Click "Up" for the causes of asthma.  However, in addition to the standard treatment for asthma, allergic rhinitis, and COPD which is briefly mentioned at the bottom of this page, I would encourage asthmatics to take selenium 200 mcg., vitamin C 1000 mg., vitamin D 1000 units/day, two capsule of fish oil, and magnesium 250 mg. each day along with a cup of yogurt and an apple a day in addition to their regular asthma medications.  These supplements should allow great improvement and some definite decrease in medication requirements. Boswellia, and butterbur might also be worth a try.  Both have a number of studies helping other allergic conditions.

Standard treatment is important and is focused on inhaled corticosteroids and bronchodilators. Of the inhaled cortisteroids, QVAR (beclomethasone) is the most cost-effective ($35/month)(40 or 80 mcg #100 per inhaler, 80 mcg 15% more expensive than the 40).  Pulmicort (budesonide), Asmacort (triamcinolone), and Flovent (fluticasone) are all $48/month while the new Asmanex and the older Aerobid (flunisolide) are $96/month.  All are best twice a day.  These prices are for the low dose treatment (Asmanex and Pulmicort 1 inhalation; Asmacort and Aerobid 2 inhalations; QVAR 40 mcg and Flovent 110 mcg: all twice a day).  High dose treatment would be twice as much.  Thus, switching from the most to least expensive at the high dose could save $1364/year.  The Medical Letter reports that there is no evidence one is superior to another (12/5/05). Med Letter national prices somewhat less on average than Walgreens below.

Advair Discus inhalers are a combination of an inhaled corticosteroid powder of fluticasone in dosages of 100, 250, or 500 mcg with 50 mcg of a long-acting beta-2 agonist (LABA) bronchodilator salmeterol. $143, $179, and $245 for 60 doses to be used twice daily and not more often (Walgreens, 3/30/06).  LABA salmeterol (Serevent Diskus--$122/mo.) and formoterol (Foradil) last at least 12 hours and are often used on a regular basis with conticosteroids.  Albuterol (Proventil, Ventolin; generic $17 inhaler, 17 gm) and pirbuterol (Maxair--$100, 400 puffs, 14 gm) are short-acting beta-2 agonist bronchodilator lasting 4-6 hours.  

Leukotriene modifiers include montelukast (Singulair)($106 for 10 mg/day) and zafirlukast (Accolate)($92 for 10 mg or 20 mg twice a day).  Inhaled cromolyn (Intal--$185; generic $40/month) or nedocromil (Tilade) may help prevent attacks of mild to moderate asthma.  Theophyllin ER 200 mg is inexpensive at $22 per 100 and low dose therapy helps.  

For COPD, the anti-cholinergic bronchodilator once-daily inhaler Spiriva (tiotropium) ($115/month) is slightly superior to LABAs, at least for COPD to slow the rate of decline in lung function.  It can be added to a LABA.  The shorter acting anti-cholinergic inhaler ipratropium (Atrovent) ($52) is less effective.

Anti-Histamines: Histamine is an important mediator in airway inflammation. It is elevated in the airways of asthmatic patients and is responsible for many of the pathophysiological features in asthma. Antihistamines block the actions of histamine and also have effects on inflammation which is independent of histamine-H(1)-receptor antagonism. Antihistamines have been shown to have bronchodilatory effects, effects on allergen-, exercise-, and adenosine-monophosphate-challenge testing, and also to prevent allergen-induced nonspecific airways hyperresponsiveness. Clinical studies have shown mixed results, and some studies have reported beneficial effects of azelastine, cetirizine, desloratadine, and fexofenadine on asthma symptoms or physiological measures in patients with asthma. The combination of an antihistamine and a leukotriene receptor antagonist has been shown to have additive effects in certain studies. Antihistamines have also been shown to delay or prevent the development of asthma in a subgroup of atopic children. These data suggest that antihistamines may have beneficial effects in the management of asthma.

Boswellia Helped Asthma: The gum resin of Boswellia serrata, known in Indian Ayurvedic system of medicine as Salai guggal, contains boswellic acids, which have been shown to inhibit leukotriene biosynthesis. In a DB PC 80-patient 6-week trial of 300 mg three times a day for long-standing asthma, 70% of patients had decreases in dyspnea, rhonchi, number of attacks, increase in FEV subset1, FVC and PEFR as well as decrease in eosinophilic count and ESR. Only 27% of patients in the control group showed improvement. Effects of Boswellia serrata gum resin in patients with bronchial asthma: results of a double-blind, placebo-controlled, 6-week clinical study. Gupta I, Gupta V, et al. Universitat Tubingen, Eur J Med Res. 1998 Nov 17;3(11):511-4. For studies on other conditions, see Boswellia.

Butterbur Helped Asthmatics as an Add-On to Inhaled Steroids: In a DB PC crossover study of 16 atopic asthmatic patients maintained on their constant dose of inhaled corticosteroids but given either twice daily for 1 week BB 25 mg or placebo (PL), with a 1-week washout period prior to each, adenosine monophosphate bronchoprovocation improved (P<0.05) with BB, 0.6 vs. -0.1 for placebo. Exhaled nitric oxide as change from baseline was reduced (P<0.05) with BB, -1.2 vs. 0.5 for placebo. Both serum eosinophil cationic protein and peripheral blood eosinophil count as change from baseline were also suppressed (P<0.05) with BB, -3.9  microg/L, -31 x106/L vs. PL, 3.3microg/L, 38 x106/L. Butterbur, a herbal remedy, confers complementary anti-inflammatory activity in asthmatic patients receiving inhaled corticosteroids. Lee DK, Haggart K, et al. University of Dundee, Scotland, UK. Clin Exp Allergy. 2004 Jan;34(1):110-4. For studies on other conditions, see Butterbur.

Fish Oil Helped Exercise-Induced Bronchoconstriction: In a DB PC crossover study of 10 highly trained athletes with exercise-induced bronchoconstriction (EIB), after (1) 3.2 grams of EPA and 2.2 grams of DHA from fish oil (omega-3 fatty acids) per day for three weeks, lung function was significantly better, and inflammatory markers lower with omega-3 during an exercise challenge after each treatment period. EIB doesn’t respond well to asthma medications, although its symptoms are the same, breathlessness, wheezing, coughing, and chest tightness on exercising. Indiana University. Fish Oil Supplementation Reduces Severity of Exercise-Induced Bronchoconstriction in Elite Athletes. Mickleborough TD, Murray RL, et al. Am J Respir Crit Care Med. 2003 Aug 6.    

Fish Oil Helps Asthma: Asthma increasingly common. 20-25% kids have at least one symptom. High ALA may exacerbate. U Wyoming report 26 patients ages 19-25 were followed for one month on normal diet then had fish oil added to increase the n-3:n-6 balance to .1:1 and then .05:1 which required 3.3g/d fish oil. 40% had improved breathing and better resistance. Shave Broughton, Am J Clin Nutr 4/97;65:1011-7

Fish Oil No Benefit Hay Fever: Small study DB PC 27 allergenic patients given 3.2g/d for 6 months found no benefit hay fever or asthma. Am Rev Resp Des 5/93;147:1138

Fish Oil No Benefit for Asthma Found in Small Study: DB PC with 39 8-12-year-olds with asthma found no difference in their asthma after 6 mo. Hodge, Sydney, Eur Respir J 2/98;11:361. Ed: Small studies will often miss beneficial effects. Overall, it looks like fish and fish oil are beneficial for allergies and asthma.

Fish Oil: Omega-3s Helps Asthma: A DB study of 27 patients found decreased severity of attacks and decreased medications. Decline late allergic response due to replacement of AA with with n-3 in cell membranes of inflammation cell effectors. Ter Arkh ’97;69:33

Lycopene Supplement Lowers Asthma: Israeli study of 20 asthma sufferers given lycopene 30 mg/d supplement or placebo. After one week, 55% lycopene group had resistance to asthma after exercise vs. 15% decrease in lung function with placebo. Reduction of exercise-induced asthma oxidative stress by lycopene, a natural antioxidant. Neuman I, Nahum H, Ben-Amotz A. Allergy 2000;55:1184-9

Magnesium: Asthma Helped Slightly by Magnesium Supplement: In an Hungarian DB PC study of 89 asthmatic children ages 4-16, half were given 200-260 mg/day (lower dose in those under age 7). At 8 and 12 weeks, there was a 7% decrease in the number of doses of bronchodilators used by the magnesium group. Urinary magnesium excretion in asthmatic children receiving magnesium supplementation: a randomized, placebo-controlled, double-blind study. Bede O, Suranyi A, Pinter K, Szlavik M, Gyurkovits K. Magnes Res. 2003 Dec;16(4):262-70. Ed: While the benefit is small, the cost is very low and totally without side-effects.

Selenium Treated Asthmatics Decreased Corticosteroids 60%: 17 asthmatics were put on 200 microg/day for 2 years had a marked decrease in steroid requirements. Bratisl Lek Listy 2002;103(1):22-5. Decreased consumption of corticosteroids after selenium supplementation in corticoid-dependent asthmatics. Gazdik F, Kadrabova J, Gazdikova K.

Selenium Didn't Help in Study: In a 24 week DB PC study of 197 adult asthmatics, 75% on inhaled steroids, 100 mcg of high-selenium yeast was not associated with any significant improvement compared with placebo. Randomised, double-blind, placebo-controlled trial of selenium supplementation in adult asthma. Shaheen SO, et al. Imperial College London, United Kingdom. Thorax 2007 Jan 18.

Selenium, Vitamin C Good to Prevent Asthma: Serum levels of vitamin E, beta-carotene, vitamin C and selenium in 6,153 subjects aged 4 to 16 years were measured to determine any relationship with the prevalence of asthma. There was little or no association of vitamin E with asthma prevalence, but increases in beta-carotene, vitamin C and selenium were associated with a reduction in asthma prevalence of from 10% to 20%. Selenium was particularly protective of kids in homes where smoking occurred. Patricia A. Cassano, Cornell Univ. Am J Respir Crit Care Med 2/1/2004;169:393-398. 

Vitamin E No Benefit for Adult Asthma in Small Study: Increased dietary vitamin E intake is associated with a reduced incidence of asthma, and combinations of antioxidant supplements including vitamin E are effective in reducing ozone induced bronchoconstriction. In a 6-week DB PC study of 72 atopic adults with asthma, there was no effect of vitamin E supplementation on any other measure of asthma control. Vitamin E supplements in asthma: a parallel group randomised placebo controlled trial. Pearson PJ, Lewis SA, Britton J, Fogarty A. University of Nottingham, UK. Thorax. 2004 Aug;59(8):652-6

Yogurt: Allergic Symptoms Decreased in Adults: In a 1-year, randomized study of adults 20-40 and 55-70, those consuming 1 cup per day of live-culture yogurt vs. a pasteurized yogurt vs. no yogurt found that yogurt consumption, especially for the live-culture groups, was associated with a decrease in allergic symptoms in both age groups. The influence of chronic yogurt consumption on immunity. Van de Water J, Keen CL, Gershwin ME. J Nutr. 1999 Jul;129(7 Suppl):1492S-5S

Yogurt: Atopic Dermatitis Children Helped by Bifidobacterium: In a small 15-patient, Japanese DB PC 1-month study, the eight children taking the bifidobacterium capsules did better than the placebo group with significantly fewer cutaneous symptoms and a longer allergy score. Effects of administration of bifidobacteria on fecal microflora and clinical symptoms in infants with atopic dermatitis Hattori K, Yamamoto A, Sasai M, Taniuchi S, Kojima T, Kobayashi Y, Iwamoto H, Namba K, Yaeshima T. Arerugi. 2003 Jan;52(1):20-30

Yogurt: Atopic Eczema in Infants Markedly Improved: In a controlled study of 27 breast-fed 5-month old infants with atopic eczema scores averaging 16, those switched to either lactobacillus or bifidobacillus in their formulas for two months showed a dramatic reduction in symptoms to 0 and 1 while those in the control group decreased only to 14. Probiotics in the management of atopic eczema. Isolauri E, Arvola T, Sutas Y, Moilanen E, Salminen S. Clin Exp Allergy. 2000 Nov;30(11):1604-10; 

Yogurt: Atopic Eczema in Infants Helped Only by Live Yogurt Bacillus: In a Turkish DB PC study of 35 atopic children ages 5-6 months who also had allergies to cow's milk, the children received a formula, formula with Lactobacillus GG, or formula with heated treated LGG. Supplementation of infant formulas with viable but not heat-inactivated LGG is a potential approach for the management of atopic eczema and cow's milk allergy. Probiotic bacteria in the management of atopic disease: underscoring the importance of viability.  Kirjavainen PV, Salminen SJ, Isolauri E. J Pediatr Gastroenterol Nutr. 2003 Feb;36(2):223-7

Yogurt: Atopic Eczema Still Reduced Four Years Later: The benefits of perinatal lactobacillus administration had a measurable benefit even at age 4 with 14 of 53 children receiving lactobacillus had developed atopic eczema, compared with 25 of 54 receiving placebo (relative risk 0.57). Probiotics and prevention of atopic disease: 4-year follow-up of a randomised placebo-controlled trial. Kalliomaki M, Salminen S, Poussa T, Arvilommi H, Isolauri E. Lancet. 2003 May 31;361(9372):1869-71

Yogurt: Asthma Patients No Benefit in Small, Short Study: In a 15-patient, 1-month, crossover DB PC study, yogurt containing L. acidophilus generated trends in the increase in interferon gamma and decreased eosinophilia. However, there was no impact on clinical parameters in asthma patients in association with these modest immune changes. Univ Arkansas. Immune and clinical impact of Lactobacillus acidophilus on asthma. Wheeler JG, Shema SJ, Bogle ML, Shirrell MA, Burks AW, Pittler A, Helm RM. Ann Allergy Asthma Immunol. 1997 Sep;79(3):229-33. Ed: This study may have been simply too short and too small to detect a benefit.

Medical Treatment

Standard Medications: Allergic Rhinitis Treatment: The best treatment is corticosteroid nasal sprays. Rhinocort Aqua (Budesonide) is the cheapest at $34/mo. Loratadine is the cheapest of H1-receptor blockers. Montelukast helps as much as h1-receptor blockers but costs $84/mo. Med Let 3/17/03

BCG Vaccine Repeated Helped in One Study: 20 patients given a first injection in a DB PC study and then all given a second after one year. During the first year, there was an improvement in lung function and a decrease in asthma medication in the BCG group. In the second year, there was further evidence of benefit with a shift in the Th1/Th2 ratio and a further improvement in lung functioning. Inseon S. Choi, Y. I. Koh, Chonnam National University Medical School, Gwangju. Allergy 12/2003;58:1114-1116.

BCG No Value and Side-Effects: In a 31 patient randomized study of two BCG vaccinations, no benefit was found and the study had to be stopped early due to severe reactions. New Zealand. Clin Exp Allergy. 2004 Feb;34(2):207-212

Reducing Advair Diskus: After 12 weeks of open-label treatment with FSC 250/50 microg twice daily, 484 patients whose asthma was well controlled were randomized to FSC 100/50 microg twice daily or fluticasone propionate (FP) 250 microg twice daily for 12 weeks. The adjusted mean change in morning peak expiratory flow from the end of open-label treatment was -0.3 L/min for FSC and -13.2 L/min for FP (treatment difference, 12.9 L/min; P<.001). Secondary efficacy endpoints also showed FSC 100/50 microg twice daily to be more effective than FP 250 microg twice daily alone. The majority of patients remained well controlled, but the proportion was higher with FSC. Asthma control can be maintained when fluticasone propionate/salmeterol in a single inhaler is stepped down. Bateman ED, et al. University of Cape Town, South Africa. J Allerg Clin Immunol 2006 Mar;117(3):563-70. Ed: Patients were apparently not allowed to use rescue albuterol.  Such a prohibition would have a much less negative impact on patients staying on the long-acting bronchodilator than on those switched to a low dose Advair Diskus.  An alternative inhaled steroid such as Qvar with PRN albuterol would be roughly half the price of the lower dose Advair Discus.

Theophylline Works Fine in Low Dose: Charles G. Irvin, University of Vermont, CHEST 2003 annual meeting. 488 patients with poorly controlled asthma randomized to: placebo, theophylline 300 mg daily at bedtime, or montelukast 10 mg daily at bedtime in addition to their currently prescribed suboptimal treatment regimens for six months. The investigators used half the dose that was typically used 30 or 40 years ago to avoid side-effects. No effect on acute asthma exacerbations but there was an improvement in lung function. Theophylline improved both pre- and postbronchodilator FEV₁, while montelukast only improved prebronchodilator FEV₁. Adverse effects was similar in all three treatment arms and had disappeared completely within three months. In the group receiving theophylline and inhaled corticosteroids, measures of lung function deteriorated, suggesting that theophylline and inhaled corticosteroids are antagonistic. Theophylline much cheaper ($8) than inhaled corticosteroids and montelukast.

Theophylline Low Dose Didn't Help Kids: In a small 36-patient DB PC study, no difference was found with add-on theophylline. Pediatr Allergy Immunol. 2003 Oct;14(5):394-400

Tiotropium (Spiriva Inhaler) Better than Atrovent for COPD, But Serevent About as Good: In a 1-year, DB PC study of 921 COPD patients, tiotropium bromide (Spiriva inhaler; $115/mo) 18 mcg daily in addition to short-acting beta2-agonists and other standard drugs for COPD improved FEV1 by an average of 22% at peak and 12% at trough over baseline, and maintained the beneficial effect throughout the study. R Casaburi et al, Eur Respir J 2002, 19:217. A DB study of 535 patients found that once-daily tiotropium was superior to q.i.d. ipratropium bromide (Atrovent; $68) in patients with COPD exacerbations (35% vs. 46%), improvement in FEV1 and decreased use of rescue beta2-agonists (4 fewer inhalations per week). Tiotropium also led to greater improvement in quality-of-life scores, but some of the differences were not statistically significant. W Vincken et al, Eur Respir J 2002; 19:209. In two 6-month DB PC studies of 1207 patients, tiotropium decreased the number of COPD exacerbations (1.07 vs 1.49), decreased the number of hospital admissions, decreased dyspnea, improved quality of life scores, and produced greater improvement in FEV1 compared to placebo. But long-acting twice-daily beta2-agonist salmeterol (Serevent; $88) was superior to placebo in decreasing dyspnea and improving FEV1. The only statistically significant advantage of tiotropium over salmeterol was in FEV1. V Brusasco et al, Thorax 2003; 58:399

Tiotropium: Meta-Analysis Favors Slightly Over LABAs: In a meta-analysis of 9 randomised trials of over 11 weeks duration comparing tiotropium to placebo, ipratropium bromide, or long-acting beta2-agonists (LABA), tiotropium reduced the odds of a COPD exacerbation (OR 0.73; 95% CI, 0.66 to 0.81) and related hospitalisation (OR 0.68; 95% CI, 0.54 to 0.84) but not pulmonary (OR 0.50; 95% CI, 0.19 to 1.29) or all-cause (OR 0.96; 95% CI, 0.63 to 1.47) mortality compared to placebo and ipratropium. Reductions in exacerbations and hospitalisations compared to LABA were not statistically significant. Similar patterns were evident for quality-of-life and symptom scales. Tiotropium yielded greater increases in FEV1 and FVC from baseline to 6-12 months than did placebo, ipratropium and LABA. Decline in FEV1 over one year was 30 ml (95% CI, 7 to 53 ml) slower with tiotropium than with placebo and ipratropium (data were not available for LABA). Reports of dry mouth and urinary tract infections were increased with tiotropium. Long-term trials are warranted to evaluate the effects of tiotropium on decline in FEV1 and to clarify its role compared to LABA. Tiotropium for stable chronic obstructive pulmonary disease: a meta-analysis. Barr RG, et al. Columbia University. Thorax 2006 Jul 14.

Vitamin D: Strong Relationship Vitamin D and Pulmonary Function: Using data from the Third National Health and Nutrition Examination Cross-sectional Survey of 14,091 American adults, after adjustment for age, gender, height, body mass index, ethnicity, and smoking history, the mean FEV1 was 126 mL, and the mean FVC was 172 mL greater for the highest quintile of serum 25-hydroxy vitamin D level (> 85.7 nmol/L) compared with the lowest quintile (< 40.4 nmol/L; p < 0.0001). With further adjustment for physical activity, the intake of vitamin D supplements, milk intake, and the level of serum antioxidants, the mean difference between the highest and lowest quintiles of 25-hydroxy vitamin D was 106 mL for FEV1, and 142 mL for FVC (p < 0.0001). Relationship between serum 25-hydroxyvitamin d and pulmonary function in the third national health and nutrition examination survey. Black PN, et al. University of Auckland, New Zealand. . Chest 2005 Dec;128(6):3792-8.

Asthma attacks in children, but not adults, are increased with fungal spore counts are elevated.  The relationship is much stronger than with pollution in general.  Children with severe, but not with mild, asthma have much high carbon monoxide levels in exhaled breath (Pediatr Pulm 2006 Mar 17;41(5):470-474). The prevalence of GERD symptoms is higher among students with current asthma (19.3% vs.2.5%). In children with current asthma, GERD that occurred at least weekly wis strongly associated with emergency department visits (400% higher), physician visits (150% higher), missed school (100% higher), and inhaled medication use (150% higher)(Pediatric Pulm 2006 Mar 17;41(5):475-481).