Inhaled corticosteroids are used by millions of COPD patients worldwide to improve their breathing and reduce the fre-quency of hospitalization, but this new evidence suggests that they may be doing themselves more harm than good.
Researchers from the US and UK reviewed and analyzed 23 previously published studies comparing inhaled cortico-steroids (with more than six months of use) with a control treatment in patients with COPD. The inhaled corticosteroids evaluated were fluticasone, sold in combination with salmeterol as Advair, and budesonide, sold in combination with formoterol as Symbicort. In total, just over 86,500 people were included in the review, most of whom were men aged 60 and older.
The results revealed a significantly increased risk of fractures among those using inhaled corticosteroids. Moreover, the seven observational studies included in the analysis showed evidence of a dose-response relationship: the risk of fracture increased as the steroid dosage increased (Thorax, 2011 May 20; Epub ahead of print).
The review's lead author Sonal Singh, of the Johns Hopkins University School of Medicine in Baltimore, MD, USA, said the findings were troubling: "There are millions of COPD patients who use long-term inhaled corticosteroids in the United States and millions more across the world . . . The number of people who are getting fractures because of these medications is quite large."
Even more worrying, as the participants in these studies were mostly older men, the results raise questions as to the drugs' effects on women with COPD, a group who already have a substantially higher risk of fractures than do men.
Although more research is clearly needed, considering the other adverse effects associated with inhaled corticosteroids (high blood pressure, cataracts and diabetes), patients with COPD would be wise to look into alternative ways to manage the disease.
While there's no known cure for COPD, there's a range of ways to improve symptoms and slow down damage to the lungs-from mind-body techniques to herbs and supplements.
- Tai chi Qigong. This gentle, meditative form of exercise was recently tested in a controlled trial of just over 200 COPD patients. The participants were randomly split into three groups: the first was assigned to a Tai chi Qigong (TCQ) programme consisting of two 60-minute sessions a week for three months; the second was taught to practice breathing techniques combined with walking as an exercise; and the third was instructed to maintain their usual activities (the controls). At the end of the study, the results showed that, while the breathing-with-walking treatment helped to maintain lung function and slowed the disease progression, the TCQ programme actually improved lung function and increased activity tolerance. The control group, on the other hand, saw a decline in lung function (Complement Ther Med, 2011; 19: 3-11). Other Tai chi-based clinical trials have reported similarly positive results (Contemp Clin Trials, 2011; 32: 267-72; Respir Care, 2010; 55: 1475-82).
- Yoga. A randomized controlled trial of 29 elderly COPD sufferers found that a twice-weekly yoga programme was safe and effective for relieving the distress associated with one of the key symptoms of COPD: shortness of breath (medically known as 'dysp-noea'). After 12 weeks, the yoga-goers were also able to tolerate more activity and improved their functional performance (J Altern Complement Med, 2009; 15: 225-34). Another study, although uncontrolled, concluded that yoga results in improvements in lung function and quality of life in patients with COPD-at least for the short term (Am J Ther, 2010 Oct 22; Epub ahead of print).
- Singing. Regular singing practice is showing promise for a variety of chronic conditions, particularly COPD. Learningto sing requires breath control and good posture, and may have benefits that translate into everyday life. Indeed, one randomized controlled trial found that twice-weekly singing classes for six weeks resulted in positive physical changes as well as a reduction in anxiety in COPD sufferers (BMC Pulm Med, 2010; 10: 41). Another study reported that regular singing practice could improve lung function as well as quality of life (Int J Chron Obstruct Pulmon Dis, 2009; 4: 1-8).
- Playing the harmonica. Like singing, harmonica-playing involves breath control, which may help with pulmonary health. Although there don't appear to be any published clinical trials on this form of music therapy, a number of hospitals in the US and Canada have started harmonica classes for patients with lung disease, and are seeing positive results. MeiLan Han, a pulmonologist at the University of Michigan Health System in Ann Arbor, says, "In order to play a song, you have to be able to take a deep breath in and blow out against resistance, which can help to strengthen the respiratory muscles . . . I'm hopeful that the harmonica class has at least improved their quality of life, made them happier, and taught them some breathing techniques" (www. sciencedaily.com/videos/2006/0109-music_for_your_lungs.htm).
- Supplements. There are a number of nutritional supple-ments that appear to be helpful for COPD, including:
- N-acetylcysteine (NAC). A study in the Netherlands looked at two groups of patients who had been hospitalized for COPD, one of which received NAC after discharge while the other did not. After following the patients for up to a year, the researchers discovered that the use of NAC was significantly associated with a reduced risk of hospital readmission. More-over, the readmission risk was markedly lower in patients taking high average daily doses of NAC (Eur Respir J, 2003; 21: 795-8).
- vitamin D. Patients with lung disease often have low levels of vitamin D (Respir Res, 2011; 12: 31), so supplementing with this nutrient may be helpful. In a study presentedat the American Thoracic Society 2011 International Conference in Denver, CO, Belgian researchers revealed that patients treated with high-dose (100,000 IU/month) vitamin D saw significant improvements in exercise capacity and respiratory muscle strength compared with those given a placebo (www.sciencedaily.com/releases/2011/05/110515201306.htm).
- other vitamins. Low levels of other vitamins, including vitamins C, E and A, have also been associated with COPD (Respir Res, 2010; 11: 171). Although it's unclear from this research whether vitamin supplementation can improve symptoms, it's a good idea to get checked for any nutritional deficiencies and to supplement where necessary.
- coenzyme Q10 (CoQ10). COPD sufferers also appear to be lacking in CoQ10. In a study of eight patients, 90 mg/dayof CoQ10 taken for eight weeks led to no changes in lung function, although blood oxygenation improved, as did exercise performance and heart rate (Clin Investig, 1993; 71 [8 Suppl]: S162-6).
- Herbs. The following remedies may help people with COPD.
- Echinacea purpurea. This may be a useful complemen-tary therapy for respiratory tract infections that can worsen COPD. In a Swiss study, Echinacea combined with zinc, selenium and vitamin C resulted in significantly less severe and shorter exacer-bation episodes following an upper respiratory tract infection compared with a placebo (J Clin Pharm Ther, 2010 Nov 10; Epub ahead of print).
- Panax ginseng. In a double-blind controlled trial, ginseng was found to be significantly superior to placebo in improving lung function in patients with moderately severe COPD (Monaldi Arch Chest Dis, 2002; 57: 242-6). Recently, a literature review of a dozen trials concluded that ginseng shows evidence for improving lung function and quality of life (Respir Med, 2011; 105: 165-76).
- Traditional Chinese herbal medicine (TCHM). Trials using TCHM decoctions such as Jinshui Liujin and Jiawei Yupingfeng have reported encouraging results, so it may be worthwhile contacting a qualified Chinese herbal practitioner (Eur Respir J, 2006; 28: 330-8).
Factfile: What is COPD?
The term 'chronic obstructive pulmonary disease' refers to a group of lung diseases-including chronic bronchitis and emphysema-that narrow the airways and make it increasingly difficult to breathe. COPD can lead to respiratory infections, high blood pressure and heart problems, and is a leading cause of death and illness worldwide. Symptoms of COPD include shortness of breath, wheezing, chest tightness and chronic cough, which can severely affect quality of life.
Factfile: Diet and lifestyle changes
- Eat well. Malnutrition is common in COPD sufferers and can affect lung function and overall health. So, it's crucial to eat a balanced diet that includes all of the essential nutrients. Also, consider investigating the possibility of a food allergy, as COPD has been linked to allergies in some reports.
- Stop smoking. Smoking is the underlying cause in the majority of COPD cases. Although quitting will not reverse lung damage, it can help to preserve any remaining lung function. Exposure to second-hand smoke and other respiratory irritants, such as air pollution and dust, can also have detrimental effects, so avoid these whenever possible (see WDDTY vol 18 no 5, for advice on reducing your exposure to air pollution).
- Avoid cold air. Breathing in cold air can trigger bronchospasm and shortness of breath, so remember to always wear a cold-weather face mask before going outdoors.
WDDTY VOL. 22 NO. 5