Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Alternatives to Inhalers
- Sharon J Williams (23 May 2003)
-
Asthma diagnosis
- Olle Löwhagen, Göteborg (29 May 2003)
-
Another alternative
- Frank J Leavitt (29 May 2003)
-
The impact of illustrations must be considered
- Jane C Davies (4 June 2003)
-
Further to my response
- Frank J Leavitt (5 June 2003)
-
Evidence of equivalence rather than difference
- Nick Freemantle (18 June 2003)
|
|
|||
|
Sharon J Williams, ex-R.N. n/a
Send response to journal:
|
While steroid or non-steroid inhalers have their uses, side effects can include an intractable sore throat. Steroid inhalers can have additional side effects and some inhaler medications such as Isuprel can cause paroxysmal atrial tachycardia in susceptible patients. Homeopathic remedies can control asthma without side effects and with better control of symptoms in many patients. They should be tried without stopping inhaler usage until the patient reports whether they are providing control and the doctor approves discontinuing inhaler medication. The patient should still carry an emergency inhaler. There are also homeopathic/herbal remedies that enhance the body's immune system to help control allergies, the most common cause of asthma. These remedies do not conflict with any prescribed pharmaceuticals and are free of annoying side effects such as dry mucous membranes and drowsiness. The cost of homeopathic remedies on a per dose basis is 8 - 10 times lower than over-the-counter medications. The gap is even greater with prescription drugs. Safety is also an issue. Many patients fail to disclose that they are taking additional over-the-counter drugs, many of which can be in conflict with prescribed drugs. They believe that OTC medications are perfectly safe just because they do not require a prescription. Rarely do they consult with their pharmacist to check for possible drug interactions. In my opinion, based on observation of others and personal experience, I think the homeopathic route should be tried before committing to long-term steroid inhalers. Homeopathic remedies should, of course, be prescribed by competent homeopaths. The question that must be asked is this: Why is the thinking of the medical profession (in general) so narrow and inflexible that the least expensive, least dangerous methods are not tried first? If the best interests of the patient were considered as paramount, we could also reduce the cost of health care. Frequent incidences of side effects and adverse effects caused by prescribed pharmaceuticals and OTC drugs are not in the best interests of the patient and create a conflict with the first principle of the Hippocratic Oath: To do no harm. The ideal situation would be to include homeopathic training as part of existing medical education to give physicians a wider choice of treatment and increased safety for the patient. All insurance plans that cover drug coverage should include homeopathic testing, diagnosis and remedies. Sharon J Williams Competing interests: None declared |
|||
|
|
|||
|
Olle Löwhagen, Head physician, professor Asthma and Allergy Centre, Sahlgrenska University Hospital, Göteborg
Send response to journal:
|
This is an article of considarable value showing that stepping down the steroid dose in asthmatic patients is worth while. However, may I ask how you know that all patients had asthma ? In the clinic we continously find patients with an asthma-like disorder such as sensory hyperreactivity (Respir Med, 1999;93:851-5). Most of these patients are treated as asthmatics, sometimes with high doses of steroids. Airway symptoms are often similar to those with classical asthma but they have no use of steroids. You found a mean beta2-reversibility of about 5 %. Is this sufficient ? In consensus reports >12% is required for "clinical significance". How many patients had no reversibility ? Exacerbation was the primary variable. Were there a significant correlation to a simultaneously decrease in lung function (PEF or FEV1) ? Thank you for the answers. Competing interests: None declared |
|||
|
|
|||
|
Frank J Leavitt, Chairman, Centre for Asian and International Bioethics Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. 84105
Send response to journal:
|
Bravo to Sharon Williams for her suggestion of an alternative. Homeopathy, however, is not my personal preference, however. I prefer to try to be aware of what is going on in my body, and to seek solutions while turning to doctors of any kind, conventional or alternative, as little as possible. I had mild asthma and was addicted to an inhaler for many years. Taking up martial arts a few years ago, and learning to breath low in the abdomen, helped me considerably. But it was not enough and my addiction to the inhaler remained. Last autumn, however, I had a few yoga lessons with a student of Iyengar in Pune, India. She did not like my low -abdomen breathing and said I was restricted in my upper chest. She taught me to open the upper chest and breath higher. I now do a breathing exercise which I worked out by myself, combining the low, Japanese martial arts breathing, with the high-chest breathing which I learned from the yoga instructor. Although for around 20 years I was using the inhaler several times every day, I have now used it only once since December, 2002. I think I am totally free of it. I would like to write up the details to help others, but I do not know of any reputable medical journal which would consider publishing such "anecdotal" information. Competing interests: None declared |
|||
|
|
|||
|
Jane C Davies, Senior Lecturer and Honorary Consultant Imperial College and Royal Brompton Hospital, London, SW3 6NP
Send response to journal:
|
EDITOR- As a paediatrician practicing in Respiratory Medicine, I spend a great deal of time educating patients, parents and junior colleagues on the importance of correct inhaler technique. Many hospital clinics and General Practitioners’ surgeries now employ specialist nurses with specific roles in teaching and monitoring of such inhaled therapies. The benefits on asthma control of correct technique are clear1,2 and largely undisputed. The photograph you chose to accompany your comment (This week in the BMJ) on the article by Hawkins et al3, albeit a rather beautiful demonstration of modern photographic technique, did little to further our cause. The child pictured is holding a metered-dose inhaler several inches from an open mouth, and may or may not be inhaling. What is not in doubt is the complete lack of pulmonary deposition that will have ensued. That the photo was pointed out to me by my non-medical, asthmatic and recent (somewhat reluctant) convert of a husband, was doubly galling. Competing interests: None declared |
|||
|
|
|||
|
Frank J Leavitt, Chairman, Centre for Asian and International Bioethics Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel. 84105
Send response to journal:
|
Since my response to this article appeared, I received an email kindly informing me of the existence of studies of retraining in breathing. Since I do not like to publish correspondents' names unless they give me explicit permission to do so, I won't mention the writer of the email by name. He informd me of the existence of a review article appearing in Respiratory Medicine 2003; Vol. 97: pages 501-507, which surveys a number of methods of breathing retraining for asthma. Readers may be interested. Competing interests: None declared |
|||
|
|
|||
|
Nick Freemantle, professor of clinical epidemiology & biostatistics University of Birmingham, Edgbaston, Birmingham, UK B15 2TT
Send response to journal:
|
Hawkins et al [1] conclude that 'By adopting a stepdown approach to the use of inhaled steroids at high doses in asthma a reduction in the dose can be achieved without compromising asthma control'. However, for their principal analysis they cite: 'The proportions of subjects with asthma exacerbations were not significantly different (stepdown 31%, control 26%, P=0.354).' In the text they give the odds ratio, with confidence intervals, but the odds ratio has no natural interpretation. Actually, if we reanalyse their data, we find that 5.2% more subjects in the stepdown group suffer asthma exacerbation, and the 95% confidence intervals describe a plausible range of the true result from -5.8% to 16.1%. The confidence interval on the risk difference scale gives a very different impression (up to a 16.1% increase in exacerbation attributable to step down) when contrasted to the p value. This is because the latter is answering the wrong question (we are not interested whether there is a statistically significant difference, but we are interested in a confidence interval providing the plausible bounds for an estimate of the difference. Further, we need this to be described on a scale that we understand thus on an absolute scale rather than a ratio scale. This is not a methodologically new area but there should be firm guidance on the way that such conclusions should be drawn (ie requirements for papers that claim non inferiority / equivalence). 1. Hawkins G, McMahon A D, Twaddle S, Wood S F, Ford I, Thomson Nl C. Stepping down inhaled corticosteroids in asthma: randomised controlled trial. BMJ 2003; 326: 1115-0. Competing interests: None declared |
|||