect might explain the findings of those trials that have reported improvements in symptoms or reduction in reliever use, but failed to demonstrate lung function improvements. Regardless of the mechanism for observed effects, such a modality may confer clinically significant benefits (e.g. reduction in adrenergic adverse effects resulting from reduced reliever use, reduced response to allergens, reduced mast cell tachyphylaxis).3-5

In Australia, most complementary medicines are regulated by the Therapeutic Goods Administration to ensure that they conform with lists of permitted ingredients, and are manufactured under the same standards as pharmaceuticals.6 Products that have undergone this assessment are indicated on the label by the codes Aust L or Aust R. Most complementary medicines are Aust L coded. Patients should be encouraged to choose TGA-assessed products in preference to unregulated products (e.g. those obtained via the internet), and advised that The Aust L code does not indicate that the product is effective.

Most complementary therapists are not required to be registered with a professional association regulating their practice, so the ‘buyer beware' principle applies.

Table 1. Some potential adverse effects of CAM
CAM modalities Potential safety issues
Any product Interactions between complementary and conventional medicines7

Refer to Advisory Committee on the Safety of Medicines (ACSOM) reports for information about specific products.
Echinacea
Royal jelly
Willow tree bark extracts (aspirin)
Camomile		 Allergic reactions8-10
Traditional Chinese medicines
  • Mahuang (ephedra) preparations contain ephedrine, associated with headache, nausea, irritability, restlessness, insomnia, tachycardia, hypertension, motor disturbances.11
  • Heavy metal contamination12
  • Adulteration with conventional pharmaceuticals, e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids12-14
Indian Ayurvedic medicines
  • Heavy metal contamination14,15
  • Adulteration with conventional pharmaceuticals, e.g. NSAIDs, corticosteroids14
Ginkgo biloba
  • Headache, nausea, dizziness, palpitations, allergic skin reactions, bleeding (rarely).8
  • Interaction with warfarin.8
Vitamin and mineral supplements Toxic in high doses 7
Refer to Approved Product Information 

Breathing Techniques

There is evidence for subjective improvements in asthma symptoms with some breathing techniques, but not for improvement in lung function. Studies should be interpreted with reference to the baseline prevalence of dysfunctional breathing among patients with asthma.16

Practice point

There is evidence for subjective improvements in asthma symptoms with some breathing techniques, but not for improvement in lung function. (I)

Buteyko breathing technique

The Buteyko breathing technique is a system of breathing exercises that focuses on breathing through the nose, hypoventilating and avoiding deep breaths. It is based on the theory that slowing the rate of breathing will raise levels of carbon dioxide, a natural bronchodilator, and will therefore result in bronchodilatation and symptomatic improvement. Controlled studies of the Buteyko breathing technique have demonstrated symptomatic improvement and reduction in the use of reliever medication in some patients,17-19 but have not demonstrated changes in carbon dioxide levels, lung function measures or measures of airway inflammation.

Yoga

Some studies of yoga have reported subjective improvement of asthma symptoms but not examined lung function or airway inflammation. Overall, the evidence for benefit in patients with asthma is inconclusive.20-23

Dietary modification

While patients with demonstrated food allergies should be advised to avoid food allergens, routine dietary restrictions in patients with asthma are not beneficial.

Food supplements

  • Based on very limited data from randomised clinical trials, food supplements that might offer some benefit as adjunctive treatment in the control of asthma symptoms include omega-3 fatty acids (fish oils),24-26 lycopene27 and selenium supplements.28 Except for omega-3 fatty acids, none have been shown to improve objective lung function parameters.
  • Other food supplements that have been assessed in the management of asthma but cannot be recommended based on current evidence include Lactobacillus acidophilus,29 vitamin C,30 vitamin E and magnesium supplements.31-33

For information on dietary approaches to asthma therapy, see Diet and Asthma.

Manual therapies

Practice points
  • Current evidence does not support the use of manual therapies (chiropractic, osteopathy and related modalities) for patients with asthma. (I)
  • Current evidence does not support the use of acupuncture as a treatment for asthma. (I)
  • Physical training improves cardiopulmonary fitness but does not improve lung function or symptoms. (I)

Current evidence does not support the use of manual therapies for patients with asthma.34

  • Chiropractic manipulation is not effective in improving asthma symptoms, lung function, or reducing medication requirement in adults and in children with persistent asthma35-37
  • Controlled studies of osteopathy and cranial therapy in patients with asthma or allergic rhinitis have shown inconsistent results for effects on lung function and no convincing evidence of effectiveness in reducing medication requirements or symptoms.38, 39
  • Massage therapy has been reported to reduce reliever medication requirement in children.40

Acupuncture

Current evidence does not support the use of acupuncture as a treatment for asthma.41,42

Exercise therapies

Various programs of physical training have been assessed in adults and children.

  • Physical training improves cardiopulmonary fitness but does not improve lung function or symptoms.43
  • Swimming has not been shown to improve lung function or reduce medication requirement in limited available clinical trial evidence.44
Tai chi and qigong

The effects of tai chi and qigong on asthma have not been investigated in randomised controlled trials.

Medicinal therapies

Practice points
  • Based on current evidence, health professionals can advise patients that homeopathy is ineffective. (I)
  • Although some traditional Chinese medicines might be beneficial in asthma, they cannot yet be recommended for clinical use based on current efficacy and safety data. (I)

Homoeopathy

Based on current evidence, health professionals can advise patients that homeopathy is ineffective.45-47

Herbal remedies and traditional Chinese medicine

Many traditional Chinese medicines are the subject of ongoing study, and some have shown promising results in recent studies. However, effectiveness and safety is yet to be defined and their use is not currently recommended.

Some have been associated with adverse effects (Table 1).

Psychological therapies

The use of psychological interventions in adults or children with asthma is not well supported.48,49

  • Limited data suggest heart rate-variability biofeedback may help reduce asthma medication requirement.50
  • There is no convincing evidence for effectiveness of relaxation therapies in the management of asthma.51
  • Hypnotherapy may be an effective adjunct to asthma treatment in some patients, based on limited data.52

For information on links between asthma and mental illness, see Other Comorbidities.

Other therapies

  • There is no published evidence from randomised controlled trials for the effects of aromatherapy, vega matrix regeneration therapy or radionics (psionic medicine, dowsing) in the treatment of asthma.
  • Clinical trials assessing reflexology in patients with asthma have not demonstrated improvements in lung function, symptoms or medication requirement, compared with standard care or sham treatment.53,54
  • Current evidence does not support the use of enzyme-potentiated immunotherapy, which involves adding allergen extracts to a suspension of freshly drawn patient blood, mixing with beta glucuronidase and injecting the resultant solution intradermally.

For information on immunomodulatory therapy, see Asthma and Allergy.

Alternative diagnostic tests

Practice point

Alternative diagnostic tests should not be used in the diagnosis of asthma and allergies. [√]

Various unorthodox tests used by alternative therapy practitioners have not been shown to be reliable or reproducible when subjected to formal study. The following tests are not appropriate for the diagnosis of asthma and allergies or to guide asthma management: 55

  • cytotoxic food testing (Bryan's test)
  • oral provocation and neutralisation
  • Vega testing (electrodermal testing)
  • kinesiology
  • radionics (psionic medicine, dowsing)
  • iridology
  • pulse testing
  • hair analysis
  • tests for ‘dysbiosis'
  • blood assays for essential fatty acids, vitamins and minerals.

Key points

  • There is no strong evidence for a beneficial role of CAM in asthma therapy.42
  • There is some evidence that the Buteyko breathing technique may reduce asthma symptoms and requirement for reliever medication, but there is not evidence for an improvement in lung function or airway inflammation.
  • There is preliminary evidence that some Chinese herbal medications may benefit some patients with asthma, but their effectiveness and safety have not yet been established in clinical trials. Their use is not recommended in clinical practice.
  • A range of other CAM modalities currently used for asthma have not been proven effective, and some carry potential adverse effects.

Information resources

For patients

Asthma and complementary therapies. An evidence-based guide

For health professionals 

Asthma and complementary therapies. A guide for health professionals.
ASCIA Position Statement: Unorthodox techniques for the diagnosis and treatment of allergy, asthma and immune disorders. 

Mullins, Heddle R, Smith P.
Non conventional approaches to allergy testing: reconciling patient autonomy with medical practitioners' concerns.
Med J Aust 2005;183:173-4.