Protocol development in integrative medicine is not typically a simple process. Individuals require individualized care, and what works for one patient may not work for another.

To establish these protocols, we first developed a Rating Scale that could be used to discern the rigor of evidence supporting a specific nutrient’s therapeutic effect.

The following protocols were developed using only A through C-quality evidence.

Class
Qualifying studies
Minimum requirements
A
Systematic review or meta-analysis of human trials
 
B
RDBPC human trials
2+ studies and/or 1 study with 50 + subjects
C
RDBPC human trials
1 study

The global prevalence of adult asthma is roughly 4-8%, although this varies widely as significant debate remains regarding misdiagnosis and underdiagnosis of the condition. (1)(16)(20)

There is a common misconception that the prevalence decreases with age, with an emphasis on children experiencing spontaneous remission once past adolescence. When assessing this misconception it is found that the risk of a severe asthma exacerbation decreases with each year of life. (9)(12) The number of adolescents that have to achieve remission is a conservative 16%. (9) 

Asthma that starts in adulthood was found to correlate strongly with having multiple allergic conditions and to be inversely associated with age. (21) Due to the link between asthma and allergies, there is also a correlation between asthma-related hospitalizations, emergency, or urgent care visits, and environmental factors that exacerbate the condition such as mold and financial struggle. (6) Another factor in the management of asthma is identifying and managing small airways disease. The prevalence of small airway disease is estimated to affect between 50-60% of patients with asthma. (22) Focusing on reducing inflammation, comorbidities, and optimizing pulmonary efficiency are priorities for a suitable treatment plan in this population. 

The ingredients presented below have shown promising results to assist in the management of adult asthma and bronchoconstriction.

Vitamin C

500-1500 mg, total per day of ascorbic acid, minimum 2 weeks (15)(19)

  • Mean number of leukocytes increased in patients with chronic stable asthma when compared to placebo; however, no effect on spirometry measures (15)
  • When given in conjunction with corticosteroids, vitamin C decreased the inhaled corticosteroid dose by 49 mcg compared to 11 mcg in placebo (4) 
  • Vitamin C (1500 mg daily for two weeks) significantly improved FEV1, asthma symptom scores, and post-exercise scores in patients with exercise-induced bronchoconstriction (19)
Vitamin C in the Fullscript catalog

Magnesium

340 mg, total per day of magnesium citrate, minimum 6 months (8)

Note: Oral magnesium supplementation evidence is limited while nebulized and intravenous interventions are more common.

  • Bronchial reactivity to methacholine improved as demonstrated by improvements in FEV1, PEFR (Peak expiratory flow rate), AQLQ and ACQ when given prophylactic oral magnesium compared to placebo (8) 
  • Mild to moderate asthma benefited from oral magnesium supplementation in both adults and children as demonstrated improved FEV1 (2)
  • Notably, treatment with magnesium is typically given intravenously or nebulized, when comparing the two therapies intravenous magnesium improves pulmonary function in children and adults while nebulized magnesium seems to only be effective in adults (18)
Magnesium in the Fullscript catalog

Fish oil 

1.8-3.2 g EPA 1.3-2.0 g DHA, total per day, minimum 3 weeks (13)(23)

  • PUFA improved pulmonary function and inflammation as shown by improved FEV1, exhaled nitric oxide, and peak increase in PGF2 in patients with hyperpnoea induced bronchoconstriction (23)
  • Asthmatic patients experienced improved oxylipid ratio when supplemented with fish oils containing PUFA for 3 weeks compared to placebo (11)
  • Pulmonary function improved as shown by a decrease in LTC4-LTE4, PGD2, IL-1beta, TNF-alpha, bronchodilator use, and improved EIB threshold in patients given fish oil (3.2 g EPA, 2.0 g DHA) and tested for exercise-induced bronchoconstriction (13)
  • Elite athletes given fish oil for 3 weeks improved postexercise pulmonary function and inflammation demonstrated by decreases in FEB1, Leukotriene (LT)E4, 9alpha, 11beta-prostaglandin F2, LTB4, tumor necrosis factor-alpha, and interleukin-1beta compared to placebo (14)
Fish oil in the Fullscript catalog

Black cumin (Nigella sativa)

500-2000 mg total per day, minimum of 4 weeks (10)(17) 

  • Pulmonary function improved as shown by an increase in asthma control test (ACT) and FEV1 compared to control (5)
  • Normalized blood eosinophils as shown by a decrease of 50 cells/μL in treatment compared to 15 cells/μL in placebo; additionally pulmonary function improved as shown by ACT score of 21.1 in treatment compared to 19.6 in placebo and FEV1 by 4 compared to 1 in placebo (10)
  • Pulmonary inflammation and function improved as demonstrated by a decrease in asthmatic exacerbations, and improvements in INF-gamma, ACT, PEF, and FEV1 (17)
  • Nigella sativa is effective for prophylactic asthma treatment as demonstrated by a decrease in the frequency of asthmatic episodes, chest wheezing, and improved PFT, as well as a decrease in the use of inhalers, oral beta-agonists, oral corticosteroids, and oral theophylline (3)
Nigella sativa in the Fullscript catalog

Cineole (derived from Eucalyptus or Sage)

Minimum 5 mg of cineole (Approximately 200mg dry parts of 5mL liquid) total per day, minimum of 12 weeks (7)

  • Dyspnea decreased shown by improved FEV1, symptoms of asthma also decreased as shown by improvement in asthma quality of life questionnaire (AQLQ) (24)
  • Oral steroid use of daily prednisone decreased by 36% in treatment group compared to 7% placebo demonstrating steroid sparing effects in patients with asthma (7)
  • Pulmonary function improved as shown by a decrease in dyspnea as well as severity and duration of exacerbation in patients with COPD (25)
Cineole in the Fullscript catalog

Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

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References
  1. Aaron, S. D., Boulet, L. P., Reddel, H. K., & Gershon, A. S. (2018). Underdiagnosis and Overdiagnosis of Asthma. American Journal of Respiratory and Critical Care Medicine, 198(8), 1012–1020. https://pubmed.ncbi.nlm.nih.gov/29756989/ (F)
  2. Abuabat, F., AlAlwan, A., Masuadi, E., Murad, M. H., Jahdali, H. A., & Ferwana, M. S. (2019). The role of oral magnesium supplements for the management of stable bronchial asthma: a systematic review and meta-analysis. NPJ Primary Care Respiratory Medicine, 29(1), 4. https://pubmed.ncbi.nlm.nih.gov/30778086/ (A)
  3. Boskabady, M. H., Javan, H., Sajady, M., & Rakhshandeh, H. (2007). The possible prophylactic effect of Nigella sativa seed extract in asthmatic patients. Fundamental & Clinical Pharmacology, 21(5), 559–566. https://pubmed.ncbi.nlm.nih.gov/17868210/ (C)
  4. Fogarty, A., Lewis, S. A., Scrivener, S. L., Antoniak, M., Pacey, S., Pringle, M., & Britton, J. (2006). Corticosteroid sparing effects of vitamin C and magnesium in asthma: a randomised trial. Respiratory Medicine, 100(1), 174–179. https://pubmed.ncbi.nlm.nih.gov/16338599/ (C)
  5. He, T., & Xu, X. (2020). The influence of Nigella sativa for asthma control: A meta-analysis. The American Journal of Emergency Medicine, 38(3), 589–593. https://pubmed.ncbi.nlm.nih.gov/31892440/ (A)
  6. Hsu, J., Chen, J., & Mirabelli, M. C. (2018). Asthma Morbidity, Comorbidities, and Modifiable Factors Among Older Adults. The Journal of Allergy and Clinical Immunology in Practice, 6(1), 236–243.e7. https://pubmed.ncbi.nlm.nih.gov/28756082/ (F)
  7. Juergens, U. R., Dethlefsen, U., Steinkamp, G., Gillissen, A., Repges, R., & Vetter, H. (2003). Anti-inflammatory activity of 1.8-cineol (eucalyptol) in bronchial asthma: a double-blind placebo-controlled trial. Respiratory Medicine, 97(3), 250–256. https://pubmed.ncbi.nlm.nih.gov/12645832/ (C)
  8. Kazaks, A. G., Uriu-Adams, J. Y., Albertson, T. E., Shenoy, S. F., & Stern, J. S. (2010). Effect of oral magnesium supplementation on measures of airway resistance and subjective assessment of asthma control and quality of life in men and women with mild to moderate asthma: a randomized placebo controlled trial. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 47(1), 83–92. https://pubmed.ncbi.nlm.nih.gov/20100026/ (C)
  9. Kjellman, B., & Gustafsson, P. M. (2000a). [Children with asthma followed up for 21 years. Reduced severity, but patients seldom grow out of asthma by adulthood]. Lakartidningen, 97(41), 4572–4577. https://pubmed.ncbi.nlm.nih.gov/11107742/ (D)
  10. Koshak, A., Wei, L., Koshak, E., Wali, S., Alamoudi, O., Demerdash, A., Qutub, M., Pushparaj, P. N., & Heinrich, M. (2017). Nigella sativa Supplementation Improves Asthma Control and Biomarkers: A Randomized, Double-Blind, Placebo-Controlled Trial. Phytotherapy Research: PTR, 31(3), 403–409. https://pubmed.ncbi.nlm.nih.gov/28093815/ (B)
  11. Lundström, S. L., Yang, J., Brannan, J. D., Haeggström, J. Z., Hammock, B. D., Nair, P., O’Byrne, P., Dahlén, S.-E., & Wheelock, C. E. (2013). Lipid mediator serum profiles in asthmatics significantly shift following dietary supplementation with omega-3 fatty acids. Molecular Nutrition & Food Research, 57(8), 1378–1389. https://pubmed.ncbi.nlm.nih.gov/23824870/ (B)
  12. Mahut, B., Trinquart, L., & Delclaux, C. (2011). Influence of age on the risk of severe exacerbation and asthma control in childhood. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 48(1), 65–68. https://pubmed.ncbi.nlm.nih.gov/21039184/ (C)
  13. Mickleborough, T. D., Lindley, M. R., Ionescu, A. A., & Fly, A. D. (2006). Protective effect of fish oil supplementation on exercise-induced bronchoconstriction in asthma. Chest, 129(1), 39–49. https://pubmed.ncbi.nlm.nih.gov/16424411/ (C)
  14. Mickleborough, T. D., Murray, R. L., Ionescu, A. A., & Lindley, M. R. (2003). Fish oil supplementation reduces severity of exercise-induced bronchoconstriction in elite athletes. American Journal of Respiratory and Critical Care Medicine, 168(10), 1181–1189. https://pubmed.ncbi.nlm.nih.gov/12904324/ (C)
  15. Nadi, E., Tavakoli, F., Zeraati, F., Goodarzi, M. T., & Hashemi, S. H. (2012). Effect of vitamin C administration on leukocyte vitamin C level and severity of bronchial asthma. Acta Medica Iranica, 50(4), 233–238. https://pubmed.ncbi.nlm.nih.gov/22592572/ (B)
  16. Preteroti, M., Whitmore, G. A., Vandemheen, K. L., FitzGerald, J. M., Lemière, C., Boulet, L.-P., Penz, E., Field, S. K., Gupta, S., McIvor, R. A., Mayers, I., Hernandez, P., Lougheed, D., Ainslie, M., Licskai, C., Azher, T., Fraser, I., Mahdavian, M., & Aaron, S. D. (2020). Population-based case-finding to identify subjects with undiagnosed asthma or COPD. The European Respiratory Journal: Official Journal of the European Society for Clinical Respiratory Physiology, 55(6).  https://pubmed.ncbi.nlm.nih.gov/32299864/ (D)
  17. Salem, A. M., Bamosa, A. O., Qutub, H. O., Gupta, R. K., Badar, A., Elnour, A., & Afzal, M. N. (2017). Effect of Nigella sativa supplementation on lung function and inflammatory mediatorsin partly controlled asthma: a randomized controlled trial. Annals of Saudi Medicine, 37(1), 64–71. https://pubmed.ncbi.nlm.nih.gov/28151459/ (C)
  18. Shan, Z., Rong, Y., Yang, W., Wang, D., Yao, P., Xie, J., & Liu, L. (2013). Intravenous and nebulized magnesium sulfate for treating acute asthma in adults and children: a systematic review and meta-analysis. Respiratory Medicine, 107(3), 321–330. https://pubmed.ncbi.nlm.nih.gov/23290189/ (A)
  19. Tecklenburg, S. L., Mickleborough, T. D., Fly, A. D., Bai, Y., & Stager, J. M. (2007). Ascorbic acid supplementation attenuates exercise-induced bronchoconstriction in patients with asthma. Respiratory Medicine, 101(8), 1770–1778. https://pubmed.ncbi.nlm.nih.gov/17412579/ (C)
  20. To, T., Stanojevic, S., Moores, G., Gershon, A. S., Bateman, E. D., Cruz, A. A., & Boulet, L.-P. (2012). Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health, 12, 204. https://pubmed.ncbi.nlm.nih.gov/22429515/ (D)
  21. Toppila-Salmi, S., Chanoine, S., Karjalainen, J., Pekkanen, J., Bousquet, J., & Siroux, V. (2019). Risk of adult-onset asthma increases with the number of allergic multimorbidities and decreases with age. Allergy, 74(12), 2406–2416. https://pubmed.ncbi.nlm.nih.gov/31269237/ (D)
  22. Usmani, O. S., Singh, D., Spinola, M., Bizzi, A., & Barnes, P. J. (2016). The prevalence of small airways disease in adult asthma: A systematic literature review. Respiratory Medicine, 116, 19–27. https://pubmed.ncbi.nlm.nih.gov/27296816/ (A)
  23. Williams, N. C., Hunter, K. A., Shaw, D. E., Jackson, K. G., Sharpe, G. R., & Johnson, M. A. (2017). Comparable reductions in hyperpnoea-induced bronchoconstriction and markers of airway inflammation after supplementation with 6·2 and 3·1 g/d of long-chain n-3 PUFA in adults with asthma. The British Journal of Nutrition, 117(10), 1379–1389. https://pubmed.ncbi.nlm.nih.gov/28606216/ (C)
  24. Worth, H., & Dethlefsen, U. (2012). Patients with asthma benefit from concomitant therapy with cineole: a placebo-controlled, double-blind trial. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 49(8), 849–853. https://pubmed.ncbi.nlm.nih.gov/22978309/ (B)
  25. Worth, H., Schacher, C., & Dethlefsen, U. (2009). Concomitant therapy with Cineole (Eucalyptole) reduces exacerbations in COPD: a placebo-controlled double-blind trial. Respiratory Research, 10, 69. https://pubmed.ncbi.nlm.nih.gov/19624838/ (B)