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 &
Group-C in chronic persistent Asthma. 83
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 &
Group-C in chronic persistent Asthma. 87
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 &
Group-C in chronic persistent Asthma. 97
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.
4
5
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.
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
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
FEV1- Forced expiratory volume in 1-second
FVC-Forced vital capacity
PEFR- Peak expiratory flow rate
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
p-value< 0.05 significant
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%)
Is cough worse than previously D-90
3 (5.0% )
Is Dyspnea worse than previously D-0
13 (21.7%)
Is Dyspnea worse than previously D-90
3 (5.0%)
Is there increase in sputum production D-0
7 (11.7%)
Is there increase in sputum production D-90
0 (0.0%)
Is sleep is more disturbed than previously D-0
7 (11.7%)
Is sleep is more disturbed than previously D-90
3 (5.0%)
Night Sleep Awakening D-0
60(100.0% )
Night Sleep Awakening D-90
23 (38.3%)
Is there any need to rescue medications D-0
60 (100.0%)
Is there any need to rescue medications D-90
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
FVC-Forced vital capacity
PEFR- Peak expiratory flow rate
p-value< 0.05 significant
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
Day-0 Day-90 p-value
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
p-value< 0.05 significant
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.
Is cough worse than previously D-0
8 (13.3% )
Is cough worse than previously D-90
4 (6.7% )
Is Dyspnea worse than previously D-0
12 (20.0%)
Is Dyspnea worse than previously D-90
5 (8.3%)
Is there increase in sputum production D-0
5 (8.3%)
Is there increase in sputum production D-90
3 (5.0%)
Is sleep is more disturbed than previously D-0
12 (20.0%)
Is sleep is more disturbed than previously D-90
8 (13.3%)
Night Sleep Awakening D-0
60 (100.0%)
Night Sleep Awakening D-90
38 (63.3%)
Is there any need to rescue medications D-0
60 (100.0%)
Is there any need to rescue medications D-90
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
statistically highly significant.
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
FEV1- Forced expiratory volume in 1-second
FVC-Forced vital capacity
PEFR- Peak expiratory flow rate
p-value< 0.05 significant
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
Day-0 Day-90 p-value
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
p-value< 0.05 significant
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%)
Is there any need to rescue medications D-90
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
Group-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
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-A: Bambuterol treated patients of chronic persistent asthma
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
CHRONIC PERSISTENT ASTHMA PATIENTS.
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-A: Bambuterol treated patients of chronic persistent asthma
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
Day-0 Day-90 Total percentage change
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
Day-0 Day-90 Total percentage change
Figure-17
74
Group-A: Bambuterol treated patients of chronic persistent asthma
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
Day-0 Day-90 Total percentage change
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.
Assessment of drug effectiveness and
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 Dyspnea worse than previously D-90 3 (5.0%) 0 (0.0%)
Is there increase in sputum production D-0 7 (11.7%) 7 (11.7%)
Is there increase in sputum production D-90 0 (0.0%) 5 (8.3%)
Is sleep is more disturbed than previously D-0 7 (11.7%) 9 (15.0%)
Is sleep is more disturbed than previously D-90 3 (5.0%) 4 (6.7%)
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-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
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
Day-0 Day-90 Total percentage change
Figure-19
81
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
Group-C: Combination (Bambuterol &Borage plus Echium seed oil) treatment
in patients of chronic persistent asthma.
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
Day-0 Day-90 Total percentage change
Figure-20
82
Group-B: Borage plus Echium seed oil treated patients of chronic persistent asthma
Group-C: Combination (Bambuterol &Borage plus Echium seed oil) treatment in
patients of chronic persistent asthma.
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
Day-0 Day-90 Total percentage change
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
Assessment of drug effectiveness and
compliance of patients B C
Is cough worse than previously D-0 8 (13.3%) 8 (13.3%)
Is cough worse than previously D-90 4 (6.7%) 0 (0.0%)
Is Dyspnea worse than previously D-0 12 (20.0%) 7 (11.7%)
Is Dyspnea worse than previously D-90 5 (8.3%) 0 (0.0%)
Is there increase in sputum production D-0 5 (8.3%) 7 (11.7%)
Is there increase in sputum production D-90 3 (5.0%) 5 (8.3%)
Is sleep is more disturbed than previously D-0 12 (20.0%) 9 (15.0%)
Is sleep is more disturbed than previously D-90 8 (13.3%) 4 (6.7%)
Night Sleep Awakening D-0 60 (100.0%) 60 (100%)
Night Sleep Awakening D-90 21 (35.0%) 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 25 (41.7%) 11 (18.3%)
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage plus Echium seed oil treated patients of chronic persistent asthma
Group-C: Combination of (Bambuterol &Borage plus Echium seed oil) treatment
in patients of chronic persistent asthma.
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
Group-A Group-B Group-C
Me
an
FV
C (
L)
Comparison of FVC Between Group-A, Group-B & Group-C
Day-0 Day-90 Change From Baseline
90
Group-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
Group-C: Combination treatment of (Bambuterol & Borage plus Echium seed oil) in
patients of chronic persistent asthma.
195.833 178.83 187.3 209.667
186.167
215.8
7.10% 4.10% 15.20% 0
50
100
150
200
250
Group-A Group-B Group-C
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.
Assessment of drug effectiveness and
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
CHRONIC PERSISTENT ASTHMA PATIENTS.
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)
Alkaline Phosphatase
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
Alkaline Phosphatase
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
Group-C: Combination (Bambuterol & Borage plus Echium seed oil) treatment in
patients of chronic persistent asthma.
144.6
158.61
139.2 143.517
159.167
143.58
125
130
135
140
145
150
155
160
165
Group-A Group-B Group-C
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
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
Group-A Group-B Group-C
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage plus Echium seed oil treated patients of chronic persistent asthma
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
Group-A Group-B Group-C
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-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage plus Echium seed oil treated patients of chronic persistent asthma
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
Group-A Group-B Group-C
Mean
HD
L (
mg
/dl)
Comparison of HDL in Group-A, B & C
Day-0 Day-90
102
Group-A: Bambuterol treated patients of chronic persistent asthma
Group-B: Borage Plus Echium seed oil treated patients of chronic persistent asthma
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
Group-A Group-B Group-C
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
statistically highly significant.
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 &
Nutrition. 2014; 2(5): 443– 463
Aggarwal, AN., Chaudhry, K., Chhabra, SK., D'Souza, GA., Gupta, D., Jindal, SK.,
Katiyar, SK., Kumar, R., Shah, B., Vijayan, VK. Asthma Epidemiology Study
Group. Prevalence and risk factors for bronchial asthma in Indian adults: a multi-
center study. Indian J Chest Dis Allied Sci. 2006; 48:13-22.
Ahmed, MAl. Bambuterol versus Montelukast in patients with chronic asthma.
Asian Journal of Pharmacy, Nursing and Medical Sciences. 2015; Volume (03)
Issue 01: 8-12.
Alsowaidi, S., Abdulle, A., Bernsen, R. Prevalence and risk factors of asthma
among adolescents and their parents in Al-Ain (United Arab Emirates). Respiration
2010; 79:105-11.
Anil Datta, News report. The News International 2007.
Arm, JP., Boyce, JA., Wang, L., Chhay, H., Zahid, M., Patil, V., Govindarajulu, U.,
Ivester, P., Weaver, KL., Sergeant, S., Isreal, E., Chilton, FM. Impact of botanical
oils on polyunsaturated fatty acid metabolism and Leukotriene‘s generation in mild
asthmatics. Lipids Health Dis. 2013; 2 (12):141.
Barnes PJ. Cytokine modulators as novel therapies for asthma. Ann Rev Pharmacol
Toxicol 2002; 42: 81–98.
Bergner, M., Bobbitt, RA., Carter, WB., Gilson, BS. The Sickness Impact Profile:
development and final revision of a health status measure. Med Care. 1981; 19:
878–885.
117
Berti, M., Johnson, BL., Dash, S., Fischer, S., Wilckens, R. Issues in new crops and
new uses. Echium: a source of stearidonic acid adapted to the Northern Great Plains
in the US. Alexandria, VA: ASHS Press; 2007. pp. 120–125.
Biltagi, MA., Baset, AA., Bassiouny, M., Kasrawi, MA., Attia, M. Omega- 3 fatty
acids, vitamin C and Zn supplementation in asthmatic children: a randomized self-
controlled study. Acta Paediatr. 2009; 98(4):737-42.
Biziulevicius, GA., Kazlauskaite, J. Following Hippocrates' advice 'Let food be thy
medicine and medicine be thy food'. An alternative method for evaluation of the
immune-stimulatory potential of food proteins. Med Hypotheses. 2007; 68: 712-3.
Bleecker, ER., Welch, MJ., Weinstein, SF., et al. Low-dose inhaled fluticasone
propionate versus oral zafirlukast in the treatment of persistent asthma. J Allergy
Clin Immunol. 2000; 105:1123–1129.
Bloom, DE., Canning, D., Rosenberg, L. Demographic change and economic
growth in South Asia: The WDA – HSG discussion paper series on demographic
issues. St. Gallen: World Demographic & Ageing Forum; 2011.
Bousquet, J., Jeffery, PK., Busse, WW., Johnson, M., Vignola, AM. Asthma from
bronchoconstriction to airways inflammation and remodeling. Am J Respir Crit
Care Med. 2000; 161: 1720–1745
Bousquet,J., Clark, TJ., Hurd, S., Khaltaev, N., Lenfant, C., O'byrne, P., Sheffer, A.
GINA guidelines on asthma and beyond. Allergy. 2007; 62(2):102-12.
Braido, F., Bousquet, PJ.,Brzoza, Z et al. ―Specific recommendations for PROs and
HRQoL assessment in allergic rhinitis and/or asthma: a GA2LEN taskforce position
paper,‖ Allergy. 2010; Vol 65, no. 8: 959–968.
Burns, JS., Dockery, DW., Neas, LM., Schwartz, J., Coull, BA., Raizenne, M.,
Speizer, FE. Low dietary nutrient intakes and respiratory health in adolescents.
Chest 2007; 132: 238-45.
118
Buss, AS and Silva MCD. Comparative study of two quality of life Questionnaires
in patients of COPD. J Bras Pneumol. 2009; 35(4): 316 324.
Busse, WW., Karaft, M. Cysteinyl leukotrienes in allergic inflammation: Strategic
target for therapy. Chest.2005; 127: 1312–1326.
Calder, PC. Omega-3 polyunsaturated fatty acids, inflammation and inflammatory
diseases. American Journal of Clinical Nutrition. 2006; 83(Suppl):1505S-1519S.
Cazzola, M., Segreti, A., Matera, MG. Novel bronchodilators in asthma. Curr Opin
Pulm Med. 2010; 16(1): 6-12.
Cazzola, M., Calderaro, F., Califano, C., Di Pema, F., Vinciguerra, A., Donner, CF.,
Matera, MG. Oral Bambuterol compared to inhale salmeterol in patients with
partially reversible chronic obstructive pulmonary disease. Eur J Clin Pharmacol.
1999; 54(11):829– 833
Cheeke, PR. Toxicity and metabolism of pyrrolizidine alkaloids. Journal of Animal
Science. 1988. 66; 2343-2350
Chilton, FH., Rudel, LL., Parks, JS., Arm, JP., Seeds, M.C. Mechanisms by which
botanical lipids affect inflammatory disorders. Am J Clin Nutr. 2008; 87(2):498S-
503S.
Chilton, L., Surette, ME., Swan, DD., Fonteh, AN., Johnson, MM., Chilton, FH.
Metabolism of gamma linolenic acid in human neutrophils. J Immunol.1996; 156:
2941–7.
Chu, SJ., Tang, LO., Watney, E., Chi, EY., Henderson, WR Jr. In situ amplification
of 5-lipoxygenase and 5-lipoxygenase-activating protein in allergic airway
inflammation & inhibition by leukotriene blockade. J Immunol. 2000; 165: 4640-8.
Cowburn, AS., Sladek, K., Soja, J., Adamek, L., Nizankowska, E., Szczeklik, A., et
al. Over-expression of leukotriene C4 synthase in bronchial biopsies from patients
with aspirin-intolerant asthma. J Clin Invest. 1998; 101:834-46.
119
Creticos, PS., Peters, SP., Adkinson, NF Jr., Naclerio, RM., Hayes, EC., Norman,
PS., et al. Peptide leukotriene release after antigen challenge in patients sensitive to
ragweed. N Engl J Med. 1984; 310:1626-30.
Crimi, E., Spanevello, A., Neri, M., Ind, PW., Rossi, GA., Brusasco, V.
Dissociation between airway inflammation and airway hyper-responsiveness in
allergic asthma. Am J Respir Crit Care Med. 1998; 157: 4–9.
Culvenor, CCJ., Edgar, JA., & Smith, LW. Pyrrolizidine alkaloids in honey from
Echium plantagineum L. Journal of Agricultural and Food Chemistry. 1981; 29:
958-960.
Dahlen, SE. Treatment of asthma with anti-leukotrienes: First line or last resort
therapy? Eur. J. Pharmacol. 2006; 533:40–56.
Dales, RE., Vandemheen, KL., Clinch, J., et al. Spirometry in the primary care
setting. Influence on clinical diagnosis and management of airflow obstruction.
Chest. 2005; 128: 2443–7.
deNijs, SB., Venekamp, LN., Bel, EH. Adult-onset asthma: is it really different?
EurRespir Rev 2013; 22:44-52.
Djukanovic, R., Wilson, JW., Britten, KM., Wilson, SJ., Walls, AF., Roche, WR.
Quantitation of Mast cells and eosinophils in the bronchial mucosa of symptomatic
atopic asthmatics and healthy control subjects using immunohistochemistry. Am
Rev Respir Dis. 1990; 142: 863–871.
Edgar, JA., Roeder, E., Molyneus, RJ. Honey from plants containing pyrrolizidine
alkaloids: a potential threat to health. Journal of Agricultural and Food Chemistry,
2002; 50: 2719-2730.
El Hafid, R., Blade, SF., Hoyano,Y. Seeding date and nitrogen fertilization effects
on the performance of borage (Borago officinalis L). Ind Crops Prod 2002; 16:
193-199.
120
Emelyanov, A., Fedoseev, G., Krasnoschekova, O., Abulimity, A., Trendeleva, T.,
Barnes PJ. Treatment of asthma with lipid extract of New Zealand green-lipped
mussel: a randomized clinical trial. Eur Respir J. 2002; 20:596-600.
Epstein MM. Do mouse models of allergic asthma mimic clinical disease? Int Arch
Allergy Immunol. 2004. 133: 84–100.
Eskin, NAM. Borage and evening primrose seed oil. Eur. J. Lipid Sci Technol.
2008;110: 655–661.
Farhadi, R., Balashahri, MS., Tilebeni, HG.,Sadeghi, M. Pharmacology of Borage
(Borago officinalis L.) medicinal plant. Int J Agron Plant Prod. 2012; 3: 73-77.
Floyd, HC., Lawrence, LR., John, SP., Jonathan, PA., Michael C. Mechanisms by
which botanical lipids affect inflammatory disorders Am J Clin Nutr. 2008;
87(suppl):498S–503S.
Fonteh, AN., LaPorte, T., Swan, D., McAlexander, MA. A decrease in remodeling
accounts for the accumulation of arachidonic acid in murine mast cells undergoing
apoptosis. J Biol Chem. 2001; 276:1439-49.
Fugleholm, AM., Ibsen, TB., Laxmyr, L., Svendsen, UG. Therapeutic equivalence
between bambuterol, 10 mg once daily, and terbutaline controlled release, 5 mg
twice daily, in mild to moderate asthma. Eur Respir J. 1993; 6 (10):1474–1478.
Galli, SJ., Kalesnikoff, J., Grimbaldestom, MA., Piliponsky, AM., Williams, CM.,
Tsai, M. Mast cells are tunable effector and immune-regulatory cells: resent
advances. Ann Rev Immunol. 2005; 23:749-86
Gibson, PG. Monitoring the patient with asthma: an evidence-based approach. J
Allergy Clin Immunol. 2000;106 (1):17-26.
Global strategy for asthma management and prevention: Global Initiative for
Asthma (GINA). Updated 2006
121
Godard, PA. Comparison of two long-acting β-agonists, oral Bambuterol and
inhaled Salmeterol, in the treatment of moderate to severe asthmatic patients with
nocturnal symptoms. Respir Med. 1999; 93:33-38
Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated 2014
Gupta, M., Singh, S. Borago officinalis Linn. An important medicinal plant of
Mediterranean region: a review. Int J Pharm Sci Res. 2010; 5: 27-34
Gupta, R., Bajpai1, KG., Johri, S., Saxena AM. An over view of Indian noval
traditional Medicinal Plants with anti-diabetic potentials. Microbiol Spectr Afr. J.
Trad. CAM 2008;5 (1): 1 – 17
Hallstrand, TS., Henderson, WR., Jr. An update on the role of leukotriene‘s in
asthma. Curr Opin Allergy Clin Immunol. 2010; 10: 60–66.
Halonen, M., Stern, DA., Lohman, C., Wright, AL., Brown, MA., Martinez, FD.
Two sub-phenotypes of childhood asthma that differ in maternal and paternal
influences on asthma risk. Am J Respir Crit Care Med. 1999; 160: 564-70.
Hardman WE. International Research Conference on Food, Nutrition & Cancer:
Omega-3 Fatty Acids to Augment Cancer Therapy. J Nutrition. 2002; 132: 3508S-
3512S.
Humbert, M., Holgate, S., Boulet, LP., Bousguet, J. Asthma control or severity that
is the question. Allergy. 2007; 62: 95-101.
Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat,
fatty acids, cholesterol, protein and amino acids 2002.
Iversen, L., Fogh, K., Kragballe, K. Effect of dihomo-gammalinolenic acid and its
15-lipoxygenase metabolite on eicosanoid metabolism by human mononuclear
leukocytes in vitro: selective inhibition of the 5- lipoxygenase pathway. Archives of
Dermatol Res. 1992; 284:222–226.
122
Johannsen, A., Lehmann, S., Omenaas, ER., et al. Post bronchodilator spirometry
reference values in adults and implications for disease management. Am J Respir
Crit Care Med. 2006; 73: 1316 -257.
Jones, PM., Burns, CJ., Belin, VD., et al. The role of cytosolic phospholipase A2 in
insulin secretion. Diabetes. 2004; 53: S172-8.
Jones, PW. Quality of life measurement for patients with diseases of the airways.
Thorax.1991; 46: 676–682.
Kazani, S., Arm, JP., et al LTC4 synthase polymorphism modifies efficacy of
botanical seed oil combination in asthma. Springer Plus. 2014; 3: 661
Kapoor, R., Huang, YS. Gamma linolenic acid: an anti-inflammatory omega-6 fatty
acid. Curr Pharm Biotechnol. 2006; 7(6): 531-4.
Klemow, KM., Clemens, DR., Threadgill, PE., Caver,BP. The biology of Canadian
weeds, Echium Vulgare L. Canadian Journal of Plant Science. 2002; 82: 235-248.
Kris-Etherton, PM., Grieger, JA., Etherton, TD. Dietary reference intakes for DHA
and EPA. Prostaglandins Leukot Essent Fatty Acids. 2009; 81(2-3): 99-104
Kroegel, C. Global Initiative for Asthma Management and Prevention—GINA
2006. Pneumologie 2007; 61: 295-304.
Lam, S., Chan, H., LeRiche, JC., Chan-Yeung, M., Salari, H. Release of
leukotriene‘s in patients with bronchial asthma. J Allergy Clin Immunol. 1988;
81:711-7.
Lindemann, J., David-Pampe, E., Peterkin, JJ., Orozco-Cronin, P., Belofsky, G.,
Stull, D. Clinical study of the effects on asthma-related QoL and asthma
management of a medical food in adult asthma patients. Curr Med Res Opin. 2009;
25(12):2865-75.
Mannino, DM.,Homa, DM., Akinbami, .LJ., Mooreman, GE., Gwynn, C., Red, SC.
Surveillance of asthma-US 1980-1999. MMWR. 2002; 51(SS01):1-13.
Masoli, M., Fabian, D., Holt, S., Beasley, R. The global burden of asthma:
executive summary of the GINA Dissemination Committee Report. Allergy 2004;
59(5):469-478.
123
Mata Lopez, P., Ortega, RM. Omega-3 fatty acids in the prevention and control of
cardiovascular disease. Eur J ClinNutr. 2003; 57: S22-5.
Miles, EA., Banerjee, T., Dooper, MM., M'Rabet, L., Graus, YM., Calder, PC. The
influence of different combinations of gamma-linolenic acid, stearidonic acid and
EPA on immune function in healthy young male subjects. Br J Nutr. 2004;
91(6):893-903.
Miller, MR., Hankinson, J., Brusasco, V., et al. ATS-ERS task force:
Standardization of Lung Function Testing. Standardization of spirometry. Eur
Respir J. 2005; 26:319–38.
Miyata, J., Aritaa, M. Role of omega-3 fatty acids and their metabolites in asthma
and allergic diseases (Review article). Allergology International. 2015; 64: 27-34
Montuschi. P. Role of Leukotriene‘s and Leukotriene Modifiers in Asthma
(Review) Pharmaceuticals.2010; 3:1792-1811
Nagakura, T., Matsuda, S., Shichijyo, K., Sugimoto, H., Hata, K. Dietary
supplementation with fish oil rich in omega-3 polyunsaturated fatty acids in
children with bronchial asthma. Eur Respir J. 2000; 16: 861-5.
NAEPP (National Asthma Education and Prevention Program), ―Expert Panel
report 3: guidelines for the diagnosis and management of asthma,‖ 2007.
National Institute for Health and Care Excellence (NICE). Quality standard for
asthma. NICE; 2013.
Nettleton, JA. Omega-3 fatty acids and health. 1995. Chapman 81 Hall. pp 204-48,
308-54.
O‘Hickey, SP., Hawksworth, RJ., Fong, CY., Arm, JP., Spur, BW., Lee, TH.
Leukotriene‘s C4, D4, & E4 enhance histamine responsiveness in asthmatic
airways. Am Rev Respir Dis.1991; 144:1053-7.
124
Okamoto, M., Mitsunobu, F., Ashida, K., Mifune, T., Hosaki, Y.,
Tsugeno,H., Harada, S., Tanizaki, Y. Effects of dietary supplementation with ω-3
fatty acids compared with ω-6 fatty acids on bronchial asthma. Intern Med. 2000;
39(2):107-11.
Persaud, SJ., Muller, D., Belin, VD., et al. The role of arachidonic acid and its
metabolites in insulin secretion from human islets of Langerhans. Diabetes 2007;
56: 197-203.
Persson, G., Baas, A., Knight, A., Larsen, B., Olsson, H. One month treatment, with
the once daily oral beta-2 agonist, Bambuterol in asthmatic patients. Euro Respir
J. 1995; 8: 34-39
Peter, J. Barnes. Pathophysiology of asthma. Br J Clin Pharmacol. 1996. 42:3-10
Petrie, GR., Chookang, J., Hassan, WU. Bambuterol: Effective in nocturnal asthma.
Respir Med. 1993. 87: 581-585.
Pieszak, M., Mikolajezak, PI., Manikowska, K. Borage: A valuable medicinal plant
used in herbal medicine. Herba Polonica. 2012; 58:95-103.
Rahimi-Rad, MH., Gaderi-Pakdel, F., Salari-Lak, S. Smoking and asthma in 20-44-
year-old adults in Urmia, Islamic Republic of Iran. East Mediterr Health J. 2008;
14: 6-16.
Revicki, D., Weiss, KB. Clinical assessment of asthma symptom control: review of
current assessment instruments. J Asthma. 2006; 43: 481-7.
Salvi, SS., Krishna, MT., Sampson, AP., Holgate, ST. The anti-inflammatory
effects of leukotriene-modifying drugs and their use in asthma. Chest. 2001;
119:1533-46.
Seo, T., Blaner, WS., Deckelbaum, RJ. Omega-3 fatty acids: molecular approaches
to optimal biological outcomes. Curr Opin Lipidol. 2005; 16: 11-8.
125
Simopoulos, AP. Importance of ratio of omega-6/omega-6 essential fatty acids.
Biomedicine & Pharmacotherapy. 2002; 56: 365-379.
Song, WJ., Chang, YS., Lim, MK., Yun, EH., Kim, SH., Kang, HR., Park, HW.,
Tomassen, P., Choi, MH., Min, KU., Cho, SH., Bachert, C. Staphylococcal
enterotoxin sensitization in a community-based population: a potential role in adult-
onset asthma. Clin Exp Allergy. 2014; 44:553-62.
Stein, RT., Sherrill, D., Morgan, WJ., et al. Respiratory syncytial virus in early life
and risk of wheeze and allergy by age 13 years. Lancet. 1999. 354: 541-5.
Subar, AF., Krebs-Smith, SM., Cook, A., Kahle, LL. Dietary sources of nutrients
among US adults, 1989 to 1991. J Am Diet Assoc. 1998; 98: 537–547
Surette, ME., Stull, D., Lindemann, J. The impact of a medical food containing
gamma-linolenic and eicosapentaenoic acids on asthma management and the
quality of life of adult asthma patients. Curr Med Res Opin. 2008; 24(2):559-67.
Thompson, PJ., Salvi, S., Lin, J., Cho, YJ., Eng, P., Abdul Manap, R., Boonsawat,
W., Hsu, JY., Faruqi, RA., Moreno-Cantu, JJ., Fish, JE., Ho, JC. Insights, attitudes
and perceptions about asthma and its treatment: findings from a multinational
survey of patients from 8 Asia-Pacific countries and Hong Kong. Respirology.
2013; 18: 957-67.
Torabi, F., Majd, A., Enteshari, S. Effect of exogenous silicon on germination and
seedling establishment in Borago officinalis L. J Med Plants Res. 2012; 6: 1896-
1901
Underwood, DC., Osborn, RR., Newsholme, SJ., Torphy, TJ., Hay, DW. Persistent
airway eosinophilia after leukotriene (LT) D4 administration in the guinea pig:
modulation by the LTD4 receptor antagonist, pranlukast, or an interleukin-5
monoclonal antibody. Am J Respir Crit Care Med. 1996; 154:.850-7.
126
Venables, KM., Chan-Yeung, M. Occupational asthma. Lancet. 1997; 349: 1465-9.
Vijayasaratha, K., Stockley, RA. Reported and Unreported Exacerbations of COPD:
Analysis by Diary Cards. Chest. 2008; Vol (133), Issue 1: 34–41
Wallert, B., Burn, P., Ostinelli, D., Murciano, D., Champel, F., Blaive, B., montane,
F., Godard,P. A comparison of two long acting β-agonist, oral Bambuterol and
inhaled salmeterol, in the treatment of moderate to severe asthmatic patients with
nocturnal symptoms. Respir Med. 1999; 93: 33-38
Wang, D., Xiao, W., Ma, D., Zhang, Y., Wang, Q., Wang, C., Ji. X., He, B., Wu,
X., Chen, H., Zhang, Y., Jiang, Y., Yin, J. Cross-sectional epidemiological survey
of asthma in Jinan, China. Respirology. 2013; 18: 313-22.
Wardlaw, AJ.,Moqbel, R., Kay, AB. Eosinophils: biology and role in disease. Adv
Immunol. 1995; 60: 151–266.
Whelan, J. Dietary stearidonic acid is a long chain (n-3) polyunsaturated fatty acid
with potential health benefits. J Nutr. 2009; 139: 5–10.
Wijendran, V., Hayes, KC. Dietary n-6 and n-3 fatty acid balance and
cardiovascular health. Annu Rev Nutr. 2004; 24: 597-615.
Wilson, CB., Jones, PW., O‘Leary, CJ., Cole, PJ., Wilson, R. Validation of the St.
George‘s Respiratory Questionnaire in Bronchiectasis. Am J Respir Crit Care Med.
1997; 156: 536-541.
Wong, GW., Leung, TF., Ko, FW. Changing prevalence of allergic diseases in the
Asia-pacific region. Allergy Asthma Immunol Res. 2013; 5: 251-7.