Non-Evidence based treatment and elimination methods in asthma

1. Non-Evidence based treatment and elimination methods in asthma Dr.Fazilet Karakoç University of Marmara Division of Pediatric Pulmonology

2. Allergic diseases are becoming more common • Predictions suggets that by the year 2020 more than 50 % of the population will suffer from some type of allergy • Respiratory allergies predominate and many of them will be triggered by house dut mites.

3. Increased exposure to high concentration of indor environmental allergens such as house dust mite, cockroach may explain the increased prevelance and severity of asthma in children • Children spend most of their time indoor and exposure to indoor allergens seems to be more significant

4. 1 2 3.0 1.2 1.4 1.6 1.8 2.2 2.4 2.6 Sensitisation to Allergens House dust mite Cat Dog Pollen Pet Ownership Dog owner Smoking Status Smoker Sex Female * * * p = <0.0001 p=0.001 - 0.0001 p=0.05 - 0.001 Sensitisation – Risk Factor for Asthma * * * * * * * Simpson.Custovic et al Clin Exp Allergy 2001; 31:391-399

5. Environmental risk factors in asthma control Treatment and elimination methods • House dust mite • Cockroach • Animal allergens • Molds • ETS • Acupuncture • Diyet/Nutritional treatment • Herbal medicine • Homeopathy • Breathing exercise • Others

6. Control Measurements in order to decrease dust mite exposure 1925 Storm van Leeuwen Living in allergen-free room (in the hospital) or Moving to high altitude Decreased the exposure to dust mite and had beneficial clinical effects

7. Environmental measurements in Asthma • Physical Measures Control environmental humidity and temperature Mechanical measures ( collection/filtration) Physical barriers (impermeable covers) • Chemical measures Pesticides (to eliminate house dust mites and substances to denature the allergens)

8. Ev tozu akarı alerjisi • One of the most significant indoor allergens • A higher incidence of mite allergy has been reported in asthmatic children of lower socioeconomic status • Most common allergen in Turkey ( %20-70) • House dust mites feed mainly flakes of human skin • A single adult person sheds between0.5-1 gr per day, enough to feed 100 000 house dust mites a day

9. Particles carrying house dust mite allergen are relatively large (> 10µm) and settle quicky • Bedding, carpets,clothing and furnishings are the major sources of allergen. • During cleaning dust is disturbed and available for inhalation

10. Can effective house dust mite allergen avoidance be achieved in homes? • Does it make any clinical difference?

11. The relationship between allergen concentrations and symptoms does not linear and predictable • Sensitivity and response vary greatly from individual • to individual. • Children are not raised in a single house • The concentration of house dust mites in each home vary according to series of factors such as geographic location, humidity, temperature, decoration and the number of the people living in the home

12. Cochrane reviews Sheikh A,2003 Gotzsche PC 2004 29 studies • Asthma symptoms • Use of asthma medication • Morning peak expiratory flow • NO statistically significant difference 5 Combination Of methods 9 Chemical methods 15 Physical measurement

13. Physcian should give advices about ideal environmental control measurements to the caregivers

14. Allergen-impermeable bed and pillow covers • Because of the high level of mite allergen exposure during sleep, the bed is probably the most clinically significant exposure site. • Encasement of the matress and pillows in allergen-impermeable covers combined with frequent hot water washing (>55 C) of bedding is the best method in order to reduce dust mite exposure

15. Do allergen-impermeable bed and pillow covers effect the control of asthma? • BHR • Asthma symptoms • Bronchodilator use • Inflammatory markers • . • Halken, 2005 • EhnertB,2002 • Murray,1983 • Carswell F,1996 • Frederick,1997 • Asthma symptoms • Pulmonary function tests • İnhaled steroid dose • Rijssenbeek N,2002 • Woodcock A,2003 • Luczynska C, 2003 • Terreehorst I,2003

16. Dust mite control measurements in bedding The use of acaracide or antimite shampoo in addition to encasement and hot washing doe not have any benefit Ehnert B,1992, CarswellF,1996,Frederick JM,1997

17. DRY CLEANING • Kill all live mites! • BUT does not reduce allergen concentration!

18. CARPETS • Carpets are amajor source for many indoor allergens • Houses with carpets have more allergens than those without • The use of Acaracides alone or in addition to other dust mite avoidance measures have not been demonstrated to be useful • Removalof carpets? Rebmann H 1996, Woodfolk 1995, • Ehnert B 1992, Carswell F 1996

19. Frequent vacuum cleaning effectively decrease dust mite in carpets • Even with improved filtration systems, vacuum cleaning may increase aeroallergen levels • It is advisable to wear a mask and open windows during and after cleaning • Adilah N,NZ Med J 1997

20. Control of house dust mite using extreme temperature, either by freezing with liquid nitrogen or steam cleaning has been shown to be effective • None of these methods is completely effective, the amount of the allergen increase following intervention

21. Respiration-gas exchange in mites is cutaneous, And they are particularly susceptible to loss of body moisture • The placement of carpets in direct sunlight has been shown to effectively decrease dust mite level, since mites are susceptible to water loss (drying) • This is a simple , safe, and inexpensive way to reduce house dust mites,especially if alternative methods are not available Tovey E JACI 1995

22. ASTHMA AND COCKROACH

23. COCKROACH • Cocroach allergens are found • İn high concentrations in, • Blag 1,Blag 2 • Cockroach feces • skin • Nest debris • Highest concentration of cockroach antigens are in dust from kitchen floors and cupboards (50-fold more than bedrooms) • Strongest relationship between exposure and sensitisation has been found in the bedroom • Cockroach sensitisation is 10-40 % in Türkiye

24. ASTHMA AND COCKROACH • Increased level of cockroach allergen have been associated more frequent; • Asthma related ER visit • Hospitalisation • Days of wheezing • Missed school days • Cockroach allergen levels has been found to be a risk factor for accelerated decline in FEV1 in adults with astma • Weiss ST J Allergy Clin Immunol 1998

25. Intervention studies showed no or modest reduction in cockroach allergen levels • Reduction in cockroach allergen levels were not associated with clinical benefits • Reduction in cockroach allergen exposure may be in important in asthma control Gergen PJ, 1999,Carter MC,2001

26. Cockroach like to live in dark, humid and warm environment • Removal of cockroach alleregen from the house is not easy • Although the effectiveness of professional cockroach extermination remains unproven, this is probably the only method that will help control infestation in the long term • The goal is to eradicate not only the living cockroach population but also the residue • Reinfestation from neighboring residences is also a problem,especially for families living in the crowded apartment buildings • İn additon to extermination, elimination of cockroach food and water sources through basic sanitation • measures , clearing harborages and • blocking entry point is important • Grocery bags, empty bottles and newspapers make • wonderful habitats for cockroach and should not be stored in the house

27. ASTHMA AND PETS

28. PET ALLERGY • All warm-blooded pets, including small rodents and birds Produce urine,dander,feces and saliva that may cause allergic reaction • Animal allergen particles are small (1-20µm), sticky and adhere surfaces • 10% of children own pets in Türkiye • Transfer of animal allergens from homes to public places (including schools) via clothing has been reported

29. The most effective environmental control measure for animal allergen is removal of animals from the house • Once the animal removed, elimination of allergens requires aggressive cleaning • Decreases in allergen levels can take months; removal of carpeting and stuffed furniture can shorten this period

30. 1000 Cat removed 100 Fel d 1 content (FDA units/gram dust) 10 1 0.1 Cat removed 0.01 0 5 10 15 20 25 30 35 40 45 Time (weeks) The Effect of Cat Removal on Fel d 1 Levels Wood et al, 1989

31. Different washing protocols for • animals have been effective in • the elimination of animal allergens • However animals need to be washed twice a week • to maintain decreased antigen levels

32. HEPA FILTER Air-Cleaners Reduce Airborne Dog Allergen Baseline 2 3 4 5 6 7 Baseline+hrs Green et al, 1999

33. HAVA FİLTRELERİ McDonald E, Chest 2002 Meta-Analiz Alerjene maruziyeti azaltmak amacı ile hava temizleyicileri ve diğer filtrasyon cihazlarının kullanılmasının etkinliği NET DEĞİLDİR! HEPA filtrasyon astım semptomlarını ve astım ile ilişkili uyku bozukluklarını azaltır. HEPA filtrasyonu sigara dumanı gibi çeşitli inhale allerjenlere maruziyeti azaltabilir Çalışmalar hangi spesifil allerjene maruziyetin azalmasının klinik fayda sağladığını göstermemektedir

34. If removal of the animal is not acceptable Expert Panle Report2 : guidelines for the diagnosis and Management of Asthma suggest, • Keep the pet out of patients room • Keep the patients bedroom dor closed • Remove upholstred furniture and carpets from the home or isolate the pet from them as much as possible

35. Avoidance from CAT & DOG Allergens

36. MOLDS AND ASTHMA Although molds were commonly considered an outdoor allergen, spores can come indoors Alterneria, aspergillus, penicillium etc are the most common molds in Türkiye. Allergic sensitisation to molds has been reported 4-50 % in different regions of Türkiye Damp homes and indoor molds have been associated with adverse respiratory symptoms and higher risk of asthma • Maintaining adry environment with simple control measures • Repair of water leaks and insulation defects • İncreased bathroom ventilation • No drying of cloths indoors • Fewer indoor plants, has been shown to be effective in reducing exposure to mold spores

37. ASTHMA AND ENVİRONMENTAL TOBACCOSMOKE

38. Environmental tobacco Smoke Exposure • ETS has been associated with increased risk of death and hospital admissions for respiratory disease as well as increased risk of asthma • Among children with established asthma • ETS increase • Asthma symtom scores • Attack frequency • Medication use • Di Franza 1996, Martinez 1992,Starchan DP 1998 • Advise caregivers and other smokers in the homes of patient with asthma to stop smking or to smoke outside the home • The asthma care team should be • knowledgeable about smoking cessation • and should actively refer smokers to • Programs • Active smoking status of the patient? • Discuss the ways to reduce exposure to reduce other sources of tobacco smoke such as from relatives, friends and day care providers

39. CLINICAL TRIALS OF MULTIFACETED ENVIRONMENTAL CONTROL INTERVENTIONS

40. Results of a home-based intervention among urban children with asthma Morgan JM,NEJM,2004

41. SONUÇ • The asthma care team should evaluate environmental conditions of the patients and discuss appropiate control measuerments in order to decrease allergen exposure • Physician should check the environmental control measurement in F/U visits • Reduction of ETS is an important target for environmental control measurements

42. ALTERNATIVE MEDICINE IN ASTHMA That’s all the health insurance will pay for alternative medicine

43. THE USE OF ALTERNATIVE MEDICINE IN DIFFERENT COUNTRIES 59 % 41% 26.5% 27.5% ENGLAND USA GERMANY SINGAPORE

44. ACUPUNCTURE A large number of small, uncontrolled trials reported that acupuncture improved asthmatic symptoms

45. EFFICACY OF ACUPUNCTURE IN ASTHMA TREATMENTS: RCT TRIALS

46. Linde K, Cochrane review,2000 7 trials with 174 pts Martine J Eur Respir J,2002 200 publications 11 Randomised controlled trials The authors did not find evidence of an effect of acupuncture in reducing asthma, whatever outcome was used This is the last time I go to an acupuncturist for my asthma?!

47. HOW ABOUT SAFETY ‘You gotto be kidding! His asthma is still not undercontrol?!’ 125 papers reporting side effcets of acupuncture in the period 1981 to 1994 Norheim AJ, J Altern Complement Med 1996 • Pneumothorax • Hepatitis • Death

48. DIYET/NUTRTIONAL THERAPY

49. HERBAL MEDİCİNE/ TRADITIONAL CHINESE MEDICINE

50. INCIDENCE OF HERBAL MEDICINE USAGE IN TURKEY 31% of children with asthma use herbal medicine Orhan F, Ann Allergy Asthma Immunol 2003