Efficacy and Safety Profile of Borage and Echium seed oil ...

Efficacy and Safety Profile of Borage and Echium

seed oil in comparison with long acting β-2 agonist in

Chronic Persistent Asthmatic Patients

A THESIS

Submitted by

DR. SYED SAUD HASAN

For the award of the Degree of

DOCTOR OF PHILOSOPHY

DEPARTMENT OF PHARMACOLOGY AND THERAPEUTICS

BASIC MEDICAL SCIENCES INSTITUTE

JINNAH POST-GRADUATE MEDICAL CENTRE

KARACHI, PAKISTAN

2016

Dedication

Every challenging work needs self-efforts as well

as guidance and prayers of elders, especially

those who are very close to our hearts, my

humble dedication of this effort is to

My Late Mother &lovely family,

Whose love, affection, encouragement and

prayers made me worthy of this success and

honor, along with my hard working and

respected

Teachers and Mentor

DECLARATION

I hereby declare that this submission is my own work and that, to the best of my

knowledge and belief, it contains no material previously published or written by

any others, neither material which has been accepted for the award of any other

degree or diploma of the University or any other Institute.

Venue: Department of Pharmacology and Therapeutics, Basic Medical Sciences

Institute, Jinnah Postgraduate Medical Centre, Karachi, Pakistan.

Title: Efficacy and Safety Profile of Borage and Echium seed oil in comparison

with long acting β2- agonist in Chronic Persistent Asthmatic Patients.

Date: __________

Signature: __________________

Name: Dr. Syed Saud Hasan

P.M.D.C Registration. No: 5004-S

CERTIFICATE

This is to certify that the thesis entitled: “Efficacy and Safety Profile of

Borage and Echium seed oil in comparison with long acting β2- agonist in

Chronic Persistent Asthmatic Patients” is submitted by Dr. Syed Saud Hasan

to the Department of Pharmacology and Therapeutics, Basic Medical Sciences

Institute, Jinnah Postgraduate Medical Centre, for the award of the degree of

Doctor of Philosophy, have an excellent record of the research work carried out

by him, under my supervision and guidance. The contents of the thesis in full or

parts have not been submitted to any other Institute or University for the award

of any other degree or diploma.

Signature of the Research Supervisor:

Prof Dr. Moosa Khan

MBBS, M.Phil. PhD

Department of Pharmacology and Therapeutics,

BMSI, JPMC, Karachi,

Pakistan.

ACKNOWLEDGEMENT:

The blessings of Allah upon us, are countless there are so many

blessings that we can’t express them ever. If we start expressing

them all our life would come to an end, but Allah’s blessings will

never finish. So first of all I would like to thank and praise Allah

Almighty for giving me the way to be able to complete this project. I

am thankful to God for blessing me with much more than I

deserved.

I express my deepest gratefulness to my supervisor and mentor Prof Dr. Moosa

Khan whose excellent guidance, encouragement and gentle personality made it

possible for me to successfully complete this research study. His valuable advice

and endless support was a pillar of strength throughout the project.

I express my sincere thankfulness to Associate Prof Asif Iqbal, Chairman

Institute of Eastern Medicine, Hamdard Medical University, Karachi, for

facilitating me in this project by arranging Research Associates, from the

Institute, support research work at the center and help in the collection of patients

from his center as well as from the Institute OPD. I also appreciate the valuable

support by Prof Dr. M. Furqan, Principal /Head of Department of Physiology,

Hamdard College of Medicine & Dentistry, Hamdard Medical University, to

provide the Spirometer of the Department for research project.

Prof Dr. Shamsul,Arfeen,Qasmi PhD, facilitate in laboratory sample analysis.

Special thanks to Dr. Mehvesh Hussain PhD (Statistics), Senior lecturer

Department of Research, Dow University of Health Sciences, Karachi sparing her

valuable time to assist me with statistical evaluation of research results.

I would like to thanks Dr. Talha Farooqui M.D, Las Vegus Hospital USA, Dr.

Asif Ali Zaidi, MD Neurology, North Carilona, USA, Dr. S. Anwer Ali Zaidi

FRCS, Glasgow, UK providing drugs and also facilitate in collection/searching of

original articles from University Libraries.

I give special thanks to Mr. Muhammad Azeem, Computer data operator of Q-

Bank (DHUS), for his support to design graphs of the results and Zulfiqar

Kaskali, computer assistant in the Department of Pharmacology Dow Medical

College, DUHS Karachi, to computer support.

I am also thankful to Prof. Dr. M. Asif Durrani, Coordinator BMSI, Member

ethical committee BMSI, JPMC Karachi.

Kind regards to my colleagues, Prof Dr. Mahboob Alam PhD, BMSI, JPMC,

Karachi. Prof Dr Aftab Turabi PhD, Post Doc (USA). Dr. Fuad Sheikh, Associate

Professor, Department of Pharmacology, DMC and Professor Dr. M. Yousuf

Salat, Head of Department Pharmacology, JSMU, Karachi gives their academic

and research expertise.

Last but not the least; I would like to thanks my wife & son (Syed Nabeel Hasan),

Medical Student DUHS, Karachi) for bearing me through the trials and

tribulations and for their endless love, encouragement and support.

No. Title

Page

1 SUMMARY

1

2 SUMMARY URDU TRANSLATION

4

3 INTRODUCTION

6

4 LITRATURE REVIEW

29

5 PURPOSE OF STUDY

34

6 MATARIALS & METHODS

35

7 OBSERVATION & RESULTS

44

8 DISCUSSION

103

9 CONCLUSION

112

10 RECOMMENDATIONS

114

11 LIMITATIONS OF STUDY 115

12 REFRENCES

116

No. Title Page 1. SUMMARY 1

2. SUMMARY URDU TRANSLATION 4

3. INTRODUCTION:

3.1 Epidemiology of Asthma 6

3.2 Asthma & clinical presentation 7

3.3 Disease Severity Classification (NAEPP ) expert panel 8

3.4 Inflammatory cells in Asthma 9

3.5 Mechanism of Botanical oils effect on inflammation in Humans. 12

3.6 Botanical oil combinations and Leukotriene generation. 15

3.7 Borage seed oil & Fatty acid composition 19

3.8 Echium seed Oil &composition 22

3.9 Dietary fatty acid 24

3.10 Bambuterol (Long acting β2-adrenergic agonist) 25

3.11 Clinical respiratory questionnaire 26

3.12 Lung function measurements 26

3.13 Classification severity of air-flow limitation 27

314 Common problems related to Pulmonary functions 27

3.15 Peak expiratory flow Meter 28

4. LITRATURE REVIEW: 4.1 Pathophysiology of Asthma 29

4.2 Inflammatory mediators and its role in Asthma 29

4.3 Role of botanical oil supplements 31

4.4 Enhancing Plant Seed Oils for Human Nutrition. 33

5. PURPOSE OF STUDY: 34

5.1 Primary Outcome Measures: 34

5.2 Primary Outcome Measures: 34

6. MATARIAL & METHODS: 35

6.1 Inclusion Criteria: 35

6.2 Exclusion criteria 35

6.3 Drug & compounds 36

a. Long acting β2-adrenergic agonist (Bambuterol HCl 10mg)

b. Borage Seed Oil Capsule 1.3 gram

c. Echium Seed Oil Capsule 500 mg

d. Short acting β2 adrenergic agonist (Rescue medicine)

6.4 Equipment’s:

a. Spirometer

b. Peak expiratory flow meter

36

6.5 Respiratory Parameters: 36

a. Force Expiratory Volume in one second (FEV1).

b. Force vital Capacity (FVC).

c. Peak expiratory flow rate (PEFR).

d. Clinical respiratory questionnaire.

e. Daily Diary Card Symptoms

6.6 Laboratory Parameters: 37

a. Lipid Profile (Cholesterol, HDL, LDL)

b. Liver Function Test Alkaline Phosphatase, SGPT)

6.7 Grouping of Patients: 37

GROUP-A:Treated by long acting β2 agonist (Bambuterol 10mg

orally) daily for 90 days.

GROUP-B:Treated by Borage seed oil 1.3 gram + Echium seed oil

Capsule 500mg eachtwice daily for 90 days.

GROUP-C: Treated by combination therapy, Borage seed oil

&Echium seed oil capsules twice daily and long acting β2 agonist

(Bambuterol 10mg orally)daily for 90 days.

6.8 Lung function measurements& Procedure: Force Expiratory volume in one second (FEV1) Force Vital Capacity (FVC)

38

6.9 Peak expiratory flow rate (PEFR)& Procedure. 40

6.10 Clinical Respiratory Questionnaires 41

6.11 Assessment of drug effectiveness and compliance of asthma patients 42

6.12 Symptom Evaluation Daily Diary Card of Asthma 43

7. OBSERVATION /RESULTS: 44

7.1 Comparison of baseline characteristics of Bambuterol (Group-A),

Borage Plus Echium seed oil Group-B) & Combinations of Bambuterol

&Borage plus Echium seed oil (Group-C) Therapy in chronic persistent

Asthma. 47

7.2 Group-A- Effects of Bambuterol on FEV1, FVC & PEFR in chronic

persistentAsthma 49

7.3 Group-A- Effects of Bambuterol on symptom score & exacerbations in

chronic persistent Asthma. 50

7.4 Clinical questionnaire Group-A- patients of chronic persistent Asthma

treated with Bambuterol for the assessment of drug effectiveness and

compliance. 51

7.5 Group-B Effects of Borage plus Echium seed oil on FEV1, FVC &

PEFR in chronic persistent Asthma Patients. 53

7.6 Group-B- Effects of Borage plus Echium seed oil on symptom score &

exacerbations in chronic persistent Asthma Patients. 54

7.7 Clinical questionnaire Group-B- patients of chronic persistent Asthma

treated with Borage plus Echium seed oil for the assessment of drug

effectiveness and compliance. 55

7.8 Group-C- Combination therapy of Bambuterol & Borage plus Echium

seed oil on FEV1, FVC & PEFR in chronic persistentAsthma. 58

7.9 Group-C- Effects of combination of Bambuterol & Borage plus Echium

seed oil on symptom score & exacerbations in chronic persistent

Asthma. 59

7.10 Clinical questionnaire Group-C- patients of chronic persistent asthma

treated with combination of Bambuterol & Borage plus Echium seed

oilon, Assessment of drug effectiveness and compliance. 60

7.11 Comparison of FEV1, FVC & PEFR between Group-A& Group-B in

chronic persistent Asthma patients. 63

7.12 Comparison ofBambuterol & Borage plus Echium seed oil on symptom

score & exacerbations in chronic persistent Asthma. 67

7.13 Clinical questionnairecomparison ofGroup-A& Group-B,onAssessment

of drug effectiveness and compliance in chronic persistent Asthma

patients. 68

7.14 Comparison of FEV1, FVC & PEFR between Group-A &Group-C in

chronic persistent Asthma patients. 71

7.15 Comparison ofsymptom score & exacerbations between Group-A &

Group-C in chronic persistent Asthma. 75

7.16 Comparison ofclinical questionnaire, (Assessment of drug effectiveness

and compliance) between Group-A &Group-C in chronic persistent

Asthma. 76

7.17 Comparison of FEV1, FVC & PEFR between Group-B& Group-C in

chronic persistent Asthma. 79

7.18 Comparison of symptom score & exacerbations between Group-B &


7.19 Comparison of clinical questionnaire, (Assessment of drug effectiveness

and compliance) between Group-B & Group-C in chronic persistent

Asthma. 84

7.20 Comparison of FEV1, FVC & PEFR between Group-A, Group-B &


7.21 Comparison of symptom score & exacerbations between Group-A,

Group-B & Group-C in chronic persistent Asthma. 91

7.22

Comparison of clinical questionnaire, (Assessment of drug effectiveness

and compliance) between Group-A, Group-B & Group-C in chronic

persistent Asthma.

92

7.23 Comparison of adverse drug reactions between Group-A, Group-B &

Group-C in chronic persistent Asthma patients. 96

7.24 Blood parameters for safety profile between Group-A, Group-B &


No. Title Page

FIGURES

1 Pathway of metabolism of omega-6 and Omega-3 fatty acids in human. 14 2 Potential mechanism by which Eicosapentaenoic acid (EPA) and γ-

linolenic acid (GLA) inhibits lipid mediator production. 16

3. Polyunsaturated fatty acid derived lipid mediators. 18 4 Borago officinalis Plant 19 5 Borage seeds 21 6 Cap Borage seed oil 21 7 Echium plantagineum Plant 22 8 Echium seeds 23 9 Cap Echium seed oil 23 10 Tablet Bambuterol 10mg. 25 11 Vitalograph micro (Cat No 630000 Series) 39

12 Peak Flow Meter (Datopir Peak-10) 40 13 Comparison of FEV1 between Groups-A & Group-B treated patients. 64

14 Comparison of FVC between Groups-A & Group-B treated patients. 65 15 Comparison of PEFR between Groups-A & Group-B treated patients. 66 16 Comparison of FEV1 between Groups-A & Group-C treated patients. 72 17 Comparison of FVC between Groups-A & Group-C treated patients. 73 18 Comparison of PEFR between Groups-A & Group-C treated patients. 74 19 Comparison of FEV1 between Groups-B & Group-C treated patients. 80 20 Comparison of FVC between Groups-B & Group-C treated patients. 81 21 Comparison of PEFR between Groups-B & Group-C treated patients. 82 22 Comparison of FEV1 between Groups-A, Group-B & Group-C treated

patients. 88

23 Comparison of FVC between Group-A, Group-B & Group-C treated

patients. 89

24 Comparison of PEFR between Group-A, Group-B & Group-C treated

patients. 90

25 Comparison of Blood parameters serum Alkaline Phosphatase between

Group-A, Group-B & Group-C treated patients. 98

26 Comparison of Blood parameters of liver, Serum alkaline phosphatase,

SGPT (serum glutamic-pyruvic transaminase) between Group-A,

Group-B & Group-C treated patients.

99

27 Comparison of Blood parameters Cholesterol Between Group-A,

Group-B & Group-C treated patients. 100

28 Comparison of Blood parameters HDL Between Group-A, Group-B &

Group-C treated patients. 101

29 Comparison of Blood parameters LDL Between Group-A, Group-B &

Group-C treated patients. 102

No. Title

ABBREVIATIONS

1 AA: Arachidonic Acid

2 ACQ: Asthma control questionnaire

3 ACT: Asthma control test

4 AHR; Airway hyper-responsiveness

5 AI: Adequate Intake

6 ALA: Alpha-linolenic acid

7 AMDR: Acceptable Macronutrient Distribution Range

8 ATAQ: Asthma therapy assessment questionnaire

9 BAL: Broncho-alveolar lavage

10 BO/BSO: Borage Oil/Borage Seed Oil

11 BTS: British Thoracic Society

12 COPD: Chronic Obstructive Pulmonary Disease

13 Cys-LTs: Cysteinyl-Leukotriene’s

14 DGLA: Dihomo-γ-linolenic acid

15 DRI: Dietary Reference Intake

16 ELOVL 5 (Elongase 5): Elongation of very long chain fatty acids protein 5

17 EO/ESO: Echium Oil/ Echium Seed Oil

18 EPA: Eicosapenteanoic acid

19 FAD: Fatty acid desaturase

20 FEV1: Force Expiratory Volume in one second

21 FVC: Force Vital Capacity

22 GA(2)LEN: Taskforce Global Allergy and Asthma European Network

23 GINA: Global Initiative for Asthma

24 GLA: γ-linolenic acid

25 HPTLC: High performance thin layer chromatography

26 HRQoL: Health-related quality of life

27 IgE: Immunoglobulin E

28 DRI: Dietary Reference Intake

29 IOM: Institute of Medicine

30 LTC4, LTD4 and LTE4: Leukotriene C4, D4, E4

31 NACP: National Asthma Control Program

32 NAEPP:National Asthma Education and Prevention Program Expert Panel Report

33 PMNs: Polymorphnuclear granulocytes

34 PUFAs: Poly-Unsaturated Fatty Acids

35 SDA: Stearidonic acid

36 SIGN: Scottish Intercollegiate Guidelines Network

37 PAs: Pyrrolizidine Alkaloids

38 SDA: Stearidonic acid

39 SGPT: Serum glutamic-pyruvic transaminase

40 SGRQ: Saint George’s respiratory questionnaire

41 Δ5

desaturase: Delta-6 desaturase

42 Δ6: Delta-6

43 ω−3: Omega-3

44 ω−6: Omega-6

45 5-LO: Five-lipoxygenase

46 15-HETre: 15-hydroxyeicosatrienoic acid

STATISTICAL DATA ANALYSIS

Data were double entered for check of correct entries. IBM SPSS version 21 was

used to enter and analyze data. To express findings of variables, descriptive

statistics were obtained. Categorical variables were presented as frequency

(percentages) and quantitative variables were presented as Mean ± SD. The

clinical data of chronic asthmatic patients were analyzed.

The Demographic characteristics i.e. Sex, Age & Smokers were compared among

the three groups using Chi-square test. The changes in continuous variables such

as lipid profile, liver function parameters and respiratory functions from Day 0 to

Day 90 were tested using paired samples t-test.

Percentage change in outcome variables was computed. The anthropometric

measurements and disease severity among three groups were compared using

One Way ANOVA with post-hoc analysis.

FEV1, FVC & PEFR, Clinical respiratory symptoms questionnaire, Daily diary

card (Symptoms of dyspnea, cough, sputum, sleep disturbances, night sleep

awakening, numbers of exacerbations) within the groups were also compared

using t-test.

Finally, the adverse events were reported among the three treatment groups as

percentage. For all sets of analysis p-value < 0.05 was considered significant.

1

Efficacy and Safety Profile of Borage and Echium seed oil in comparison with long

acting β-2 agonist in Chronic Persistent Asthmatic Patients

SUMMARY:

BACKGROUND: Asthma is chronic inflammatory disease of respiratory air-passage,

recognized as a highly prevalent health problem of all ages, characterizes by symptoms,

in particular cough, shortness of breath, mostly at sleeping hours or in the early

morning, chest tightness, and wheezing and address considerable impairment in

physical activities.

Exact pathophysiology of asthma is not yet identified, but number of factors that

contribute or trigger the disease, inflammatory cells degranulation results in the release

of numbers of chemical mediators and toxic substances, evident that no single

inflammatory cell is able to account for the complex pathophysiology of asthma, but

some cells are predominant in asthmatic inflammation, of which leukotriene‘s derived

from the arachidonic acid, are consider to be the important in the pathophysiology of

the disease.

Treatment efficacy in asthma has traditionally been determined by measurement of

symptoms and pulmonary function, much research into the development of

questionnaires, designed to quantify the impact of disease on daily life and well-being

of the patient's.

Pharmacological access in the therapy of asthma, include number of classes and

approaches through different mechanism of actions, to prevent or control asthma

symptoms or at least to reduce the frequency and severity of acute exacerbations.

The important consideration in therapies is the limitation and monitoring of toxicities.

In this regard Bambuterol, long acting β2-adrenergic agonist, activate the β2-receptors

in the lung reducing the frequency of recurrent episodes of bronchospasm and the other

Borage & Echium seed oil, inhibits the leukotriene‘s generation as well as competing

2

with the arachidonic acid, thus decreasing the inflammatory process. Dietary

supplementation provides good opportunity for modulating inflammatory diseases.

OBJECTIVE: In this research study, divided groups treated with Bambuterol 10 mg

orally daily, Borage seed oil 1.3 gram daily plus Echium seed oil 500 mg twice daily

and combination therapy, measuring the efficacy of individual groups and comparing

with each other to assess the improvement, safety and compliance of the drugs.

METHODS: This was an interventional study conducted in Pharmacology Department

of BMSI, JPMC with participation Department of Eastern Medicine Hamdard

University, approved BASR University of Karachi. In this research study, patients

were divided into three groups, Group A (Treated with Bambuterol 10 mg oral daily),

Group B (Borage seed oil oral 1.3 gram once daily plus Echium seed oil capsule 500

mg oral twice daily) and Group C (combination of Bambuterol & Borage plus Echium

seed oil daily).

Out of 210 reported patients, 180-patients of chronic Persistent asthma were registered,

after fulfilled the inclusion and exclusion criteria and demonstrate the objective signs of

reversible airway obstruction, classified in term of severity by (GOLD 2014), by

measuring at least 12% increase in FEV1 after 15 minutes with an inhalation of 200

microgram Salbutamol.

Research study Divided groups are treated as per protocol and compares the results of

pulmonary functions, peak expiratory flow rate, daily diary symptoms card and clinical

questionnaire, to estimate the improvement and compliance of the drugs.

RESULTS: Bambuterol treated groups at day-90, FEV1 was mean 1.31+0.18 (L) with

percentage change of 4.7%, Borage plus Echium seed oil treated group FEV1 was mean

1.3±0.2 with total percentage change of 1.99%. Combination drug treated group

improvement in FEV1 mean of was 1.5+0.3 with the total percentage increase of

13.3%.

3

FVC changes at day-90 in Bambuterol treated group was mean 2.5+0.3 with the

percentage increase of 5.9%. Borage plus Echium seed oil treated group, FVC was

mean 2.3±0.3 with total percentage change of 2.19%, while in combination drug treated

group, FVC was mean 2.5+0.4 with the total percentage increase of 9.2%.

PEFR at day-90 in Bambuterol treated patients results were mean 209.7+37.3 (L/mins)

with the total percentage change of 7.1%, in group- B treated patients PEFR was mean

186.2±34.1with the total percentage change of 4.1%, combination drugs treated groups

mean 215.8+50.3, with the total percentage change of 15.2%, results are statistically

highly significant.

Symptoms of daily dairy card evaluation at day-90 shows improvement, and reduction

in night sleep awakening in Group-A, Bambuterol treated patients 38.3%, in Group-B

was 63.3% and in Group-C combination treated group 41.7%, results are highly

significant.

Patient‘s health related quality of life and asthma symptoms control, evidenced by

pulmonary functions, shows improvement. Comparative study of clinical questionnaire

for the assessment of drug effectiveness and compliance treated groups at day-90

exhibit, decreased need of recue medicine.

CONCLUSION: We applied the therapy of Bambuterol, Borage plus Echium seed oil

(rich source of omega-6 & Omega-3) & combination therapy, provided best option, to

reduce the severity of asthma and improvement in the symptoms, as well as quality of

life along with the safety profile, results are highly significant. We concluded that

combination provide a synergistic effect on this chronic inflammatory disorder and may

exerts a positive impact on disease and its comorbidities, in future research studies,

with more scientific approach may further improves patient quality of life and

decreases reliance on rescue medication.

6

3. INTRODUCTION:

3.1 Epidemiology of Asthma:

It is currently observed that Asthma is at large in prevalence and severity, which is a

common chronic airway inflammatory disorder. In this regard, to observe the incidence

and prevalence of asthma becomes difficult, due to intrinsic glitches, surveys and

possible definitions of this disease. It has been seen that the ratio of its prevalence is

10-20% in different populations of countries, which represent an estimated 300 million

cases across the globe (Mannino, et al 2002).

In summary, the status of epidemiological research in adult population in Asia with

overall perception comes to <5%, this is significantly lower than in comparison to adult

population in Europe. The occurrence of adult asthma was 1.3-15.3% in Asian

population. It has not yet been proved in present scenario that asthma in adults is at

increase in other Asian countries, because no relevant data is available. Keeping in

view rapid expansion in Asian population, the prevalence is expected to increase in

those countries, apt to modernization. It may be passed over from childhood to newly

developed disorder in response to occupational hazards and environmental pollutions

(de-Nijs et al 2013)

It is well established fact, that Asia is the largest and most populated continent which

covers the world‘s population, which occupied about 60% of total globe. In recent

decades, the population of the Asia has increased four folds with sharp rise in economy

(Bloom et.al 2011). Like other continents, the asthma has been recognized as major

chronic disease (Thompson et al 2013).

The Prevalence of asthma in childhood has considerably increased in last many decades

in this continent. This has speckled from 0.7% to 11.9%, only one study tried to utilize

7

the objective testing (bronchodilator response), so as to define this disease i.e. Asthma,

whereas others used questionnaires.

In china the prevalence was reported as 0.7 to 3.8% in response to local surveys, when

defined by combination of specific questionnaire and methacholine challenge tests

(Wang et.al 2013).

The recent asthma prevalence was found to be 3.6 to 5.8% in two Korean local studies.

(Song et al 2014). While in Iran, three varied local zone surveys revealed the current

asthma rate, as 1.4 to 6.1% (Rahimi-Rad et al 2008).

Asthma prevalence was reported, the highest as 12%, at Al Ain, UAE (Alsowaidi et al

2010), in another study prevalence ranged from 2.4-3.5% in different local areas of

India (Aggarwal et al 2006). In Pakistan, bronchial asthma is major health issue with a

prevalence of 5% (Anil 2007).

In comparing Asian and European adult population, updated situation in asthma

prevalence is 5% lower in Asian, while earlier severity of Asthma based on the status of

symptoms and limitation of airflow variability, classified by (GINA) global initiative

for asthma guidelines, no more now accepted (Kroegel 2007).

In new GINA, guideline of asthma control by periodic evaluation and assessing the

severity of the disease and treatment response (Humbert et al 2007).

3.2 Asthma & Clinical Presentation:

Asthma symptoms control, design new instrument, to judge the improvement of,

restriction of daily activity, redeem medicine use & discovery of different questionnaire

models, to approach the understanding of the asthma (Revicki et al 2006).

Many cell and cellular elements play vital parts in the inflammatory disorder, which

increase the bronchial hyper-reactivity, leads to repeated episodes of hyperventilation,

dyspnea, thorax compression and episode of cough, mostly observed at sleeping time

8

or early in the morning, usually to variation in airflow obstruction, reversibility largely

either spontaneously or with medications.

The large numbers of chemical mediators are released in response to activation of

different inflammatory cells, which act on the target cells, in a complexes way, in

asthma these mediators are responsible for bronchospasm even in the mildest form,

while some studies established that asthma may involve some distinctive types of

inflammation in airway (Peter, 1996).

Multiple factors are involved in etiology of asthma although the basic pathophysiology

of the disease is unknown, but most commonly associated, with trigger factors like

allergy, hereditary, psychosocial, socioeconomics, environmental and infectious,

resulting in hyper-responsiveness and exacerbation that display the severity of the

disease (National Asthma Control Program 2007).

The important part in asthma is that difficulty in passing air through the airways due to

narrowing of air passage as a result of inflammation and edema, usually IgE-mediated

antigen-antibodies interaction and release of chemical mediator‘s like histamine,

prostaglandin, and most importantly leukotriene‘s (Galli et al 2005).

3.3 Disease Severity Classification:

Asthma is classified by expert panel NAEPP (National Asthma Education and

Prevention Program 2007) in term of severity has developed a four-tiered system to

classify severity of the disease. Four asthma classes are intermittent, mild, moderate

and severe persistent.

1. Asthma Intermittent class is least severe of the four classes of disease severity, in this

category patient experience symptoms two or more times per week, experience the

nocturnal symptoms of coughing, wheezing and breathlessness no more than two times

per month. They require short acting β2 agonist not more than twice per week.

9

2. Mild Persistent Asthma patient experience symptoms of coughing & wheezing two

times per week but less than one per day, nocturnal symptoms experience of coughing,

wheezing and breathlessness two times per month, requires short acting β2 adrenergic

agonist more or less twice per week but not daily. These symptoms cause a minor

limitation to normal daily activities. Exacerbation may be more frequent, but pulmonary

functions are normal.

3. Moderate Persistent Asthma patients experience the symptoms of coughing & wheezing

on daily basis. Moderate persistent asthma patients generally experience nocturnal

symptoms of coughing, wheezing and breathlessness more than once per week. Short

acting β2 adrenergic agonist use daily, symptoms cause some interference with normal

daily activities. Spirometer result shows an FEV1 more than 60 percentages but below

80 percentage of predicted and Forced expiratory volume and forced vital capacity ratio

is less than 5%.

4. Severe Persistent Asthma patients generally experience nocturnal symptoms of

coughing, wheezing or breathlessness almost daily night. Patients may use their Short

acting β2 adrenergic agonist several times daily. Symptoms that cause extremely

limited activities of daily living. Spirometer result shows an FEV1 less than 60% of

predicted and FEV/FVC % is reduced more than 5%.

3.4 Inflammatory cells in Asthma:

Most contemporary technology and changes in the heritable characteristics of

biological populations over successive generations, in complex syndrome of asthma,

originate in early childhood, hereditary, environments, viruses (Stein et al 1999),

allergens (Halonen et al 1999), and occupational exposures, (Venables et al 1997).

In this novel research age, unable to accurately define, the underlying cause of airway

inflammation of bronchial asthma. Since, last many decades, developing new

hypothesis for the understanding of the disease.

10

Design experiments to understand, some basic components that take place in at least

some types of asthma. Animal models cannot actually meet the model of human

asthma; however, they provide foundation, to understand some of the elemental

mechanisms involved in the catering of the disease (Epstein, 2004).

Degranulation, number of inflammatory cells responsible in the release of list of

chemical mediators and toxic substances, claim to be the important in the

pathophysiology of the asthma disease, of which leukotriene‘s derived from the

arachidonic acid exist in a variety of isoforms, importantly as a definite products of

various arachidonic acid modifying enzymes, such as Cysteinyl leukotrienes, (LTC4,

LTD4 & LTE4) are considered to play dominant role in asthma (Montuschi, 2010).

Recognition of receptors and the developments of potent selective leukotriene receptor

antagonist, provided the researchers to study the leukotriene receptor antagonist in the

treatment of asthma and evaluate the improvement of lung functions and symptoms,

although improvement of pulmonary functions were comparably be less mark with

inhaled steroids (Bleecker, et al 2000).

The diversity of mediators that involved in asthma is unlikely, targeting a single

cytokine/chemokine, to provide significant and persistent clinical benefit. However

inflammatory components in number of chronic diseases have significant contribution

in health and disease (Busse, 2005).

Dietary adjustments may benefit the asthma and as well as contribute in health, poly

unsaturated fatty acids are widely accepted, in asthma, type of consumed fat may be

more important than the amount of fat intake.

Research on fatty acid effects, focus on two main parts, use of ω-3 & ω-6

polyunsaturated fatty acids, while ω-3 acids are considered necessary, essential to

11

human health but not synthesized by the body, obtained from seeds oils of certain

plants.(Kapoor et al 2006).

The activation of Cysteinyl-leukotriene receptors have the tendency to potentiate the

predominant symptoms of asthma, by increasing by mucus secretion, enhances

microvascular permeability, edema, impaired ciliary activity and neuronal dysfunction.

Due to the recruitment of inflammatory cells result smooth muscle hypertrophy and

hyperplasia.

Phospholipid under the influence of phospholipase A2 produces, arachidonic acid,

which is metabolized either by cyclooxygenase pathway, generating prostaglandins &

thromboxane‘s, and involving five-lipoxygenase pathway, in association with 5-

lipoxygenase–activating protein as a helper protein, produces the leukotriene‘s,

LTB4&forming the Cys-LT (LTC4, LTD4, LTE4), LTC4 is metabolized enzymatically

to LTD4 and finally to LTE4, and eliminated in the urine.

Inflammatory cells, mast cell and endothelial cells, T lymphocytes to a less degree

produced Cysteinyl leukotrienes, (Salvi et al 2001).

Studies of Lam et al 1988, in broncho-alveolar lavage (BAL), Creticos et al 1984, in

urine collections, exclusively after allergen challenge, while Chu et al 2000, detected

increased production of Cysteinyl-leukotrienes, during an acute asthma attack.

Asthmatic patients established an increased interpretation of LTC4 synthase in

bronchial biopsy specimens as well as increased elucidations of five-lipoxygenase and

5-lipoxygenase-activating protein enzymes (Cowburn et al 1998).

Hallstrand, 2010, mention the significance of multiple mechanisms of Cysteinyl-

leukotrienes in pathophysiology of asthma.

12

In vitro, Guinea pig studies (Underwood et al 1996), as well as vivo studies (Fonteh et

al 2001) in asthma patients, Cysteinyl leukotrienes, induce recruitment of eosinophil in

the air passage.

Most importantly, that eosinophil, increases bronchial hyper-reactivity results

hypertrophy of smooth muscle in both healthy and asthmatic individuals (O‘Hickey et

al 1991).

Earlier, mostly medicinal products were extracted from natural sources (Herbs &

Botanical product) represents large contents of nutraceuticals, proven scientifically

non-toxic, health benefit component, in the avoidance and treatment (Pieszak et al

2012).

Botanical oils, as a source of ω-3 and ω-6 fatty acids, developed an enormous interest

in research, to prevent the incidences of inflammatory diseases, for health protection

against chronic diseases by regulating the lipid mediators production, responsible in

inflammatory diseases (Chilton 2008).

Modulating the inflammatory diseases by dietary supplementation, with Borage and

Echium seed oil provides, favorable opportunity by modifying the metabolism of fatty

acid and thus balance the pro-inflammatory mediators. (Miles et al 2004).

3.5 Mechanisms of Botanical oil effect on inflammation in humans:

Since last 20-years research has been looking forward, how arachidonic acid

metabolism can be intercepted by dietary manipulation, which prevents the leukotriene

generation, derived from the ω-6 poly unsaturated fatty acids, which implicate in the

pathophysiology of the disease and there are sufficient evidences, that leukotriene

modifying drugs are an established therapy in the management of asthma.

Investigators have tried to inhibit leukotriene‘s generation by applying borage seed oil,

containing the metabolic intermediate, γ-linolenic acid which is not present in human

diet. γ-linolenic acid is a product of the Δ6

desaturase, obtaining dietary γ-linolenic acid

13

bypasses the Δ6-desaturase regulatory step, while humans have very little Δ

6-desaturase

activity, γ-linolenic acid (GLA) is elongated to dihomo-γ-linolenic acid, then converted

to arachidonic acid by Δ5-desaturase (Eskin, 2008).

However, crucial inflammatory cells lack Δ5-desaturase activity, resulting in an

accumulation of DGLA relative to arachidonic acid, then bind to 5-lipoxygenase and

compete with arachidonic acid, leading to a reduction in leukotriene‘s synthesis.

Dihomo-γ-linolenic acid released can be metabolized to 15-lipoxygenase product, 15-

hydroxytrienoic acid, and virtually complete inhibition of leukotriene B4 biosynthesis

(Chilton et al 1996).

Direct inhibition of enzymes, regulating lipid mediator production, dihomo-γ-linolenic

acid, can be converted by lipoxygenases and cyclooxygenases to products, that act as

activator to the conversion of arachidonic acid to leukotriene‘s. Therefore,

supplementation of borage oil, leads to the accumulation of leukotriene‘s, as natural

inhibitors within inflammatory cells.

14

FIGURE-1

Pathway of metabolism of omega-6 and Omega-3 fatty acids in human

(Adopted from Kazani, 2014)

Borage seed oil (ω-6) & Echium seed oil (ω-3 & ω-6) derived fatty acid, would be

expected to enter the pathways of fatty acid metabolism

Borage

Echium

Borage

Echium

Linoleic acid (18-2)

Gamma-linolenic acid (18:3)

Dihomo-γ-Linoleic acid (20:3 18-2)

Arachidonic acid (AA;

20:2)

Adrenic acid (22:4)

24:2

24:5

22:5

FAD (∆6 Desaturase)

ELOVL 5 (Elongase 5)

FAD (∆5 Desaturase)

ELOVL 2

ELOVL 2

FADS2

β oxidation

α-Linoleic acid (18-2)

Stearidonic acid (18-4)

Eicosatetraenoic acid (20:4)

Eicosapentanoic acid (EPA; 22:5)

Docosapentaenoic acid (DPA; 22:5)

24:5

24:6

Docosahexaenoic acid (22:6) Linoeic acid (18-2)

Linoeic acid (18-2)

Linoeic acid (18-2)

Linoeic acid (18-2)

Linoeic acid (18-2)

Echium

Echium

Long chain (20-24 carbon) highly

unsaturated PUFAs:

15

3.6 Botanical oil combinations and leukotriene generation:

Echium seed oil has fatty acids, contains as Stearidonic acid 12.5 percent and γ-

linolenic acid 11 percent. Stearidonic acid (SDA) is metabolized to Eicosapentaenoic

acid (EPA) in humans and Eicosapentaenoic acid (EPA) or some intermediate, block

the increase in serum arachidonic acid that would otherwise occur with γ-linolenic acid

supplementation (Miles, 2004).

The hypothesis regarding the combination of Echium and Borage seed oils as sources

of Stearidonic acid & γ-linolenic acid will inhibit leukotriene‘s generation without the

side effect of increasing circulating arachidonic acid (Arm et al 2013).

16

FIGURE-2

Potential mechanism by which Eicosapentaenoic acid (EPA) and γ-linolenic

acid (GLA), inhibits lipid mediator production.

Lipid mediators are PGE1, 15-HETre, DGLA, LT, FLAP.

.

(Adopted from Chilton, 2008)

EPA + GLA PGE 1 or 15 - HETre

DGLA

Leukotriene A4 Arachidonic Acid

5- Lipoxygenase FLAP

LTA4 Hydrolase

LTB4 LTC4

LTC4 Synthase

17

Institute of Medicine, of National academies in United States and Canada in 2002,

recommended intake of alpha-linolenic acid (ALA), stand for Dietary reference intake

(DRI), accepted as the "official" dietary guidance or policy directives for the health of

the individuals. Eicosapentaenoic acid & Docosahexaenoic acid, do not has, Dietary

reference intake.

The National Academies have recommended that approximately 10% of the acceptable

macronutrient distribution range (AMDR) for alpha-linolenic acid can be utilized, as

Eicosapentaenoic acid and Docosahexaenoic acid. Global recommendations for

demanding, need to establish dietary reference intake for Eicosapentaenoic acid and

Docosahexaenoic acid (Kris-Etherton et al 2009).

Utilization of fatty acids in diet markedly altered over the past century, this leads to

marked rise in the incidence of inflammatory diseases, which is due to large quantity

intake of omega-6 and concomitant decrease in omega-3 fatty acids are consider to be

an extensive contribution in the inflammatory disorders.

http://www.ncbi.nlm.nih.gov/pubmed?term=Kris-Etherton%20PM%5BAuthor%5D&cauthor=true&cauthor_uid=19525100

18

Omega -6 Fatty Acid

Omega-3 Fatty Acid

Prostagladin

Thromboxane

Leukotriene

Lipoxin

Arachidonic acid (AA,20:4N-6)

Eicosapanteanic acid (EPA,20:5n-1)

Docosahexaenoic acid (DHA,22:6n-3)

Resolvin

E Series

Cyloocygenase (COX). Lipoxygenase (LOS) Cytochrome) P450 (CYP)

FIGURE-3

Polyunsaturated fatty acid-derived lipid mediators

(Adapted from Miyata, 2015)

Protectin

resolving

D series

Maresin

Prostaglandin E2 Resolvin E1 Protectin D1

Resolvin D1 Resolvin E2 Leukotriene B4

Maresin1 Resolvin E3 Lipoxin A4

Precursor

Enzyme

Mediator

19

3.7 Borage seed oil & Composition:

Historically, the people from North Africa tribes have migrated to Spain and then to

other regions (Torabi et al 2012). Most researchers, however say that this plant exist to

Mediterranean areas (El Hafid et al 2002).

Figure-4

Borago officinalis Plant

Adapted from www.flowersociety.com

Borage seed oil is derived from the Borago officinalis, contains17–28 percent, of plant-

based source of fatty acid (Eskin, 2008).

Fatty acid Composition of the borage seed oil:

35–38 percent of Linoleic acid

17–28 percent of γ-linolenic acid

16–20 percent of Oleic acid

10–11percent of Palmitic acid

3.5–5.5 percent of Eicosenoic acid

3.5–4.5 percent of Stearic acid

1.5–3.5 percent of Erucic acid

1.5 percent of Nervonic acid

http://www.flower/

http://onlinelibrary.wiley.com/doi/10.1002/fsn3.121/full#fsn3121-bib-0048

20

Borage seed oil is derived from the Borago officinalis, contains high percentages of

gamma linolenic acid, is change to dihomo-gamma-linolenic acid, a precursor to

different prostaglandins and Leukotriene‘s. GLA inhibits leukotriene synthesis, may

have anti-inflammatory effects and benefit people at risk of different inflammatory

disorders such as respiratory inflammation (Farhadi, et al 2012).

21

Figure-5

Borage seed

Picture adopted from www.china4u2.com

Boraginaceae family seeds extricate oil; contain omega-6 and omega-3, which are

γ-linolenic acid, α-linolenic acid, and stearidonic acid.

Borage seed oil has an important polyunsaturated fatty acid of medicinal value in

human diets, helpful in the treatment of a vast range of disorders (Gupta, 2010).

Figure-6

Cap Borage seed oil

PHOTOGRAPH

22

The dietary supplement of Borage seed oil could be offered as soft gelatin capsules.

Dietary change since many centuries have markedly altered the utilization of fatty

acids. Echium and borage seed oils hold great commitment for regulating inflammatory

diseases. (Floyd et al 2008).

3.8 Echium Seed Oil & Composition:

Over 50-species, genus echium contain and belongs to Boraginaceae, many species of

Echium originated in the Mediterranean region, now found throughout Europe, North

America, and Australia. Echium derived from echis, ancient Greek word, means

―viper‖ closeness to its nutlet, look like viper head or due to old days in the cure of

viper bite (Klemow, 2002).

Figure-7

Echium Plantagineum Plant

Photograph

Picture adopted from www.strangewonderfulthings.com

Echium seed oil composition has a unique ratio of ω-3 to ω-6 contain (Berti et al

2007).

30–33 percent of α-linolenic acid

14–18 percent of Linoleic acid

14–17 percent of Oleic

13–15 percent of Stearidonic),

10–13% percent of γ-linolenic

6–7% percent of Palmitic acids

23

Echium plantagineum seeds contain sufficient amounts of γ-linolenic acid, α-linolenic

acid, and stearidonic acid lipids (Abedi, 2014).

Figure -8

Echium seed Photograph

Picture adopted from www.riceplex.com

The dietary supplement of Echium seed oil could be offered as soft gelatin capsules,

bottles oils and/or oral emulsions (Calder el al 2006).

Figure-9

Cap Echium seed oil

Photograph

24

Echium plants produce alkaloids; are called Pyrrolizidine alkaloids, are hepatotoxic,

and cause liver damage (Cheeke, 1988).

For humans, it is suggested that pyrrolizidine alkaloids levels in herbal products, should

be 1 mg per day for oral and 100 mg per day for external use, for a period of about 6

weeks in a year, proven safe (Edgar et al, 2002).

The pyrrolizidine alkaloids are contraindicated in pregnancy and lactating mothers

(Culvenor et al. 1981).

3.9 Dietary fatty acids:

Gas chromatography certify the pyrrolizidine alkaloids content in Echium

plantagineum contain of fatty acid oils, and found to be less than 4 ng/gram. German

laboratory, (Chemisches Laboratorium Dr. Hermann Ulex Nachf, Hamburg-

Norderstedt), estimate pyrrolizidine toxin, by high performance thin layer

chromatography (HPTLC). Bioriginal (Saskatoon, SA, Canada), supplied Echium seed

oil (500 mg) and Borage seed oil (1300 mg).

GLA (γ- linolenic acid) is likely safe, when taken by mouth for short-term, up to 18

months, and for long term, up to 36 months, in recommended doses. Study of

Simopoulos, 2004, found that γ- linolenic acid to be non-toxic in patients using large

doses i.e. 1.4 grams to 2.8 grams per day for up to one year.

The botanical oil supplementation develops awesome interest in the protection of

chronic inflammatory disorders, botanical lipid as a source of omega-3 and 6 are

effective against the diseases, where inflammation is the major concern.

Echium and Borage seed & other stearidonic acid containing oils, influence appropriate

regulation of inflammatory response, demonstrated by the Center of Botanical lipids.

Natural non-Genetically modified structure from Echium oil is, γ- linolenic acid and

stearidonic acid, after ingestion of Dihomo- γ- linolenic acid, Eicosapentaenoic acid

25

and Docosapentaenoic acid, a true substitute for vegetable source, and produces anti-

inflammatory effects of omega-3 and omega-6 of long chain polyunsaturated fatty acids

(Simopoulos, 2002).

3.10 BAMBUTEROL:

Bambuterol, oral β2-adrenergic agonist with high metabolic stability, is a pro-drug of

terbutaline, used once-daily. The use of long acting β2-adrenoceptor agonists in the

treatment of asthma, are still central in the symptomatic management. Figure-10

Figure-10

Photograph Bambuterol

Tablet Bambuterol 10mg

Currently, varieties of β2 –adrenoceptor, particularly with long half-lives, are useful.

Bambuterol, the once-daily dosing as a bronchodilator would show significant relief

and apparently a complementary-enhancing advantage, is providing improved overall

clinical results (Cazzola et al 2010).

The significant action of Bambuterol on nocturnal asthma symptoms and the decreased

need, for inhaled β2-adrenergic agonists have been confirmed (Petrie et al 1993).

Bambuterol act as an inner depot, terbutaline is slowly released; results in a smooth and

sustained plasma concentration of achieve terbutaline. Bambuterol compared with other

oral β2-agonists have fewer side effects.

26

3.11 Clinical Respiratory Questionnaire:

Since last three decades many research highlighted, regarding questionnaires to justify

the impact of the disease on the daily living. Although clinical parameters estimate the

disease status but the respiratory questionnaires provide how the patients anticipated

their state of health.

Health related questionnaire of life (HRQoL), recommended, part to assess asthma

control, in treated patients, provision an important indication, on the observation of

asthma symptoms, daily functioning and wellbeing. The precise questionnaire most

widely used to measure three components: Symptoms, Activity and Impacts (Buss and

Silva 2009).

The symptom component contains the level of symptomatology, while physical activity

that limits the breathlessness is activity component. Need for medication, its side effect

and disturbance of daily life cover the impact component. The Questionnaires are

considered, authentic and receptive in both COPD and asthmatic population (Wilson

1997).

3.12 Lung function measurements:

Clinically pulmonary functions calculate the efficacy of the asthma management.

However, the relationship is complex between overall health of the patients and

pulmonary functions, measured by spirometer, participants perform at least three

maneuvers to achieve GINA standards (Bousquet et al 2007).

Symptoms were documented by measuring Force expiratory volume in one second and

Force vital capacity. Spirometry is an expiratory force-dependent analysis, is necessary

for obtaining results which shows the improvement of pulmonary functions. The

usefulness of the results is dependent on the patient‘s attempt.

27

3.13. Classification Severity of Air flow Limitation

(Based on Post-Bronchodilator FEV1)

GOLD-1 Mild FEV1 > 80% Predicted

GOLD-2 Moderate 50% < FEV1 < 80% Predicted

GOLD-3 Severe 30% < FEV1 < 50% Predicted

GOLD-4 Very Severe FEV1 < 30% Predicted

(GOLD) 2014

Definitive diagnosis of asthma and COPD is detected by spirometry. Spirometers

provide traces of volume expired against time, plot of flow (L/sec) versus volume

expired in liter. Estimating the reversibility by bronchodilator is important to resolve

that either any permanent airway narrowing is present (Johannsen et al 2006).

Bronchodilator reversibility testing is best done on the first visit. Short-acting

bronchodilators need to be withheld for at least 4 hours prior to testing, and long-acting

bronchodilators for 12 hours. Reversibility tested to be interpreted, in the light of the

patient‘s clinical history and examination.

3.14. Common problems related to pulmonary functions reported (Dale, 2005):

Not adequately or completely perform inhalation

Inadequate exhalation or sub-maximal effort

Slow action of maximal expiratory effort

Not completely exhale the lung air

Take breathing in between the maneuver

Lips not tight around mouthpiece

Exhalation through the nose

Throat irritations

Teeth or tongue obstructing the mouthpiece

Wrong posture

Poor technique and training

Spirometer is not accurately calibrated

28

3.15 Peak Expiratory Flow Meter:

Peak expiratory flow rate (PEFR) were recorded with the help of peak expiratory flow

meter, determine the severity of exacerbations in acute asthma, helps in handling the

therapeutic decisions.

Peak expiratory flow meter, is a simple hand held instrument, with one end a

mouthpiece on the other a scale. A small plastic arrow moves when air is passed with

forced expiration into the mouthpiece, measuring the airflow speed. PEFR is a simple

test that does not require much preparation.

The most frequent use of peak flow rate measurement at home, in monitoring of

asthma, where it can be beneficial in patients for both short and long-term monitoring

of the disease. When properly performed and interpreted, peak flow rate measurement

can provide the patient and the clinician with objective data upon which provide

therapeutic decisions.

Numbers of studies have exhibited a benefit, when peak flow rate monitoring is linked

to daily symptom diaries

Frequent review of technique are important in measurement of peak expiratory flow

rate, depends significantly on correct demonstrations. Peak flow rate should be

measured at the same time every day due to diurnal variation (Gibson, 2000).

29

4. LITRATURE REVIEW:

4.1 Pathophysiology of Asthma:

Commonly, fraction of asthma patients have atopy, this type appears to be more severe

than that of allergic asthma and mostly attained later in life. It is referred to as

‗intrinsic‘ asthma (Djukanovic et al 1990).

The bacterial and viral antigens along with the pathophysiology, which is analogous to

allergic asthma; there is a thriving sign for local IgE production (Crimi et al 1998).

Various inflammatory cells engage in asthma, yet the role of any of these cell types is

not specifically confirmed (Wardlaw et al 1995). It is obvious that no particular

inflammatory cells can single handedly cause the compound pathophysiology of the

allergic diseases, however few cells have the lead role in asthmatic inflammation. It is

generally acknowledged now that chronic airway inflammation is the basis of asthma

(Bousquet et al 2000).

Global Allergy and Asthma European Network, consensus reports provides clinical

trials, conducted on recommendations for Patient-Reported Outcomes (PROs),

assessments of allergic diseases. This constitutes a health problem globally, setback

physically, psychologically, economically and socially (Braido et al 2010).

4.2 Inflammatory mediators and its role in Asthma:

Most current definitions, include an essential feature of asthma, is a chronic

inflammation of the airways in which mast cells, eosinophil‘s and T-lymphocytes are

particularly involved presented by Global Strategy for Asthma Management and

Preventions.

For individuals susceptible to the disease, the inflammation comes with symptoms such

as recurring episodes of whistling, dyspnea, chest compression and cough, especially

30

early morning or/and at night. These symptoms are common but variable airflow

obstruction that at least can be partly reversed by treatment or spontaneously.

The persistent inflammation in asthma is still not properly understood, particular role of

the many different inflammatory cells involved in asthma is still not confirmed (Busse,

2001).

It is however apparent that no lone inflammatory cell can be the cause for the

composite pathophysiology of the allergic diseases, but some cells has the lead role in

asthmatic inflammation. Lipid mediators, the Cysteinyl leukotrienes, play a key role in

asthma, considered most potent constrictors of bronchial airways (Dahlen, 2006).

Cytokines are being progressively acknowledged, as important factor of chronic

inflammation and have a vital role is deciding the type of inflammatory response.

Almost every cell is able to produce cytokines, due to the lack of specific antagonists;

the research of this subject is hindered. Still valuable information‘s have been made by

using definite counterbalance antibodies that have been established as innovative

therapies (Barnes et al 2002).

Over 100 different inflammatory mediators comprises of many inflammatory cells

involved in complex inflammatory diseases.

Mast cells have an imperative role to intervene acute symptoms of asthma, while

eosinophils, macrophages and T-helper type-2 cells are a part of the chronic

inflammation that triggers airway hyper-reactivity.

Various inflammatory mediators involve in bronchoconstriction, comprising of lipid

and peptide mediators, chemokine‘s, cytokines and growth factors.

Due to the intricacy of the drugs for asthma, that target a cell or mediator is dubious,

but provide important clinical benefit, and most effective drugs are those, which target

many mechanisms. (Masoli et al 2004).

31

4.3 Role of Botanical oil supplements:

The basis of Ayurveda is diet (Gupta, 2008) likewise, Hippocrates states, ‗Let food be

thy medicines and medicine be thy food‘ (Biziulevicius et al 2007).

For ideal health, modern lifestyles must try food varieties and habits that contribute to

the buildup of ω-3 levels in the body (Hardman et al 2002). Without acknowledging

integral ω-3 fatty acids deficiencies in individuals, who are at risk for diet induced

diseases, vitamin supplementation, dietary restrictions, prescription remedies, physical

exercise and alternate medicine will not be fully shielding, defensive, or therapeutic

(Mata Lopez et al 2003).

Along with pharmacologic modifiers, diet supplements of botanical oils have been

proven to reduce the harshness of many inflammatory diseases, including asthma.

Additionally, seed oil from the Boraginaceae family member, comprises of both ω-6

and ω-3 PUFAs, including a γ-linolenic acid, α-linolenic acid and Stearidonic acid are

beneficial for health.

The transformation of α-linolenic acid to Eicosapentaenoic acid and Docosahexaenoic

acid is indigent in humans, which may possibly be due to the incompetency of the

initial rate-limiting step Δ6-desaturase. Also, Stearidonic acid has been proved to hinder

vitro leukotriene generation and in vivo inflammatory processes (Whelan, 2009).

The method changed and built on new suggestions, of updating the guideline in 2014,

relating to specific crucial questions. Non-pharmacological management section had

major amendments made along with the organization and delivery of care and self-

management supports were reviewed.

Past 30 years, there had been much quantitative study regarding the impact of asthma

disease on daily life and welfare of the patient from questionnaires, to measure the

effect of variety of the states of the disease (Bergner et al 1981).

32

They seem to offer tremendous estimates of health in patients with distressed airflow;

however they may be indifferent for patients with mild to moderate disease (Jones et al

1989).

A pattern may produce, a sensitive questionnaire, but it may lack the advantages

convened by standardization, especially would not be able to match directly the results

of other studies or populations. One disease-specific measure, the St. George‘s

Respiratory Questionnaire (SGRQ), was design to standardized and capable of

distinguishing and measuring the sensitively of any change in health after treatment

(Jones et al 1991). The questionnaire to quantify the consequences of airways disorders

on life and general welfare.

Throughout standardized, all patients can answer to the same questions. This way direct

evaluation of different health scores from different studies and drugs or therapeutic

modalities is made possible. In most nations, asthma is managed by general-practice

backgrounds, so the organization of these recommendations affects how the health care

should be provided.

The National Asthma Education and Prevention Program directives and the Global

Initiative for Asthma guidelines are most repeatedly referred to and beseeched by

American practitioners, and are now evidence-based and have related outlines as both

are devised from the National Institutes of Health.

Nutritional medicine, not properly recognized, but the need of Eicosapentaenoic acid

and Docosahexaenoic acid, an ω-3 fatty acid may be one of the most essential nutrition,

in the recent days, importance of omega-3 supplementation is rapidly growing for

health (Seo, 2005).

Also awareness regarding the pro-inflammatory properties of ω-6 fatty acids is being

improved (Persaud et al 2004, Jones et al 2004).

33

Inadequate versus ample Eicosapentaenoic acid and Docosahexaenoic acid, status is

now clinically linked respectively, too many diseases as a co-cause or co-treatment

(Wijendran et al 2004).

It is now necessary to scrutinize the balance of omega fatty acids. Ratio of ω-3 and ω-6

had become an ideal for calculating the appropriate balance of these fats in oil and diet.

Diets with ω-3 & ω-6 ratio of 1:10 are not recommended while a 1:1 ratio is considered

perfect.

4.4 Enhancing Plant Seed Oils for Human Nutrition:

The time for designed, plant oils by the means of biotechnology tools, it is now

practicable to alter the content of fatty acid in plants seed oil to modify the comparative

richness of respective fatty acids in seed oils, for health ambition or yield nutritive fatty

acids, not usually available in plants.

Human diet need fats and oil and consumes approximately 25kg/ person per annum,

mostly (80%) from plant sources (Subar, 1998).

The advantages of long-chain omega-3 fatty acids have not gone unseen by health

aware individuals, thus creating a larger demand. Now there is a great requirement for a

plant-based, renewable and maintainable source of LCPUFAs, ω-3 for the human diet.

It has been noted that α-linolenic acid change to Eicosapentaenoic acid, with only a

portion of Stearidonic acid shows efficacy in healthy subjects (Miles, 2004).

Seed is now being cultivated on thousands acres of lands; soon the food we eat will

have some of its oil. It is may be more notable that the oil seeds fatty acid structure may

be rearranged by advanced pathway engineering to produce important fatty acids,

formerly only attainable from non-sustainable sources.

34

5. PURPOSE OF STUDY:

The objective of the study was to prevent bronchoconstriction with the minimum

amount of medication and hence reduces the risk of adverse effects; primary purpose

was to decreases the inflammation over long term and decreases the episodes of

exacerbations.

1. To evaluate the effects of Bambuterol (long acting-β2 agonist) in improving asthma

control in chronic persistent asthmatic patients.

2. To evaluate the effects of combination therapy of Borage seed oil and Echium seed oil

in improving asthma control in chronic persistent asthmatic patients.

3. To evaluate the effects of combination therapy of Bambuterol & Borage plus Echium

seed oil, in improving asthma control in chronic persistent asthmatic patients.

4. To compare the effects of Bambuterol with both combination therapies of

Borage/Echium seed oils and combination therapies with each other, in improving

asthma control in chronic persistent asthmatic patients.

5. To observe the safety & compliance of study drugs in chronic persistent asthmatic

patients.

5.1 Primary Outcome Measures:

Improve in symptoms & quality of daily life in chronic moderate persistent asthma.

5.2 Secondary Outcome Measures:

The role of drugs used in study can be effective in prolong asthma control.

Changes in lung function were accessed via spirometer & PEFR at each visit,

investigate the Lipid profile& LFT to evaluate the safety of drugs, as single therapy

or/and combination therapy in prolong asthma control.

35

MATARIAL & METHODS:

This Open label randomized clinical trial, were carried out in the Department of

Pharmacology & Therapeutics BMSI, JPMC, Karachi in participation with the Institute

of Eastern Medicine, Hamdard University, Karachi, under the supervision of Prof Dr.

Moosa Khan, Department of Pharmacology BMSI, JPMC, Karachi. Patients

participated and registered after giving consents and applied the inclusion and

exclusion criteria.

CRITERIA OF SELECTION:

6.1. Inclusion Criteria:

Diagnosed asthma patients of either sex and ages, that ranging from 18 years to 70

years, diagnoses based on the history of recurrent episodes of dyspnea, wheezing,

cough, nocturnal awakenings and objective signs of reversibility, by measuring at least

12% increase in FEV1, with an inhalation of 200 microgram (µg) Salbutamol, after 15

minutes (GOLD, 2014).

6.2. Exclusion Criteria:

Pregnant or lactating women

Clinically significant renal and hepatic impairment

Chronic restrictive pulmonary Diseases.

Diagnosed Diabetes mellitus.

Patients with history of allergy /hypersensitivity to any of the study medication

Having any serious infection in the last six months and has taken oral steroids to

treat this infection.

36

MATERIALS:

6.3 Drugs & Compounds:

Bambuterol HCl 10 mg (Long acting β2-adrenergic agonist)

Capsule Borage Seed Oil, One capsule 1.3 gram contains Omega-6 fatty acid

781mg. (Product of Canada, Distributor Nature‘s way product, LLC Green Bay,

USA Batch 20072700)

Capsule Echiomega (Echium Seed Oil) each capsule of 500mg given twice daily,

I-gram total fat contain 728 mg of PUFA of which 469 mg of Omega-3 & 259 mg

of Omega-6 (Igennus Ltd, UK) Batch number 5102

6.4 Equipment’s:

a. Sphygmomanometer

b. Stethoscope

c. Spirometer (Vitalo-graph Micro, Made in Irland Cat No 630000 Series)

d. Peak flow meter (Datopir Peak-10)

e. Disposable Syringes (Collection of blood samples)

6.5 Respiratory Parameters:

a. Force Expiratory Volume in one second (FEV1).

b. Force vital Capacity (FVC).

c. Peak expiratory flow rate (PEFR).

d. Clinical respiratory symptoms Questionnaire.

e. Diary Card (Symptoms of dyspnea, Cough, sputum, Sleep disturbances, Night sleep

awakening, Numbers of Exacerbations)

37

6.6. Laboratory Parameters:

a. Lipid Profile

Cholesterol

HDL (High density lipoprotein)

LDL (Low density lipoprotein)

b. Liver Function Test

Serum Alkaline Phosphatase,

SGPT (Serum glutamic-pyruvic transaminase)

6.7 Grouping of Patients:

At the time of enrollment, each patient, consent was signed and explaining the study

duration of ninety days and strict compliance of drugs and also describes the safety

status of the therapy. All the required information of the patients were recorded on pro

forma design for the study, such as Name, Age, Sex, Address, Previous medication,

Date of follow up visits and laboratory investigations etc. After scrutinizing, 210

patients were registered and divided into three groups.

After follow up, how many patients reported and maintained daily diary symptom cards

and adherence to therapy and have no adverse reaction reported& used of any other

asthma medication, at first schedule visit at day-30. After scrutinizing registered 60-

patients, from each group for the study duration, and monitored throughout study

period and the remaining patients provided medical assistance when needed but not

included in the study project.

GROUP-A: were treated with Bambuterol (long acting β2 agonist) 10mg orally, daily

for 90 days.

GROUP-B: were treated with Borage seed oil (1.3 gram) once, plus Echium seed oil

500mg twice daily for 90 days

38

GROUP-C: were treated by combination of Borage seed oil 1.3 gram once daily

&Echium seed oil capsules twice daily and Bambuterol 10mg orally, daily for 90 days.

Inhaled bronchodilator SOS (β2-agonist was allowed for the quick relief of positive

symptoms.

GROUPING OF PATIENT:

TOTAL NUMBER OF PATIENTS-180

GROUP-A n-60 GROUP-B- n-60 GROUP-C- n-60

Tab Bambuterol

10mg once daily at

bed time for 90-

days

Cap Borage seed oil

1.3 gram once daily

& Echium seed oil

500mg twice daily

for 90-days

Combination of Tab

Bambuterol 10mg &

Cap Borage 1.3 gram

once & Echium seed oil

500mg twice daily for

90-days

FOLLOWUP OF PATIENTS:

Baseline

(Day-0)

Day

30

Day

60

Day

90

6.8 Lung functions measurements:

Pulmonary functions FEV1, FVC were measured by spirometer (Vitalo-graph Micro),

at the center.

Patient‘s age, sex, and height entered into the Spirometer, before the procedure started.

39

Figure-11

Vitalo-graph micro (Cat No 630000 Series)

Photograph

Photograph during procedure performed

Procedure performed to measured best possible results.

Spirometer was turned on and checked calibration, insert a new mouthpiece.

Make clear that patient was not wearing any tight cloths

First demonstrated the procedure, to the patient that how deeply you need to inhale,

how to place the mouthpiece into your mouth and how fast and long you exhale.

Patient positioned & after deep inhalation made a forceful expiration for at least six

seconds

Performance was closely watched.

Three readings were recorded, print and review the results.

At the end of the procedure, the best forced expiratory values were selected.

During the study periods, from baseline (day-0), spirometry were performed on

schedule visits, on day-30, day-60 & day-90.

40

Spirometry results were estimated statistically of the measured FEV1, FVC during the

study periods from baseline to day-90. Study patients from each groups were perform at

least three force vital capacity maneuvers to achieve GINA standards (Bousquet 2007).

The one best forced expiratory value was selected from three measurements.

Spirometers must be regularly cleaned and maintained as directed in the manufacturer‘s

instructions in order to provide accurate and repeatable results. The frequent calibration

for correct functioning must be done (Miller, 2005)

6.9Peak Expiratory Flow Rate & Procedure:

Peak expiratory flow rate (PEFR) were recorded with the help of peak expiratory flow

meter, measuring peak flow rate, to determine the severity of exacerbations in acute

asthma, helps in handling the therapeutic decisions.

Figure-12

Peak Flow Meter (Datopir Peak-10)

Photograph

Frequent review of technique are important in measurement of peak expiratory flow

rate, depends significantly on correct demonstrations. Peak flow rate should be

measured at the same time every day due to diurnal variation (Gibson, 2000).

41

The purpose was to estimate peak expiratory flow rate

Monitor response to treatment regularly.

Severity of an asthma estimated

Gauge the response to treatment

Test should be performed on a regular basis, even when asthma symptoms are not

present. Patients should enter daily peak flow meter readings in asthma diary card and

also measured the rate when exposed to potential asthma triggers, asthma medication

and exaggerated symptoms.

Procedural steps were taken to obtain accurate value of peak flow meter:

Patient standing up straight, Zero reading was checked, before peak flow meter used,

take a deep breath and placed, flow meter with disposable mouthpiece, tightly circle the

lips around the mouthpiece, and patient directed to exhaled air as fast as possible.

Repeated the procedure three times.

One best of the three measurements selected.

6.10 Clinical Respiratory Questionnaire:

The measurement of health-related quality of life is increasingly accepted as an

important endpoint, in the impression of the effects of the disease from a patient‘s

perspective. It showed a multidimensional concept, not only associated with the disease

itself but the medical actions developed for its management, also with the physical,

social and psychological functioning of the patient.

Several questionnaires have been developed to assess health-related quality of life.

Some are used for specific diseases, while others are generic. (Braido et al 2010)

42

An important, questionnaire most widely used in asthma studies which calculate health-

related quality of life is the Saint George‘s respiratory questionnaire (SGRQ) (Buss and

Silva 2009).

6.11 Assessment of drug effectiveness and compliance of asthma patients

Questions Group-A Group-B Group-C

Is cough worse than previously?

Yes No Yes No Yes

No

Is Dyspnea worse than

previously?

Is there increase in sputum

production?

Is your sleep is more disturbed

than previously?

Night Sleep Awakening

Is there any need to rescue

medications?

43

6.12 Symptoms Evaluation Daily Diary Card of Asthma

The diary card analysis provides a means, to document the therapies that influence

health care dependent exacerbations of Asthma (Vijaysaratha, 2008).

Dyspnea Score Evaluation Group-A Group-B Group-C

0 None unaware of difficulty

1 Mild: noticeable during light

strenuous activity.

2 Moderate: noticeable during light

activity.

3 Marked: noticeable when washing or

dressing

4 Severe: almost constant, even when

resting

Cough Score Evaluation

0 None: unaware of coughing

1 Rare: cough now and then

2 Occasional: less than hourly

3 Frequent: one or more times an hour

4 Almost constant: never free of cough

need to cough

Sputum Score Evaluation

0 None: unaware of any difficulty

1 Mild: rarely caused problem

2 Moderate: noticeable as problem

3 Marked: great deal of inconvenience

4 Severe: an almost constant problem

Sleep Score Evaluation

0 None: unaware of any difficulty

1 Mild: rarely caused problem

2 Moderate: noticeable as a problem

3 Marked: Frequent night awakenings

4 Severe: did not sleep at all

% of Awakening free night

0 Night with sleep

1 Night with awakening

44

7. OBSERVATIONS /RESULTS

Total 210 diagnosed, chronic persistent asthma patients, based on post-bronchodilator

FEV1, severity of air flow limitation (GOLD, 2014), of either sex, were examined for the

study purpose, after taking consent and applied inclusion & exclusion criteria and finally

registered 180-patients for the study duration of 90-days.

Registered patients were divided in three groups and directed to pursue the advice and

follow-up visits along with the daily diary card to evaluate the symptoms, tolerability and

compliance of the therapy. Patient‘s pulmonary parameters were repeated and blood

sample collected for safety profile analysis.

Patients were directed strictly, to follow-up visits on day 30, 60 and 90 and maintain

symptoms daily diary card, keep all record safe and note any adverse effects, either time

limiting or severe enough to stop the drug and in case of severe exacerbation of

bronchospasm used of rescue medicine (short acting β2-adrenergic agonist) and report on

scheduled visit.

BASELINE CHARACTERISIC IN THREE TREATED GROUPS:

GROUP-A Patients treated with one daily dose of Bambuterol 10 mg at bed time.

Registered 70-diagnosed patients and their baseline data collected, and directed follow up

scheduled visits along with daily diary symptoms card and pulmonary parameters

(Spirometry & PEFR), clinical respiratory questionnaire, and collection of blood sample

till day 90 to evaluate statistically, to conclude the efficacy by mean of clinical

improvement in respiratory symptoms.

Only 63 patients reported on the follow-up visit at day-30, two of the study patient not

maintain daily record of symptoms, and one patient during his visit informed, that he used

other anti-asthmatic drug as prescribed by his locality physician, so all three drop from the

45

study but medical support is provided on his visits. Only 60-registered patients completed

the study duration of 90-days.

Male patients were 59 (98.3%) and female were 1 (1.7%) with mean age of 56+ 5.6

ranging from 47 years to 68 years. Out of 60 selected patients 55 (91.7%) were smokers

& 5 (8.3%) were non-smokers. In this study 42 (70%) of moderate severity and 18

(30.0%) were of severe rank of asthma classification. Baseline parameter recorded

before the start of Bambuterol therapy FEV1 was mean 1.25+0.19, FVC mean 2.4+0.4

and Peak expiratory flow rates mean 195.8+39.5 depicted in table-7.1

GROUP-B: Treated orally with, Borage 1.3 gram once and Echium seed oils 500 mg

twice daily, for 90-days. 70 registered patients only 62 reported on the follow up visit,

and two patients not properly maintained daily diary card were drop from study but

medical support provided on the visit. Total 60 registered patients completed the follow

up of 90-days.

Study group-B, 58 (96.7%) male and 2 (3.3%) female with mean age 59.4+7.5 ranging

from 45 years to 70 years. 58 (96.7%) smokers and 2 (3.3%) non-smoker.

According to asthma severity rank,42 (70%) of moderate severity and 18 (30.0%) were

of severe class. Baseline pulmonary estimation of FEV1 was mean 1.2+0.2, FVC

2.3+0.3 and PEFR 178.8+35.3 depicted in table-7.1

GROUP-C: Combination therapy of Bambuterol 10 mg daily and Borage 1.3 gram

once plus Echium seed oil 500 mg twice daily for 90 days.

Registered 70-patients only 61-reported on follow up visit, out of which one patient

loss the daily diary card, because non-availability of symptom record, patient was

dropped from the study but medical support provided on visits.

46

Only 60-registered patients follow up for 90-days. Study group-C, 58 (96.7%) male and

2 (3.3%) female with mean age 56.4+6.3 ranging from 42 years to 70 years, 53

(88.3.7%) smokers and 7 (11.7%) non-smokers.

According to asthma severity rank, group-B treated patients have 47 (78.3%) of

moderate severity and 13 (21.7%) of severe class. Baseline pulmonary estimation of

FEV1 was mean 1.3+0.3, FVC 2.3+0.4 and PEFR 187.8+46.2 shown in tale-7.1.

47

TABLE-7.1

COMPARISON OF BASE LINE CHARACTERISTICS BETWEEN

BAMBUTEROL (GROUP-A), BORAGE/ECHIUM SEED OIL (GROUP-B) AND

COMBINATION OF DRUGS (GROUP-C) THERAPY IN ASTHMA PATIENTS

Group-A: Tab Bambuterol 10 mg once daily

Group-B: Tab Borage 1.3 gram once plus Echium seed oil 500 mg twice daily

Group-C: Combination of Tab Bambuterol 10 mg daily &Tab Borage 1.3 gram once

plus Echium seed oil 500 mg twice daily

n- Number of Patients

FEV1- Forced expiratory volume in 1-second

FVC-Forced vital capacity

PEFR- Peak expiratory flow rate

GROUP-A

n=60

GROUP-B

n=60

GROUP-C

n=60

p-value

Gender

Female 1 (1.7%) 2 (3.3%) 2 (3.3%) 0.814

Male 59 (98.3%) 58 (96.7%) 58 (96.7%)

Age in years

(Mean+SD) 56.9±5.6 59.4±7.5 56.4±6.3 0.025

Smokers 55 (91.7%) 58 (96.7%) 53 (88.3%) 0.23

Non-Smokers 5 (8.3%) 2 (3.3%) 7 (11.7%)

Severity of Asthma

Moderate 42 (70.0%) 42 (70.0%) 47 (78.3%) 0.496

Severe 18 (30.0%) 18 (30.0%) 13 (21.7%)

FEV1 Baseline 1.25±0.19 1.2±0.2 1.3±0.3 0.451

FVC Baseline 2.4±0.4 2.3±0.3 2.3±0.4 0.304

PEFR 195.8±39.5 178.8±35.3 187.3±46.2 0.075

48

GROUP–A: BAMBUTEROL TREATED PATIENT.

Bambuterol treated patients in chronic persistent asthma, study parameters were

compared from baseline to day-90. Forced expiratory volume in one second (FEV1),

were changed from mean 1.25±0.19 to mean 1.31±0.18 compared with total percentage

change was 4.7%. Overall FEV1 improvement in mean was statistically highly

significant. Table 7.2

Forced vital capacity (FVC) improved, from baseline mean 2.4±0.4 to 2.5±0.3 at day-

90 with total percentage change was 5.9%, FVC showed statistically highly significant

improvement in Bambuterol treated patients. Table-7.2

Peak Expiratory Flow Rate were changed from mean 195.8±39.5 to mean 209.7±37.3,

with total percentage changed was 7.1%, showed statistically highly significant

improvement of PEFR in Bambuterol therapy. Depicted in Table -7.2

Pulmonary symptoms diary card (Cough, Dyspnea, Sputum production, sleep

disturbances) improved and night sleep awakening reduced from 100% at day-0 to

38.3% at day-90, and reduction of exacerbation was significant with daily dose of 10

mg Bambuterol. Depicted in Table-7.3

Clinical Questionnaires of group-A, for estimation of drug effectiveness and

compliance was, cough at day-0 was 18.3% reduce to 5.0%, dyspnea from 21.7% to

5.0%, sputum production 11.7% to 0%, sleep disturbances reduces from 11.7% to

5.0%, and need of rescue medication (Short acting β2 –adrenergic agonist) was reduced

from 100% to 15% at day-90 . Depicted in Table-7.4

49

TABLE-7.2

GROUP-A, EFFECT OF BAMBUTEROL ON FEV1, FVC & PEFR IN

CHRONIC PERSISTENT ASTHMA PATIENTS

Day-0 Day-90 Total

Percentage

change

p-value

FEV1 (L)

Mean+SD 1.25±0.19 1.31±0.18

4.7%

<0.0001

FVC (L)

Mean+SD 2.4±0.4 2.5±0.3

5.9%

<0.0001

PEFR

(L/min)

Mean+SD

195.8±39.5 209.7±37.3

7.1%

<0.0001




p-value< 0.05 significant

50

TABLE-7.3

GROUP-A- EFFECTS OF BAMBUTEROL ON SYMPTOM SCORE &

EXACERBATIONS IN CHRONIC PERSISTENT ASTHMA

Day-0 Day-90 p-value

Dyspnea

2 (0)

1 (0)

<0.0001

Cough

1.5 (1)

1 (0)

<0.0001

Sputum

Production

1.5 (1)

1 (0)

<0.0001

Sleep

disturbances

2 (0)

1 (0)

<0.0001

Night Sleep

awakening

60 (100%)

23 (38.3%)

<0.0001

Exacerbation

2 (0)

2 (0)

<0.002


51

TABLE-7.4

CLINICAL QUESTIONAIRES IN GROUP-A PATIENTS OF CHRONIC

PERSISTENT ASTHMA TREATED WITH BAMBUTEROL

Assessment of drug effectiveness and compliance of

patients

Group-A (Bambuterol

orally 10mg daily)

Is cough worse than previously D-0

11 (18.3%)


3 (5.0% )

Is Dyspnea worse than previously D-0

13 (21.7%)


3 (5.0%)

Is there increase in sputum production D-0

7 (11.7%)


0 (0.0%)

Is sleep is more disturbed than previously D-0

7 (11.7%)


3 (5.0%)

Night Sleep Awakening D-0

60(100.0% )


23 (38.3%)

Is there any need to rescue medications D-0

60 (100.0%)


9 (15.0%)

52

GROUP–B: BORAGE PLUS ECHIUM SEED OIL TREATED PATIENTS.

Patients of Group-B treated were investigated for pulmonary parameters in chronic

persistent asthma. Forced expiratory volume in one second (FEV1), compared from

baseline to day 90, changed from mean 1.2±0.2 to 1.3±0.2 with total percentage change

was 1.99%. The mean of FEV1 was statistically highly significant.

Forced vital capacity (FVC) were increased from mean 2.3±0.3 to 2.3±0.3 at day-90,

with total percentage change was 2.19%. The mean of FVC was statistically highly

significant. Depicted in Table-7.5

Peak Expiratory Flow Rate (PEFR) changed from day-0 mean 178.8±35.3 to mean

186.2±34.1 at day-90 with the total percentage change was 4.1%, showed statistically

highly significant. Depicted in Table -7.5

Pulmonary symptoms of daily diary card entered (Cough, Dyspnea, Sputum production

& Sleep disturbances), showed improved and night sleep awakening reduced at day-90.

Patients of group-B exhibits significant reduction of exacerbation. Depicted in Table-

7.6

Clinical Questionnaires of Group-B patients, for assessment of drug effectiveness and

compliance in chronic persistent asthma were determined from baseline to day-90,

cough reduced from13.3% to 6.7%, dyspnea reduced from 20.0% to 8.3%, sputum

production decreased from 8.3% to 5%, sleep disturbances decreased from 20.0% to

13.3%. Night sleep awakening decreased from 100% to 63.3%, and need of rescue

medication (Short acting β2 –adrenergic agonist) decreased from 100% to 41.7% at day-

90. Table-7.7

53

TABLE-7.5

GROUP-B, EFFECT OF BORAGE PLUS ECHIUM SEED OIL ON FEV1, FVC

& PEFR IN CHRONIC PERSISTENT ASTHMA PATIENTS

FEV1- forced expiratory volume in 1-second




Day-0 Day-90 Total

Percentage

change

p-value

FEV1 (L)

Mean+SD

1.2±0.2

1.3±0.2

1.99% <0.0001

FVC (L)

Mean+SD

2.3±0.3

2.3±0.3

2.19% <0.004

PEFR

(L/min)

Mean+SD

178.8±35.3

186.2±34.1

4.1% <0.0001

54

TABLE-7.6

GROUP-B EFFECT OF BORAGE PLUS ECHIUM SEED OIL ON SYMPTOM

SCORES & EXACERBATION IN CHRONIC PERSISTENT ASTHMA

PATIENTS


Dyspnea

2 (0)

1 (1)

<0.0001

Cough

2 (1)

1 (0)

<0.0001

Sputum

production

2 (0)

1 (1)

<0.0001

Sleep

disturbances

2 (0)

1.5 (1)

<0.0001

Night Sleep

awakening

60 (100%)

38 (63.3%)

<0.0001

No of

Exacerbation

2 (0)

2 (0)

0.157


55

TABLE-7.7

CLINICAL QUESTIONAIRES GROUP-B PATIENTS OF CHRONIC

PERSISTENT ASTHMA, TREATED WITH BORAGE SEED OIL PLUS

ECHIUM SEED OIL

Assessment of drug effectiveness and compliance of

patients

Cap Borage seed oil

1.3gm once plus Cap

Echium seed oil 500 mg

twice daily.


8 (13.3% )


4 (6.7% )


12 (20.0%)


5 (8.3%)


5 (8.3%)


3 (5.0%)


12 (20.0%)


8 (13.3%)


60 (100.0%)


38 (63.3%)


60 (100.0%)


25 (41.7%)

56

GROUP-C: COMBINATION OF BAMBUTEROL AND BORAGE PLUS

ECHIUM SEED OIL TREATED PATIENTS.

Patients treated with combination of Bambuterol 10 mg orally daily at bed time along

with Cap Borage seed oil 1.3 gram once daily plus Cap Echium seed oil 500 mg twice

daily. Patients were evaluated by performing pulmonary functions.

Forced expiratory volume in one second (FEV1), at day-0 was mean 1.3±0.3 compared

at day-90 mean was 1.5±0.3, FEV1 with total percentage change was 13.3%, exhibits

statistically highly significant.

Mean forced vital capacity (FVC) at day-0 change from 2.3±0.4 to 2.5±0.4 at day-90

and total percentage change was 13.3%, showed statistically highly significant.

Mean Peak Expiratory Flow Rate (PEFR) at day-0 was 187.3±46.2, improved to mean

215.8±50.3, with total percentage change was 13.3% at day-90, and shown statistically

highly significant improvement in peak expiratory flow rate in group-C patients.

Depicted in Table -7.8

Pulmonary symptoms daily diary card (Cough, Dyspnea, Sputum production, Sleep

disturbances) data showed improvements in pulmonary symptom, results are


Patients of Group-C, number of exacerbation reduced markedly, statistically highly

significant. Depicted in Table-7.9

Clinical Questionnaires were applied on Group-C, for assessment of drug effectiveness

and compliance in chronic persistent asthma, in which, cough at day-0 was 13.3%

reduce to 0.0%, dyspnea 11.7% to 0.0%, sputum production from 11.7% to 8.3%, sleep

disturbances from 15.0% to 6.7% at day-90, statistically shown highly significant

depicted in the Table-7.9.

57

Night sleep awakening at day-0 was 100 % reduced to 41.7%, and need of rescue

medication (Short acting β2 –adrenergic agonist) at day-0 was 100% reduced to 18.3%

at day-90. Table-7.10

58

TABLE-7.8

GROUP-C COMBINATION THERAPY OF BAMBUTERO WITH BORAGE

PLUS ECHIUM SEED OIL ON FEV1, FVC & PEFR IN CHRONIC

PERSISTENT ASTHMA PATIENTS

Day-0 Day-90 Total

Percentage

change

p-value

FEV1 (L)

Mean+SD

1.3±0.3

1.5±0.3

13.3%

<0.0001

FVC (L)

Mean+SD

2.3±0.4

2.5±0.4

9.2%

<0.0001

PEFR

(L/min)

Mean+SD

187.3±46.2

215.8±50.3

15.2%

<0.0001





59

TABLE-7.9

GROUP-C, EFFECT OF COMBINATION OF BAMBUTERO & BORAGE PLUS

ECHIUM SEED OIL ON SYMPTOM SCORE AND NUMBERS OF

EXACERBATION IN ASTHMA PATIENTS


Dyspnea

2 (0)

1 (0)

<0.0001

Cough

2 (1)

1 (0)

<0.0001

Sputum production

2 (1)

1 (1)

<0.0001

Sleep disturbance’s

1 (1)

1 (1)

<0.0001

Night Sleep

awakening

60 (100%)

25 (41.7%)

<0.0001

No of Exacerbation

0 (0)

2 (0)

<0.0001


60

TABLE-7.10

CLINICAL QUESTIONNAIRE GROUP-C- PATIENTS OF CHRONIC

PERSISTENT ASTHMA TREATED WITH COMBINATION OF BAMBUTEROL

& BORAGE PLUS ECHIUM SEED OILS

Assessment of drug effectiveness and

compliance of patients

Combination of Tab

Bambuterol 10 mg daily

with Cap Borage seed oil

1.3 gm once plus Cap

Echium seed oil 500 mg

twice daily.

Is cough worse than previously D-0 8(13.3%)

Is cough worse than previously D-90 0(0.0%)

Is Dyspnea worse than previously D-0 7(11.7%)

Is Dyspnea worse than previously D-90 0(0.0%)

Is there increase in sputum production D-0 7(11.7%)

Is there increase in sputum production D-90 5(8.3%)

Is sleep is more disturbed than previously D-0 9(15.0%)

Is sleep is more disturbed than previously D-90 4(6.7%)

Night Sleep Awakening D-0 60(100%)

Night Sleep Awakening D-90 25(41.7%)

Is there any need to rescue medications D-0 60(100.0%)


11(18.3%)

61

COMPARISON OF ALL GROUPS FROM DAY-0 TO DAY-90

COMPARATIVE STUDY OF GROUP-A vs GROUP-B

Comparative studies in two groups were reviewed by performing pulmonary functions

& were calculated by used of Spirometer & Peak flow meter, the daily dairy card

symptoms assessment, clinical questionnaires to resolved the effectiveness and

tolerability.

On day-0 (Baseline) the difference in mean FEV1 when compared between Group-A

Bambuterol treated, mean 1.25±0.19 to Group-B FEV1 was mean 1.2±0.2, on average

showed higher value of Group-A, statistically non-significant. Similarly on day-90

mean FEV1 of Group-A was 1.31±0.18, when compared with Group-B, mean 1.3±0.2,

the results are statistically non-significant. The percentage increase was more in Group-

A (4.7%), as compared to Group-B (1.99%). Table-7.11 & Figure-13

Baseline difference in mean force vital capacity in Group-A was mean 2.4±0.4

compared with Group-B mean 2.3±0.3, on average showed higher value in group-A,

statistically found non-significant. Whereas at day-90 mean force vital capacity (FVC),

of Group-A was 2.5±0.3, when compared with group-B mean 2.3±0.3, showed

statistically highly significant difference. The percentage change was more improved in

group-A (5.9%), as compared to Group-B (2.19%). Table-7.11 & Fig-14

Mean Peak Expiratory Flow Rate (PEFR) in Group-A at day-0 was mean 195.8±39.5,

improved to mean 209.7±37.3, at day-90. Where PEFR in Group-B at baseline was

mean 178.8+35.3 increased to mean 186.2+34.1, at day-90. The difference between two

treatment groups was not significant at baseline but at day-90, when compared the two

groups results, the Group-A shown highly difference.

62

The percentage change was more increased in group-A (7.1%) as compared to group-B

(4.1%). Table-7.11 Figure-15

As compare to baseline significant improvements were found in pulmonary symptoms

daily diary card (Cough, Dyspnea, Sputum production, Sleep) at day-90.Night sleep

awakening in Group-A treated patients reduced from 100% to 38.3% at day-90 while in

Group-B it reduces from 100% to 63.3% at day-90, statistically highly significant.

Patients of group-A displayed significant improvement in reduction of number of

exacerbation, while in group-B treated patients do not exhibit any reduction in number

of exacerbation at day-90. Table-7.12

Clinical Questionnaires, of group-A showed notable reduction of symptoms from

baseline to day-90, in group-A, cough from 18.3% to 5.0%, in group-B from 13.3% to

6.7%, dyspnea in group-A, 21.7% to 5.0%, in group-B, 20% to 8.3%, in group-A

sputum production 11.7% to 0.0%, and in group-B, 8.3% to 5.0%, in group-A, sleep

disturbances 11.7% to 5.0% and in group-B reduces from 20% to 13.3% at day-90.

Night sleep awakening at day-0 was 100% reduced to 38.3% in group-A and reduces

from 100% to 63..3% in group-B at day-90, and need of rescue medication (Short

acting β2 –adrenergic agonist) in group-A at day-0 was 100% reduced to 15.0%, and in

group-B reduces from 100% to 41.7%. Table-7.13

On the basis of clinical improvement and drug compliance at day-90 the drug of group-

A (Bambuterol), treated patients were more effective as compared to the group-B

treated patients in chronic persistent asthma.

63

TABLE-7.11

COMPARISON OF FEV1, FVC & PEFR BETWEEN GROUP-A & GROUP-B IN

CHRONIC PERSISTENT ASTHMA PATIENTS.

Tab Bambuterol

Group-A

(n=60)

Cap Borage Plus

Echium seed oil

Group-B

(n=60)

p-value

FEV1

Day-0 1.25±0.19 1.2±0.2 0.746

Day-90 1.31±0.18 1.3±0.2 0.193

Total percentage

change 4.7% 1.99%

FVC

Day-0 2.4±0.4 2.3±0.3 0.116

Day-90 2.5±0.3

2.3±0.3

0.001

Total percentage

change

5.9% 2.19%

PEFR

Day-0 195.8±39.5 178.8±35.3 0.014

Day-90 209.7±37.3

186.2±34.1

<0.0001

Total percentage

change

7.1% 4.1%

64

Figure-13

Group-A: Bambuterol treated patients of chronic persistent asthma

Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma

1.2525 1.24067 1.3115 1.3

4.70% 1.99% 0

0.2

0.4

0.6

0.8

1

1.2

1.4

Group A Group B

Mea

n F

EV1

(L)

Comparison of FEV1 Between Group-A & Group-B

Day-0 Day-90 Total percentage change

65



2.4 2.298 2.53 2.348

5.90% 2.19% 0

0.5

1

1.5

2

2.5

3

Group A Group B

Mea

n F

VC

(L)

Comparison of FVC Between

Group-A & Group-B

Day-0 Day-90 Total percentage Change

Figure-14

66

Figure-15


Group-B: Borage plus Echium seed oil treated patients of chronic persistent asthma

195.833 178.83 209.667

186.167

7.1 4.1 0

50

100

150

200

250

Group A Group B

Me

an P

FVC

(L/

Min

) Comparison of PEFR Between

Group-A & Group-B

Day-0 Day-90 Mean percentage Change

67

TABLE-7.12

COMPARISON OF GROUP-A & GROUP-B ON SYMPTOMS SCORE &

EXACERBATIONS IN CHRONICPERSISTENTASTHMA

Daily Dairy

Card

Symptoms

GROUP-A

Tab Bambuterol 10 mg daily

GROUP—B

Cap Borage seed oil 1.3 gm OD

plus Cap Echium seed oil 500

mg BD

Day-0 Day-90 p-value Day-0 Day-90 p-value

Dyspnea

2 (0)

1 (0)

<0.0001

2 (0)

1 (1)

<0.0001

Cough

1.5 (1)

1 (0)

<0.0001

2 (1)

1 (0)

<0.0001

Sputum

Production

1.5 (1)

1 (0)

<0.0001

2 (0)

1 (1)

<0.0001

Sleep

disturbances

2 (0)

1 (0)

<0.0001

2 (0)

1.5 (1)

<0.0001

Night Sleep

Awakening

60

(100%)

23

(38.3%)

<0.0001

60

(100%)

38

(63.3%)

<0.0001

No of

Exacerbation

2 (0)

2 (0)

<0.002

2 (0)

2 (0)

<0.157

68

TABLE-7.13

CLINICAL QUESTIONNAIRE COMPARISON OF GROUP-A & GROUP-B, IN


Assessment of drug effectiveness and compliance

of patients GROUP-A GROUP-B

Is cough worse than previously D-0 11(18.3%) 8(13.3%)

Is cough worse than previously D-90 3(5.0%) 4(6.7%)

Is Dyspnea worse than previously D-0 13(21.7%) 12(20.0%)

Is Dyspnea worse than previously D-90 3(5.0%) 5(8.3%)

Is there increase in sputum production D-0 7(11.7%) 5(8.3%)

Is there increase in sputum production D-90 0(0.0%) 3(5.0%)

Is sleep is more disturbed than previously D-0 7(11.7%) 12(20.0%)

Is sleep is more disturbed than previously D-90 3(5.0%) 8(13.3%)

Night Sleep Awakening D-0 60(100.0%) 60(100.0%)

Night Sleep Awakening D-90 23(38.3%) 38(63.3%)

Is there any need to rescue medications D-0 60(100.0%) 60(100.0%)

Is there any need to rescue medications D-90 9(15.0%) 25(41.7%)

69

COMPARATIVE STUDY OF GROUP-A vs GROUP-C

Comparative study of two group in chronic persistent asthma, Group-A treated with

Bambuterol 10 mg daily and Group-C treated with Bambuterol 10 mg daily & Borage

seed oil 1.3 gram once daily plus Echium seed oil 500 mg twice daily for the study

duration of 90-days. Comparative studies in two groups (reviewed by performing

pulmonary functions) were calculated by used of Spirometer & Peak flow meter, the

daily dairy card symptoms assessment, clinical questionnaires for the effectiveness and

tolerability.

On day-0 (Baseline) the difference in mean FEV1when compared between Groups-A

Bambuterol treated, was 1.25±0.19 to Group-C FEV1 was mean 1.3±0.3, on average

showed higher value of Group-C, statistically non-significant. Similarly on day-90

mean FEV1 of Group-A was 1.31±0.18, when compared with Group-C mean 1.5±0.3,

the results were statistically significant. The percentage increase was more in Group-C

(13.3%), as compared to Group-A (4.7%). Table 7.14 & Figure-16

Baseline difference in mean force vital capacity in Group-A was mean 2.4±0.4

compared with Group-C mean 2.3±0.3, on average showed higher value in group-C,

statistically found non-significant. Whereas at day-90 mean force vital capacity (FVC),

of Group-A was to 2.5±0.3, when compared with group-C mean 2.5±0.4, showed

statistically non-significant difference. The percentage change was more improved in

group-C (9.2%), as compared to Group-A (5.9%). Table-7.14 & Fig-17

Mean Peak Expiratory Flow Rate (PEFR) in Group-A at day-0 mean 195.8±39.5,

improved to mean 209.7±37.3, at day-90. Whereas PEFR in Group-C at baseline was

mean 187.8+46.2 increased to mean 215.8+50.3, at day-90.

The difference between two treatment groups was not significant at baseline but at day-

90, when compared the two group‘s results, the Group-C showed highly difference.

70

The percentage change was more increased in group-C (15.2%) as compared to group-

A (7.1%).Table -7.14 Figure-18

As compare to baseline significant improvements were found in pulmonary symptoms

daily diary card (Cough, Dyspnea, Sputum production, Sleep) at day-90. Patients of

both groups exhibited statistically highly significant improvement in symptoms and

reduction of number of exacerbation, mentioned in the Table-7.15.

Clinical Questionnaires of both groups A & C for assessment of drug effectiveness and

compliance in chronic persistent asthma. In group-A from day-0 to day-90 cough

reduced from 11.3% to 5.0%, in group-C 13.3% to 0%, dyspnea in group-A reduced

from 21.7% to 5.0%, in group-C reduced from 11.7% to 0%, sputum production in

group-A reduced from 11.7% to 0.0%, and in group-C reduced from 11.7% to 8.3%,

sleep disturbances in group-A reduced from 11.7% to 5.0%, in group-C from 15% to

6.7% .

Group-A, Night sleep awakening at day-0 was 100% reduced to 38.3%, and in group-C

reduced from 100% to 41.7% at day-90 and need of rescue medication (Short acting β2

–adrenergic agonist) in group-A reduced from 100% to 15.0%, and in group-C reduces

from 100% to 18.3% at day-90 .Table-7.16

71

TABLE-7.14

COMPARISON OF FEV1, FVC & PEFR BETWEEN GROUP-A & GROUP-C

IN CHRONIC PERSISTENT ASTHMA PATIENTS.

GROUPS Tab Bambuterol

Group-A

(n=60)

Tab Bambuterol &

Cap Borage plus

Echium seed oil

Group-C

(n=60)

p-value

FEV1

Day-0 1.25±0.19 1.3±0.3 0.436

Day-90 1.31±0.18 1.5±0.3 0.001

Total percentage

change

4.7% 13.3%

FVC

Day-0 2.4±0.4 2.3±0.4 0.274

Day-90 2.5±0.3 2.5±0.4 0.958

Total percentage

change

5.9% 9.2%

PEFR

Day-0 195.8±39.5 187.3±46.2 0.281

Day-90 209.7±37.3 215.8±50.3 0.447

Total percentage

change

7.1% 15.2%

72


Group-C: Combination therapy (Bambuterol & Borage plus Echium seed oil) in

patients of chronic persistent asthma.

1.2525 1.3 1.3115 1.5

4.70% 13.30% 0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Group-A Group-C

Mea

n F

EV

1 (

L)

Comparsion of FEV1 Between Group-A & Group C


Figure-16

73

Group-A: Bambuterol treated patients.

Group-C: Combination therapy (Bambuterol & Borage plus Echium seed oil).

2.4 2.3 2.53 2.5

5.90% 9.20% 0

0.5

1

1.5

2

2.5

3

Group-A Group-C

Me

an

FV

C (

L/M

in)

Comparison of FVC Between Group-A & Group-C


Figure-17

74


Group-C: Combination treatment of (Bambuterol & Borage plus Echium seed oil)

in chronic persistent asthma patients.

195.833 187.3 209.667 215.8

7.10% 15.20% 0

50

100

150

200

250

Group-A Group-C

Me

an

PE

FR

(L

) Comparison of PEFR Between

Group-A & Group-C


Figure-18

75

TABLE-7.15

COMPARISON OF SYMPTOM SCORES & EXACERBATIONS BETWEEN

GROUPS-A & GROUP-C IN CHRONIC PERSISTENT ASTHMA.

Daily Dairy

Card

Symptoms

GROUP-A

Tab Bambuterol 10 mg daily

GROUP-C

Tab Bambuterol 10mg &

Cap Borage 1.3 gm once plus

Cap Echium seed oil 500mg BD

Day-0 Day-90 p-value Day-0 Day90 p-value

Dyspnea

2 (0)

1 (0)

<0.0001

2 (0)

1 (0)

<0.0001

Cough

1.5 (1)

1 (0)

<0.0001

2 (1)

1 (0)

<0.0001

Sputum

Production

1.5 (1)

1 (0)

<0.0001

2 (1)

1 (1)

<0.0001

Sleep

disturbances

2 (0)

1 (0)

<0.0001

1 (1)

1 (1)

<0.0001

Night Sleep

Awakening

60

(100%)

23

(38.3%)

<0.0001

60

(100%)

25

(41.7%)

<0.0001

No of

Exacerbation

2 (0)

2 (0)

0.002

0 (0)

2 (0)

<0.0001

76

TABLE-7.16

COMPARISON OF CLINICAL QUESTIONNAIRES, BETWEEN GROUPS-A &

GROUP-C PATIENTS IN CHRONIC PERSISTENT ASTHMA.


compliance of patients GROUP-A GROUP-C

Is cough worse than previously D-0 11 (18.3%) 8 (13.3% )

Is cough worse than previously D-90 3 (5.0%) 0 (0.0%)

Is Dyspnea worse than previously D-0 13 (21.7%) 7 (11.7%)


Is there increase in sputum production D-0 7 (11.7%) 7 (11.7%)


Is sleep is more disturbed than previously D-0 7 (11.7%) 9 (15.0%)


Sleep Awakening D-0 60 (100.0%) 60 (100%)

Sleep Awakening D-90 23 (38.3%) 25(41.7%)

Is there any need to rescue medications D-0 60 (100.0%) 60 (100.0%)

Is there any need to rescue medications D-90 9(15.0% ) 11(18.3% )

77

COMPARATIVE STUDY OF GROUP-B vs GROUP-C

Comparative study of all respiratory parameters, in Group-B treated with Borage 1.3

mg once daily plus Echium seed oil 500 mg twice daily and Group-C treated

Bambuterol 10 mg daily & Borage once plus Echium seed oil twice daily.

Comparative studies in two groups (reviewed by performing pulmonary functions)

were calculated by used of Spirometer & Peak flow meter, the daily dairy card

symptoms assessment, clinical questionnaires to determine the effectiveness and

tolerability.

On day-0 (Baseline) the difference in mean FEV1when compared between Group-B

mean 1.2±0.2 to Group-C FEV1 was mean 1.3±0.3, on average showed higher value of

Group-C, statistically significant. Similarly on day-90 mean FEV1 of Group-B was to

1.3±0.2, when compared with Group-C mean 1.5±0.3, the results are statistically highly

significant. The percentage increase was more in Group-C (13.3%), as compared to

Group-B (1.99). Table-7.17 & Figure-19

Baseline difference in mean force vital capacity in Group-B was mean 2.3±0.3

compared with Group-C mean 2.3±0.4, on average showed higher value in group-C,

statistically found significant. Whereas at day-90 mean force vital capacity (FVC), of

Group-B was to 2.3±0.3, when compared with group-C mean 2.5±0.4, showed

statistically highly significant difference. The percentage change was more improved in

group-C (9.2%), as compared to Group-B (2.19%). Table-7.17 & Figure-20

Mean Peak Expiratory Flow Rate (PEFR) in Group-B at day-0 was mean 178.8±35.3,

improved to mean 186.2±34.1 at day-90. Where PEFR in Group-C at baseline was

mean 187.8+46.2 increased to mean 215.3+46.2, at day-90.

The difference between two treatment groups were highly significant at day-90, when

compared the two groups‘ results, the Group-C showed highly difference.

78

The percentage change was more increased in group-C (15.2%) as compared to group-

B (4.1%). Table-7.17 Figure-21

As compared to baseline significant improvements were found in pulmonary symptoms

daily diary card (Cough, Dyspnea, Sputum production, Sleep) at day-90, results were

statistically highly significant, in both study groups of B & C.

Night sleep awakening in Group-B reduced from 100% at day-0 to 63.3% at day-90,

and in Group-C patients reduced from 100% to 41.7%, p-value are statistically highly

significant. Patients of group-B do not exhibits any significant improvement in

reduction of number of exacerbation, but patients of Group-C showed highly significant

reduction of exacerbations, mentioned in the Table-7.18.

Clinical Questionnaires of Group-B, showed drug effectiveness and compliance in

patients of chronic persistent asthma from day-0 to day-90 were, cough reduced from

13.3% to 6.7%, dyspnea from 20.0% to 8.3%, sputum production from 8.3% to 5%, and

Sleep disturbances from 20.0% to 13.3%, and need of rescue medication (Short acting

β2 –adrenergic agonist) reduced to 41.7% at day-90.

Comparatively clinical Questionnaires of Group-C, cough reduced 13.3% to 0.0%,

dyspnea from 11.7% to 0.0%, sputum production from 11.7% to 8.3%, sleep

disturbances from 15.0% to 6.7% at day-90, Night sleep awakening from 100% to

41.7% at day-90, and need of rescue medication (Short acting β2 –adrenergic agonist)

at day-0 was 100% reduced to 18.3% at the completion of study.

Comparative results of Group-B & Group-C showed that improvement in clinical

symptoms, efficacy and compliance is more in group-C treated patients than Group-B

treated patients. Table-7.19

79

TABLE-7.17

COMPARISON OF FEV1, FVC & PEFR BETWEEN GROUP-B & GROUP-C

Cap Borage plus

Echium seed oil

Group-B

(n=60)

Tab Bambuterol +

Borage Plus Echium

seed oil

Group-C

(n=60)

p-value

FEV1

Day-0 1.2±0.2 1.3±0.3 0.303

Day-90 1.3±0.2 1.5±0.3 <0.0001

Total percentage

change

1.99% 13.3%

FVC

Day-0 2.3±0.3 2.3±0.4 0.770

Day-90 2.3±0.3 2.5±0.4 0.005

Total percentage

change

2.19% 9.2%

PEFR

Day-0 178.8±35.3 187.3±46.2 0.260

Day-90 186.2±34.1 215.8±50.3 <0.0001

Total percentage

change

4.1% 15.2%

80


Group-C: Combination treatment of Bambuterol &Borage plus Echium seed oil

in patients of chronic persistent asthma.

1.2 1.3 1.3 1.5

1.99% 13.30% 0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Group-B Group-C

Me

an

FE

V1 (

L)

Comparison of FEV1 Group-B & Group-C


Figure-19

81


Group-C: Combination (Bambuterol &Borage plus Echium seed oil) treatment


2.298 2.3 2.348 2.5

2.19% 9.20% 0

0.5

1

1.5

2

2.5

3

Group-B Group-C

Me

an

FV

C (

L)

Comparion of FVC Between

Group-B & Group-C


Figure-20

82


Group-C: Combination (Bambuterol &Borage plus Echium seed oil) treatment in


178.83 187.3 186.167 215.8

4.10% 15.20% 0

50

100

150

200

250

Group-B Group-C

Mean

PE

FR

(L

/min

)

Comparison of PEFR Between Group-B & Group-C


Figure-21

83

TABLE-7.18

COMPARISON OF SYMPTOMS SCORE & EXACERBATIONS BETWEEN

GROUP-B & GROUP-C IN CHRONIC PRESISTENT ASTHMA

Daily Dairy

Card

Symptoms

GROUP-B

Cap Borage seed oil 1.3 gram OD +

Cap Echium seed oil 500 mg BD

GROUP—C

Tab Bambuterol 10 mg daily &

Cap Borage seed oil 1.3 gm OD+

Cap Echium seed oil 500mg BD

Day-0 Day-90 p-value Day-0 Day90 p-value

Dyspnea

2 (0)

1 (1)

<0.0001

2 (0)

1 (0)

<0.0001

Cough

2 (1)

1 (0)

<0.0001

2 (1)

1 (0)

<0.0001

Sputum

Production

2 (0)

1 (1)

<0.0001

2 (1)

1 (1)

<0.0001

Night Sleep

disturbances

2 (0)

1.5 (1)

<0.0001

1 (1)

1 (1)

<0.0001

Night Sleep

Awakening

60

(100%)

38

(63.3%)

<0.0001

60

(100%)

25

(41.7%)

<0.0001

No of

Exacerbation

2 (0)

2 (0)

0.157

0 (0)

2 (0)

<0.0001

84

TABLE-7.19

COMPARISON OF CLINICAL QUESTIONNAIRE, GROUP-B WITH GROUP-C

IN CHRONIC PRESISTENT ASTHMA


compliance of patients B C









Night Sleep Awakening D-0 60 (100.0%) 60 (100%)

Night Sleep Awakening D-90 21 (35.0%) 25 (41.7%)



85

COMPARATIVE STUDY OF ALL THREE STUDY GROUPS

Comparative study of, Group-A, Bambuterol, Group-B with Borage plus Echium seed

oil and Group-C combination of Bambuterol & Borage plus Echium seed oils treated

patients.

Group-A treated patients, FEV1 mean was 1.31+0.18 at day-90, with total percentage

change of 4.7%, whereas in Group-B, FEV1 was mean1.3+0.2 with the total percentage

increase was of 1.99%, and in Group-C, FEV1 was mean of 1.5+0.3 with the total

percentage increased 13.3%, results in combination treated patients are statistically

highly significant. Table-7.20 & Fig-22

Force vital capacity changes in Group-A, was mean 2.5+0.3, with the total percentage

increase of 5.9%, whereas in Group-B, the FVC was mean 2.3+0.3 with the total

percentage increase of 2.19% and in Group-C, FVC was mean 2.5+0.4 with the total

percentage increase of 9.2%, at day-90, results of FVC are statistically highly

significant in group-C patients. Table-7.20 Fig-23

Group-A treated patients, Peak expiratory flow rate at day-90, was mean 209.7+37.3

with the total percentage change of 7.1%, whereas in group-B mean 186.2+34.1 with

the total percentage change 4.1%, and in Group-C, mean 215.8+50.3 with total

percentage change was 15.2%.

In combination drugs treated groups, peak expiratory flow rate was statistically highly

significant in chronic persistent asthma patients. Table-7.20 Fig-24

Symptoms of daily dairy card evaluation at day-90, showed improvement in all study

groups and results were statistically highly significant and reduction in night sleep

awakening in group-A was 38.3%, in group-B was 63.3% and in group-C 41.7% at the

completion of study.

86

Results of daily dairy card symptoms evaluation in Group-A & Group-C are more

raised than patients in Group-B. Numbers of exacerbations in combination drugs

treated patients of group-C were statistically highly significant. Table-7.21

Comparative study of clinical questionnaire for the assessment of drug effectiveness

and compliance in all treated groups at day-90 showed reduced need of rescue

medicine, in group-A, reduced to 15%, in group-B to 41.7% and in group-C reduced to

18.3%, more valuable improvement in groups-A & groups-C treated patients. Depicted

in Table-7.22

87

TABLE-7.20

COMPARISON FEV1, FVC & PEFR IN GROUP-A, GROUP-B & GROUP-C IN

CHRONIC PERSISTENT ASTHMA.

Tab Bambuterol

Group-A

(n=60)

Cap

Borage/Echium

seed oil

Group-B

(n=60)

Tab Bambuterol+

Cap

Borage/Echium

seed oil

Group-C

(n=60)

p-value

FEV1

Day-0

1.25±0.19 1.2±0.2 1.3±0.3

0.524

Day-90

1.31±0.18 1.3±0.2 1.5±0.3

<0.0001

Total

percentage

change

4.7% 1.99% 13.3%

FVC

Day-0

2.4±0.4 2.3±0.3 2.3±0.4

0.304

Day-90

2.5±0.3 2.3±0.3 2.5±0.4

0.003

Total

percentage

change

5.9% 2.19% 9.2%

PEFR

Day-0

195.8±39.5 178.8±35.3 187.3±46.2

0.075

Day-90

209.7±37.3 186.2±34.1 215.8±50.3

<0.0001

Total

percentage

change

7.1% 4.1% 15.2%

88



Group-C: Combination therapy (Bambuterol &Borage plus Echium seed oil) in

patients chronic persistent asthma.

1.2525 1.24067 1.3 1.3115 1.3 1.5

4.70% 1.99% 13.30% 0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Group-A Group-B Group-C

Me

an

FE

V1 (

L)

Comparison of FEV1 Between Group-A, Group-B & Group-C

Day-0 Day-90 Total percentage Change

Figure-22

89

Figure-23



Group-C: Combination of (Bambuterol &Borage plus Echium seed oil) treatment


2.4 2.298 2.3 2.53 2.348 2.5

5.90% 2.19% 9.20% 0

0.5

1

1.5

2

2.5

3


Me

an

FV

C (

L)

Comparison of FVC Between Group-A, Group-B & Group-C

Day-0 Day-90 Change From Baseline

90



Group-C: Combination treatment of (Bambuterol & Borage plus Echium seed oil) in


195.833 178.83 187.3 209.667

186.167

215.8

7.10% 4.10% 15.20% 0

50

100

150

200

250


Me

an

PE

FR

(L

/min

)

Comparison of FEFR Between Group-A, Group-B & Group-C

Day-0 Day-90 Total percetage Change

Figure-24

91

TABLE-7.21

COMPARISON OF SYMPTOM SCORES & EXACERBATIONS BETWEEN

GROUP-A, GROUP-B & GROUP-C IN CHRONIC PERSISTENT ASTHMA.

Daily Dairy

Card

Symptoms

GROUP-A

Tab Bambuterol 10 mg

daily

GROUP-B

Cap Borage seed oil 1.3

gram OD plus

Cap Echium seed oil 500

mg BD

GROUP—C

Tab Bambuterol 10 mg

daily & Cap Borage

seed oil 1.3 gram OD

plus

Cap Echium seed oil

500mg BD

Day-0 Day-90 p-value Day-0 Day-90 p-value Day-0 Day90 p-value

Dyspnea

2 (0)

1 (0)

<0.0001

2 (0)

1 (1)

<0.0001

2 (0)

1 (0)

<0.0001

Cough

1.5 (1)

1 (0)

<0.0001

2 (1)

1 (0)

<0.0001

2 (1)

1 (0)

<0.0001

Sputum

Production

1.5 (1)

1 (0)

<0.0001

2 (0)

1 (1)

<0.0001

2 (1)

1 (1)

<0.0001

Night Sleep

disturbances

2 (0)

1 (0)

<0.0001

2 (0)

1.5 (1)

<0.0001

1 (1)

1 (1)

<0.0001

Night Sleep

Awakening

60

(100%)

23

(38.3%)

<0.0001

60

(100%)

38

(63.3%)

<0.0001

60

(100%)

25

(41.7%)

<0.0001

No of

Exacerbation

2 (0)

2 (0)

0.002

2 (0)

2 (0)

0.157

0 (0)

2 (0)

<0.0001

92

TABLE-7.22

COMPARISON OF CLINICAL QUESTIONNAIRE, BETWEEN GROUP-A, GROUP-B

& GROUP-C TREATED PATIENTS IN CHRONIC PERSISTENT ASTHMA.


compliance of patients A B C

Is cough worse than previously D-0 11 (18.3%) 8 (13.3%) 8 (13.3%)

Is cough worse than previously D-90 3 (5.0%) 4 (6.7%) 0 (0.0%)

Is Dyspnea worse than previously D-0 13 (21.7%) 12 (20.0%) 7 (11.7%)

Is Dyspnea worse than previously D-90 3 (5.0%) 5 (8.3%) 0 (0.0%)

Is there increase in sputum production

D-0 7 (11.7%) 5 (8.3%) 7 (11.7%)

Is there increase in sputum production

D-90 0 (0.0%) 3 (5.0%) 5 (8.3%)

Is sleep is more disturbed than previously

D-0 7 (11.7%) 12 (20.0%) 9 (15.0%)

Is sleep is more disturbed than previously

D-90 3 (5.0%) 8 (13.3%) 4 (6.7%)

Night sleep Awakening D-0 60 (100.0%) 60 (100.0%) 25 (100%)

Night sleep Awakening D-90 23 (38.3%) 38 (63.3%) 25 (41.7%)

Is there any need to rescue medications

D-0 60 (100.0%) 60 (100.0%)

60

(100.0%)

Is there any need to rescue medications

D-90 9 (15.0%) 25 (41.7%) 11 (18.3%)

93

ADVERSE EFFECTS OF THE DRUGS

Echium & Borage seed oil containing a, dangerous chemical called pyrrolizidine

alkaloids, which are hepatotoxic and cause liver damage (Cheeke, 1988). For humans,

it is suggested that pyrrolizidine alkaloids levels in herbal products, of proven health

benefit should be one mg per day for oral and 100 mg per day for external purposes, for

a period of not more than 6 weeks in a year (Edgar et al., 2002).

The pyrrolizidine alkaloid containing herbal products is contra-indicated in pregnant

and lactating women (Culvenor et al. 1981).

The alkaloids are removed during extraction, and the pyrrolizidine alkaloids content of

Borage & Echium seeds does not limit their use for the supply of ω-3, ω-6 oil, but

products are only used when they are certified and labeled free pyrrolizidine alkaloids

(PAs). Few mild side effects of Borage oil in individuals, may experience are digestive

disturbances such as nausea, headaches and gastrointestinal upset.

Contra-indication & cautions of borage seed oil use.

Bleeding disorders: Might prolong bleeding time and increase the risk of bruising

and bleeding.

Liver disease: Borage products containing hepatotoxic, pyrrolizidine alkaloids

(PAs) might make liver disease worse.

Surgery: Borage might increase the risk of bleeding during and after surgery. Stop

taking borage at least 2 weeks before a scheduled surgery.

94

SAFETY AND TOLERABILITY

Borage species have high amount of δ-tocopherols, the natural property which

contributes as an effective antioxidants (Eskin, 2008).

Adverse reactions were reported in group-A, 18 out of 60 patients, in Group-B showed

9 out of 60 patients and 25 out of 60 patients in Group-C.

Reported adverse effects were as follows: headache (one (1.7%) in group-A, two

(3.3%) in group-B and four (6.4%) in group-C patients, tremors reported in group-A

was two (3.3%), in group-B no reported case of tremors and in group-C two (3.3%).

In group-A, muscle cramps observed in four (6.7%), in group-B reported three (5.0%)

and two cases (3.3%) in group-C, tachycardia /or palpitation reported in group-A were

Two (3.3%), two (3.3%) in group-B & four (6.7%) in group-C. Vomiting not reported

in group-A, but one case (1.7%) in group-B, and two (3.3%) in group-C. In group-A,

Anorexia reported in four (6.7%), one (1.7%) in group-B and four (6.7%) in group-C

treated patients.

No reported case of hematuria and convulsions in any study groups of patients, only

one case of hypersensitivity reported in group-C, which was of mild nature quickly

responds to anti-allergic doses of Antihistamine. Table-5.23

No patients were discontinued from the study due to any serious side effects.

In all study groups, ensured the safety of the drugs, blood samples interpreted for liver

functions, notably the Serum alkaline phosphate and SGPT, and lipid profile for

Cholesterol, HDL, LDL, in all study group patients. Table-5.24

Group-A, do not showed any significant change in the serum alkaline phosphatase &

SGPT values at day-90, evidenced that Bambuterol treated patients have no liver

toxicities, and the same group patients does not have any significant change on

cholesterol, HDL and LDL and consider safe. Table-5.20

95

In group-B treated patient‘s blood parameters of serum alkaline Phosphatase are all

within the healthy limit, but SGPT level increased at day-90, and statistically showed

highly significant, but clinically within the normal healthy limit. Whereas Cholesterol

decreases, HDL increases and LDL decreases at the completion of therapy, showed

statistically highly significant, group-B drugs can safely be given in cardiac patients of

raised lipid levels with some beneficial effects.Table-5.20 Fig-25

In group-C treated patients blood parameters of serum alkaline Phosphatase & SGPT,

are statistically highly significant, but clinically within normal limit, need close

monitoring of treated patients, while Cholesterol, HDL, LDL are statistically highly

significant, can safely be administered in chronic persistent asthma patients. Table-5.24

& Fig-25, 26, 27, 28 & 29.

96

TABLE-7.23

ADVERSE DRUG REACTIONS IN GROUP-A, GROUP-B & GROUP-C OF


BAMBUTEROL

GROUP-A

BORAGE

PLUS

ECHIUM

SEED OIL

GROUP-B

BAMBUTEROL

PLUS BORAGE

PLUS ECHIUM

SEED OIL

GROUP-C

BITTER TASTE

0(0.0% )

0(0.0% ) 1(1.7% )

VOMITING

0(0.0% ) 1(1.7% ) 2(3.3% )

ANOREXIA

4(6.7% ) 1(1.7% ) 4(6.7% )

HEMOTURIA

0(0.0% ) 0(0.0% ) 1(1.7% )

SEIZURES

0(0.0% ) 0(0.0% ) 0(0.0% )

FATIGUE

5(8.3% ) 0(0.0% ) 4(6.7% )

PALPITATION

2(3.3% ) 2(3.3% ) 4(6.7% )

HEADACHE

1(1.7% ) 2(3.3% ) 4(6.7% )

TREMERS

2(3.3% ) 0(0.0% ) 2(3.3% )

MUSCLE CRAMPS

4(6.7% ) 3(5.0% ) 2(3.3% )

HYPERSENSITIVITY

0(0.0% ) 0(0.0% ) 1(1.7% )

97

TABLE-7.24

BLOOD PARAMETERS ANALYSIS FOR SAFETY PROFILE AMONGS

GROUP-A, GROUP-B & GROUP-C IN CHRONIC PERSISTENT ASTHMA

PATIENTS.

BLOOD

PARAMETERS

DAY-0 DAY-90 p-value

GROUP-A (Bambuterol Therapy)

Alkaline Phosphatase

U/L

144.6±18.2 143.5±17.5 0.354

SGPT U/L 30.3±5.3 31.3±4.5 0.023

Cholesterol mg/dl 205.3±31.5 207.2±32.2 0.014

HDL mg/dl 31.5±6.2 31.7±6.1 0.811

LDL mg/dl 137.1±18.8 139.6±18.8 0.001

GROUP—B (Borage plus Echium seed oil therapy)


U/L

158.6±15.2 159.2±15.3 0.177

SGPT U/L 34.8±18.6 36.5±18.5 <0.0001

Cholesterol mg/dl 192.8±42.1 177.5±31.1 <0.0001

HDL mg/dl 28.6±6.0 34.2±5.8 <0.0001

LDL mg/dl 127.8±8.5 123.7±9.0 <0.0001

GROUP-C (Combination of Bambuterol & Borage plus Echium seed oil

therapy


U/L

139.2±19.3 143.6±16.7 <0.0001

SGPT U/L 31.0±4.5 32.7±4.3 <0.0001

Cholesterol mg/dl 189.7±27.4 171.5±24.0 <0.0001

HDL mg/dl 29.7±5.9 36.4±5.5 <0.0001

LDL mg/dl 160.6±22.9 148.8±21.6 <0.0001

98

Figure-25



Group-C: Combination (Bambuterol & Borage plus Echium seed oil) treatment in


144.6

158.61

139.2 143.517

159.167

143.58

125

130

135

140

145

150

155

160

165


Me

an

Se

rum

Alk

ali

ne P

ho

sp

hata

se

(U

/L)

Comparison of Blood parameters of liver functions in Group-A, Group-B & Group-C

Day-0 Day-90

99



Group-C: Combination of (Bambuterol & Borage plus Echium seed oil) treatment in

chronic persistent asthma patients.

30.266 34.8

31.03 31.25 36.46

31.65

0

5

10

15

20

25

30

35

40


Mea

n S

GP

T (U

/L)

Comparison of SGPT in Group-A, Group-B

& Group-C

Day-0 Day-90

Figure-26

100



Group-C: Combination of (Bambuterol & Borage plus Echium seed oil) treatment in

chronic persistent asthma patients.

205.25 192.767 189.65 207.233

177.467 171.517

0

50

100

150

200

250


Mea

n H

DL

(m

g/d

l)

Comparison of Cholesterol in Group-A, B & C Patients

Day-0 Day-90

Figure -27

101

Figure-28



Group-C: Combination of (Bambuterol & Borage plus Echium seed oil) treatment, in chronic

persistent asthma patients.

31.5167 28.55 29.75 31.65 34.1667 36.35

0

5

10

15

20

25

30

35

40


Mean

HD

L (

mg

/dl)

Comparison of HDL in Group-A, B & C

Day-0 Day-90

102



Group-C: Combination of Bambuterol &Borage plus Echium seed oil in patients of chronic

persistent asthma.

137.083 127.783

160.583 139.617

123.683 148.75

0

20

40

60

80

100

120

140

160

180


Mean

LD

L (

mg

/dl)

Comparison of LDL in Group-A, Group-B & Group-C

Day-0 Day-90

Figure -29

103

8. DISCUSSION:

Bronchial asthma is chronic inflammatory disarray, resulting from hyper-

responsiveness of tracheobronchial smooth muscles, leads to bronchial smooth muscles

constriction, mucosal edema and increased bronchial secretions; bronchoconstriction is

mostly reversible, increasing in prevalence and severity.

Asthma is clinically characterized by coughing, wheezing, & breathlessness, the

majority of patients experience sleep disturbance and change in quality of life.

In recent years, perceptive of the mechanisms of asthma has changed. Genetic factors,

number of mediators, growth factors, and the role of leukotriene‘s are being

demonstrated. Ongoing research supports the concept that morphometric studies and

immunohistochemistry may help to understand the natural history and response to

treatment of this disease in the future.

There are many known toxic substances released, by degranulation of eosinophils,

basophils and mast cells, particular importance in asthma are the leukotriene‘s, lipid

mediators of inflammation derived from arachidonic acid. These short-lived small

molecules exist in a variety of isoforms, mostly as distinct products of various

arachidonic acid-modifying enzymes. Acting through a variety of G protein-coupled

receptors, leukotriene‘s induce or augment many features of asthma, including airway

hyper-responsiveness, eosinophilia, and airway glycoprotein hyper-secretion.

Pathophysiology of asthma is largely affiliated to the inflammation, hyper-

responsiveness and obstruction, regardless of trigger mechanism or underlying cause,

air-way inflammation plays a critical role.

Underlying many variants, to understand the pathological mechanisms, it is essential to

identify the factors that initiate, intensify, and change the inflammatory response of the

airway and to determine, how these immunologic and biologic processes produce the

104

characteristic airway abnormalities. The factors that initiate the inflammatory process

in the first phase is unknown, the atopy is the commonest identifiable pre-disposing

factor for development of asthma, a familial or genetic pre-disposition to develop, an

IgE mediated response, to common allergens in the environment‘s. Some important

factors that contribute or increase the incidence of asthma include environmental

pollution, low birth weight, tobacco smoking, diet & viral infections.

Primary objectives of asthma management and control are to maintain normal (near

normal) lung function. The estimation of asthma by knowing severity of airway

obstruction and reversibility is an integral component in the diagnosis.

Spirometry and peak expiratory flow rate reporting by Expiratory flow meter are the

most experimental way to diagnose and monitor by compiling, daily diary card of

symptoms improvement, comprises, episode of dyspnea, cough, sputum production,

sleep disturbances, night sleep awakening and use of recue medications.

Pharmacological approach in the therapy of asthma is to prevent or control asthma

symptoms or at least to reduce the frequency and severity of acute exacerbations.

Drugs used in asthma therapy can be classifying either quick relief of symptoms or long

term controllers.

Short acting β2-adrenergic agonist are commonly used to regulate the acute spasm of

bronchial smooth muscles, other groups methyl-xanthine‘s are directly acting

bronchodilators and newly introduced selective M3-receptor antagonist.

Protective approach to control the recurrent episodes of bronchospasm, number of

drugs tried with some success, includes long acting β2-adrenergic agonist, mast cell

stabilizers, corticosteroids, anti-leukotriene (Cysteinyl-leukotriene receptor antagonist),

5-LOP (five lipooxygenase proteins) inhibitors and different anti-mediators are used to

reduce the frequency as well as improve the quality of life.

105

The disadvantages of true bronchodilators, like short acting β2-adrenergic agonist

cannot be used for longer durations because of drug tolerance (Down regulation of

receptors) and higher doses produces severe toxicities, its use only as rescue medication

to terminate acute attack of bronchospasm. While directly acting bronchodilators has

low margin of safety, use under control monitoring and selective M3- receptor

antagonist, not significantly reverse the spasm while show great improvement in quality

of life. Asthma management, number of combinations used to prevent or control the

symptoms, few of them results improvement in selected cases but the problem of

toxicities, limits its long term use.

In our research study, the efficacy and safety profile of Bambuterol, botanical seed oils

of Borage & Echium (rich source of ω-3 & ω-6) and combination of Bambuterol and

Borage plus Echium seed oil were determined.

Total registered 180 patients of chronic persistent asthma, constitute to three groups of

sixty patients in each group, after measuring the severity of individual patients and

applied inclusion and exclusion criteria.

210-patients earlier registered for the study of either sexes on twice weekly basis after

complete history and examination and obtained consent for the participation in the

research study, placed in the divided groups A, B & C, each patient of different groups

were discussion in detail about the disease, its prognosis and directed to reported any

severe adverse reaction, or when stop taking drug, and any known or unusual side

effect after taking medicine, in the provided daily diary card. Used of recue medicine

(Inhaled short acting β2-agonist), in case of exacerbation of symptoms.

Patients of either groups, are encourage to make sure, follow the instruction provided

and keep records of daily symptoms & PEFR before going to sleep and maintain daily

diary card till the next follow up and report to the center from where he/she is

registered.

106

On follow up day, always with daily diary card for evaluation of symptoms and further

review of pulmonary functions and collection of blood samples for liver function test &

Lipid profile for the drug safety determination.

During the study thirty patients were dropped because of irregularity in drug intake and

follow up failure, not maintain the daily diary card, difficulty or exhaust in procedures

of spirometry, unable to perform the procedure correctly beside number of

demonstrations, but medical support continue when needed.

Registered patients in the divided group according to protocol and follow the

instruction, timely follow up, of the study design.

In group-A, 98.3% (59) male & 1.7% (1) female with the mean age 56.9+5.6, of which

91.7% smoker and 8.3% non-smokers, selected by rank of severity, of which 70% were

of moderate severity and 30% were of severe class, base line Pulmonary function of

FEV1 mean was 1.3+0.2 , FVC 2.4+ 0.4 and PEFR 195+ 39.5. Table-1

Patients were treated with long acting β2- adrenergic agonist Bambuterol 10mg daily

orally at bed time in group-A, to evaluate the improvement of the patient symptoms,

observed the pulmonary function, peak expiratory flow rate, symptom score and

clinical questionnaire estimated at day-90.

Group-A patients showed improved FEV1 Day-0 mean 1.25±0.19 to 1.31±0.18, mean

percentage change of 4.7% and Force Vital Capacity improved from mean 2.4±0.4 to

2.5±0.3 with mean percentage change of 5.9%, Peak expiratory flow rate, change from

mean 195.8±39.5 L/min to 195.8±39.5, mean percentage increase from baseline 13.83

l/min with mean percentage change of 7.1% at day-90 and p-values statistically highly

significant.

Bambuterol receiving patients exhibited improvement of clinical symptom results are


107

Our study match with Cazzola, et al 1999, shows Bambuterol high lung distribution

properties following oral intake, and is slowly hydrolyzed to terbutaline in the lung

tissue, while Fugleholm et al 1993, indicated that Bambuterol, strongly contributes to

its 24-h duration of action and has similar clinical efficacy to other oral

bronchodilators, but with less side effects, especially with regard to tremors.

A study conducted by Ahmed, 2015, compared pulmonary function test & PEFR of

Bambuterol with Monteleukast, results showed improvement in asthma symptoms,

pulmonary function. Bambuterol showed more significant improvement in pulmonary

functions compared to Montelukast.

Results of the current study showed significant improvements in asthma symptoms and

pulmonary function with Bambuterol therapy compared to baseline findings.

Bambuterol is the first once daily oral β2-agonist with 24 h duration for the treatment of

asthma.

In contrast, Persson et al 1995, treatment with 10 mg Bambuterol did not showed any

significant statistical difference versus placebo, in the FEV1, after 24 hour

administration, but improvement in FEV1, FVC & PEFR, with continuous therapy

during the study.

One study matched with Wallaert, et al 1995, oral Bambuterol once-daily dose provides

a highly effective alternative to twice-daily inhaled Salmeterol for relief of nocturnal

symptoms in moderate to severe asthma patients.

Group-B study patients, treated with Capsule Borage seed oil 1.3 gram once plus Cap

Echium seed oil 500 mg twice daily for 90 days.

Baseline characteristics are, 96.7% (58) male and 3.3% (2) female with mean age

59.4+7.5 and severity of asthma class of, moderate persistent type 70% (42) and severe

persistent class 30% (18) and baseline reading of pulmonary function mean

documented were, FEV1 1.2+ 0.2, FVC 2.3+0.3 and PEFR 178+35.3.

108

The primary objective of this Group-B study was to examine the impact of Poly-

unsaturated fatty acids of two botanical seed oils Borage & Echium on metabolism and

leukotriene generation in asthmatic patients (Arm et al 2013).

The polyunsaturated fatty acids in human diets belong to the ω-3 &ω-6 fatty acids, are

linoleic acid and α-linolenic acid, respectively. In most mammals, these fatty acids can

be converted to longer chain and more unsaturated fatty acids via a series of elongation

and desaturation steps. Humans can obtain unsaturated fatty acids, such as arachidonic

acid, directly from their diet and actually convert little of ingested linoleic acid or α-

linolenic acid to arachidonic acid or EPA, respectively, because of limited Δ6-

desaturase activity.

Mammals are unable to convert ω-3 & ω-6 fatty acids and rely on dietary sources of ω-

3 fatty acids, chiefly plants. Botanical seed oils from plants, such as borage and Echium

have shown modest efficacy in a number of animal and human inflammation models

and diseases.

Supplementation with Borage & Echium seed oil combinations increases plasma levels

of ω-3 and ω-6, circulating levels of three PUFAs, (DGLA, EPA and DPA).

It is likely that DGLA increased as a result of GLA found in both Borage and Echium

seed oil, GLA is readily elongated to DGLA in cells and tissues, once formed, is

incorporated into inflammatory cells and tissues and competes with arachidonic acid.

Additionally DGLA is converted to a 15-lipoxygenase product, 15-

hydroxyeicosatrienoic acid (15-HeTrE) by human mononuclear leukocytes (Iversen et

al 1992). 15-hydroxyeicosatrienoic acid has been demonstrated to be a potent blocker

of LTB4 formation.

109

Study of Okamoto, 2000 on Perilla seed oil, one of the highest proportion of ω-3, which

is at 54-64% & ω-6 fatty acid component is usually around 14%, established significant

differences in the value of FVC (p<0.05) and FEV1 (p<0.05), were observed after 4

weeks of dietary supplementation, suggest that supplementation of ω-6 & ω-3 is useful

for the treatment of asthma in terms of suppression of LTB4 and LTC4 generation by

leucocytes and improvement of pulmonary functions.

We can hypothesized that dietary supplementation with the botanical seed oil

combination would improve airflow obstruction in asthmatics. In a double blind study

in 12 asthmatic subjects, a 23% increase in forced air volume was observed after 9

months of consuming, 1-gram of eicosapentaenoic acid (EPA) and docosahexaenoic

acid (DHA) per day (Nettleton 1995).

Botanical oil combinations (such as Echium and Borage oils) hold great promise for

changing the inflammatory process. (Floyd et al 2008).

Our study assumption was very much similar to Surette et al 2008, parallel group trial,

in patients with mild-to-moderate asthma, were treated with 0.75 g GLA + 0.5 g EPA

(low dose), 1.13 g GLA + 0.75 g EPA (high dose) or placebo daily.

The results were, that leukotriene synthesis decreased (p<0.05) and self-reported

asthma status and bronchodilator use improved in subjects using low-and high-dose

treatments between week 2 and week 4 (p<0.01), in asthma management, as evidenced

by reduced asthma symptoms.

A related study of Lindemann et al 2009 also demonstrated an improved asthma-related

quality of life following supplementation of EPA & GLA.

Study Burns et al 2007 detected low dietary ω-3 fatty acid intake as associated with

lower pulmonary function and increased respiratory symptoms.

110

Nagakura et al. 2000 found that a 10-month intake of 120 mg ω-3 PUFAs per day

reduced asthma symptoms scores and bronchial hyper-reactivity in children compared

to controls.

In another placebo-controlled study Biltagi et al 2009, on 60 children with moderate

persistent asthma, six weeks of food supplementation with one gram of triglyceride oil

(containing 30% EPA/DHA) resulted in a significant improvement of lung functions.

There was another study conducted by Emelyanov et al 2002 showed a significant

decrease in daytime wheeze and an increase in morning peak expiratory flow in the

lipid extract group compared to the placebo group.

In different study references, we observe the findings that inhibit the biosynthesis of

leukotriene‘s are likely to be more effective than the currently available drugs that

antagonize a single leukotriene receptor.

Dietary supplementation with gamma linolenic acid in borage seed oil provides

effective inhibition of leukotriene generation but also increases circulating free

arachidonic acid, which has pro-inflammatory potential, while the ω-3 fatty acid,

eicosapentaenoic acid, prevented the conversion of GLA to AA. The role of dietary

PUFAs supplementation in airway hyper-responsiveness remains largely persistent

however the present evidences suggests that PUFAs may have a protective effect on

lung function in asthmatic individuals.

To our knowledge, this is the first study that compared the efficacy and safety of

Bambuterol plus Borage & Echium seed oil (Botanical source) therapy. Combination

therapy showed synergistic effects when compared the other two groups, one group

treated with Bambuterol and the other group with Borage plus Echium seed oil

111

for 90-days, significant improvement in the pulmonary function and quality of life with

no significant toxicity during the combination therapy.

In this combination therapy of Bambuterol Plus Borage & Echium seed oil shows the

advantage in improving the pulmonary functions and symptoms in chronic persistent

asthma, by acting two different mechanisms, thus this combination provide a

synergistic effect with minimum toxicities, because higher concentration have more

chances of cardiac and neurological toxicities.

112

9. CONCLUSIONS:

Disease prevalence and burden has continued to increase, despite progress has been

made in the treatment of asthma. Drug treatment of asthma is usually highly effective,

but may have significant side effects or develop tolerance. Need of an alternative

therapies that reduce the dose requirements of pharmacological interventions would be

beneficial, and could potentially reduce the public health burden of this disease.

Common methods for achieving targets include by encouraging long-term use of

preventive medications, like anti-inflammatory drugs. The dietary addition of the

medicinal foods, like Borage seed oil along with Echium seed oil to asthma

management regimens, can improve patients health related quality of life (HRQoL) and

can also improve asthma control, as evidenced in present study by improving

pulmonary functions and reduced asthma symptoms.

Nutritional scientists, applied the knowledge to investigate the association between

nutrients and chronic disease and reduces the incidence and mortality, based on current

hypotheses, about the role of dietary factors, PUFAs in disease control and prevention.

The present study has several strong points. The data were derived from a sample of the

general adult population. The combination therapy of group-C (Bambuterol and

addition of Cap Borage seed oil 1.3 gram plus Echium seed oil 500mg ) showed more

effective and less adverse effects than other study groups (Group-A & Group-B) treated

patients in chronic persistent asthma. In view of the clinical results, these findings mark

toward prophylactic role of plant seed oil supplementation (Borage & Echium) in

asthma.

113

To date small number of studies, drug–diet combination have been conducted and the

limited range of clinically important outcomes that have been reported, there is a need

for further research in this area.

Thus, the possibility exists for drug–diet combination that confers greater benefits of

chronic persistent asthma, than either intervention alone, combination provide

improvement in the quality of life in asthmatic with less toxicity.

114

10. RECOMMENDATIONS:

Wide scale mass education and public awareness programs are needed to take a pro-

active approach in Asthma, which modifies or reduces morbidity and mortality risk

through patient‘s education.

There is need of more trials on this research task, in relation to age, race, occupation and

other aspect, to select the most appropriate drugs in Asthmatic patients.

Focus and avoidance of allergens to which one is exposed to in daily life, over-crowded

localities, nutritional deficiencies, indoor & outdoor pollutants, microbial infections are

some of the factors implicated in the rising incidence of asthma and also trigger the

inflammatory process that aggravates the disease state

In view of our study outcomes nutritional modifications are beneficial for decreasing the

progression of primary disease and have valuable effects on reducing or controlling the

associated symptoms and exacerbations their by providing an improvement in quality

of daily life.

I recommend dietary alteration as an adjuvant therapy with currently existing standard

therapy (Bambuterol) to chronic persistent Asthmatic patients because it has shown

synergistic effect with Bambuterol in terms of enlightening the quality of Asthmatic

patient‘s life and contribute to their overall health.

115

11. LIMITATIONS OF STUDY:

Number of factors including, Lack of funding, poor financial status, inadequate

nutrition, illiteracy and over-crowded localities.

Irregular patient‘s follow-up and noncompliance to therapy.

During the study period the patients suddenly divert to some other means of drug

therapies including hakims, homeopathic-medicines or home remedies advised by

family elders.

Pulmonary measurements, by Spirometry are not available at most of the Health care

Centers.

Patients do not maintain daily diary of symptom cards for the assessment of the

symptoms and monitoring of prognosis or the control/improvement of the disease.

116

REFRENCES:

Abedi, E & Sahari, MA. Long-chain polyunsaturated fatty acid sources and

evaluation of their nutritional and functional properties (Review) Food Science &

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