Study on Allopathic and Alternative Treatments of Asthma and Factors Influencing Treatment Choices

Materials and Methods The cross-sectional survey was conducted; primary data were collected from asthmatic patients in different hospitals and clinics of allopathic, homeopathic, and herbal practitioners in Karachi, Pakistan. The study duration was from January 2020 to December 2020. Asthmatic patients aged over 13 years were selected for the study. A written informed consent was taken from the patients before the interview. Collected data were analyzed by the Statistical Package of Social Sciences (SPSS) 22. Result Among 255 asthmatic patients; 51.4% (n = 131) were male and 48.6% (n = 124) were female. For control of acute attacks of asthma 88.2% (p = 0.0001) of patients significantly preferred allopathic treatment while 6.3% (p = 0.008) used homeopathic treatment and 5.5% chose herbal treatment. For maintenance of asthma, 78.8% (p = 0.0001) patients used allopathic treatment while 12.4% (p = 0.0001) homeopathic and 8.8% (p = 0.0001) patients used herbal treatment. About 63.4% (p = 0.0001) of the asthmatic patients used short-acting β-2 agonists for managing acute asthmatic episodes while long-acting β-2 agonists (p = 0.0001) and inhaled corticosteroids (p = 0.0001) were found to be the preferred medicines for maintenance therapy. Effectiveness of treatment (p = 0.004) and cost effectiveness (p = 0.0001) significantly act as contributing factors for the selection of the treatment. The majority of the patients were satisfied with their chosen treatments for control of asthmatic symptoms. Conclusion Most asthmatic patients preferred allopathic treatment for the management of acute episodes and control of asthmatic symptoms. It was found that the major factors for selecting a specific treatment include effectiveness, cost, and minimal side effects.


Introduction
Asthma is a chronic inflammatory disorder [1]. It causes a high global burden of death and disability; around 1000 people die from asthma each day. [1] e prevalence of asthma across Asia ranges from 0.7% to 11.9% [2]. In Pakistan, over 10% of the population is a victim of asthma [1]. e largest city in Pakistan is Karachi; about 8-10% population of this mega city suffers from chronic asthma [3]. In addition, asthma is also associated with a significant socioeconomic burden [4]. Such a burden is due to costs of asthma medications, physician's visits, hospital admissions, absence from work, and premature death. Asthma interferes significantly with daily life [5] and limits a patient's physical activities due to asthmatic symptoms. Increased levels of anxiety, fear, and depression also enhance the emotional burden [6]. On the other hand, if asthma is effectively controlled, quality of life might improve and reduce the socioeconomic burden [7]. Proper control of severe asthma prevents exacerbations and limits mortality [1]. Asthma exacerbations might also result due to exposure to a number of risk factors/triggers including allergens, pollutants, smoking, pets, coexisting medical conditions, and medications. Identification and prevention of asthma triggers reduce exacerbation and help in achieving better control [8]. Traffic-related air pollution, nitrogen dioxide, and secondhand smoking exposures represent significant risk factors for asthma development in children [9]. Climate change and air pollution have a significant impact on human health and the onset and aggravation of allergic rhinitis and asthma in patients with chronic respiratory diseases [10]. More than 90% population lives in places where air quality does not meet the recommendation of the World Health Organization; due to this reason, prevalence of asthma is rising in urban areas [11].
Several types of treatments are used to maintain asthma including allopathic and alternative treatments. e allopathic method includes a wide range of drugs such as corticosteroids, short-or long-acting β-2 agonists, anticholinergics, bronchodilators, immunomodulators, leukotriene modifiers, mast cell stabilizers, and xanthine-oxidase inhibitors [12]. Immunotherapy or allergy shots improve asthma control in some patients; a recent meta-analysis demonstrated that immunotherapy may improve lung function, reduce symptoms, and decrease medication requirements in a significant number of patients [13]. Diverse treatment approaches with reliever medications, controllers, and combination medications are used for asthma. Unlike other medications, biologicals are also used for the management of asthma in a physician's office. Currently, there are five approved biological for the management of asthma such as omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab [14]. Omalizumab is an anti-IgE monoclonal antibody compound; it is used for severe asthma and concurrent allergies. It is usually administered twice monthly as an injection in a specialty physician's office. Lifethreatening anaphylaxis has rarely been reported with this medication [15]. Systematic reviews of all these five biological agents found that they reduce asthma exacerbation rates with high certainty [14]. e addition of these biological agents is a marked therapeutic advancement, especially for refractory asthma. ese agents are licensed for eosinophilic asthma. ese biological agents target the -2 pathway of cytokines, such as mepolizumab and reslizumab (IL-5), benralizumab (IL-4), and dupilumab (IL-3) [16]. e use of specific approach depends upon the need (acute or maintenance), asthma severity, and patient requirements [17]. In addition to allopathic treatments, many patients use complementary and alternative medicines (CAMs). CAMs are a group of various medical and healthcare approaches, practices, and products not commonly considered a part of conventional medicine. e documented prevalence rates of CAM practice in treating asthma is from 4% to 79% [18]. e common CAM used for asthma includes herbal and homeopathic medications. Herbal medicines are part of the traditional medical practice that uses several plant resources for prevention and therapeutic purpose. Herbal medicines are generally considered as a safe treatment for different diseases and are assumed to be relatively less toxic [19].
Other than commercially available herbal medicines, plants and herbs are also used for asthma including honey, garlic, turmeric, bitter gourd, linseed, and mustard oil [20]. Homeopathy is one of the most common and debated methods of complementary medicine used to treat asthma. Homeopathy identifies disease as a holistic issue and tries to treat the disease from the core rather than focusing on symptoms only [21].
Considering such diversity in the treatments, the primary end-point of the current study was to determine the prevalence of allopathic, homeopathic, and herbal treatments for addressing both acute onsets of asthma and its maintenance. e secondary end-point of the study was to explore which treatment is preferred by patients and which specific class of drug is mostly used for acute asthmatic attacks and for maintenance of relief from asthma.

Materials and Methods
e survey design was cross-sectional and observational. e multicenter study was conducted at government hospitals, private hospitals, and clinics in the mega city of Pakistan, Karachi. e duration of the study was from January 2020 to December 2020. e sample size of the study was calculated by the precision analysis technique [22]. All study work was conducted in accordance with the Declaration of Helsinki. Ethical approval of the study has been obtained from the Institutional Bioethics Committee, University of Karachi, with approval No. IBC-KU-24. e study was also approved by the Advanced Studies and Research Board, University of Karachi, with approval No. ASRB/02032/Pharm.
After ethical approval, a structured questionnaire was used for the primary data collection. e questionnaire was finalized after multiple iterations and pilot testing in the field. e questionnaire was both in English and Urdu language for a better understanding. Asthmatic patients of age above 13 years were selected for the study. Written informed consent was taken from every participant before the interview, and the questionnaire was completed through face-to-face interviews. e primary end-point of the current study was to determine the prevalence of allopathic, homeopathic, and herbal treatments for addressing both acute onsets of asthma and its maintenance. e secondary end-point of the study was to explore which treatment is preferred by patients and which specific class of drug is mostly used for acute asthmatic attacks and for maintenance of relief from asthma. By considering these end-points of study, information obtained from the questionnaire included demography of patients such as patient's age, gender, type of asthma, asthma severity, and choice of treatment with conventional/alternative medicines for both acute episodes of asthma and maintenance of relief from asthma. ey were also requested to highlight factors that determined their choice of a particular treatment and their satisfaction level with the treatment. Figure 1 represents the flowchart of the study.
Data confidentiality was maintained and coded to maintain the privacy of participants and consent. Collected data for the study were analyzed by the SPSS (Statistical

Result
In the survey, a total of 255 asthmatic patients were interviewed. Table 1 mentioned the frequency and percentage of different characteristics of respondents while a clinical picture of respondents is mentioned in Table 2. Respondent's treatment preferences and satisfaction levels are shown in Table 3. Respondent's drug preferences for acute asthmatic attacks and maintenance of relief are mentioned in Figures 2 and 3.
Short-acting β-2 agonist (SABA) was found to be the most prescribed and statistically significant (p � 0.0001) drug for the treatment of acute asthmatic episodes and was used by 63.4% of the patients.
e survey respondents were also asked about the factors that determine the choice of their respective treatments for acute asthmatic episodes and maintenance of relief from asthma. e different factors included effectiveness of treatment, cost effectiveness, minimal side effects, and easy long-term management among others. Effectiveness of treatment (p � 0.004) and cost of treatment (p � 0.0001) were found to be the most significant factors for patients in making treatment choices as shown in Figure 4.

Discussion
e findings of the study were consistent with the hypothesis of the study; the majority of the patients interviewed at different centers all over Karachi preferred allopathic treatment for controlling the acute attack of asthma. Very few patients choose homeopathic and herbal treatments for acute asthmatic attacks. Similarly, for controlling the chronic symptoms of asthma, the patients also preferred allopathic treatment compared to homeopathic and herbal treatments. e current study validated that allopathic is a more effective and trustworthy treatment for asthma as compared to homeopathic and herbal treatments. Some literature presented that homeopathy plays a major role in the management of asthma both in acute and chronic asymptomatic phases [23]. It reduces the use of allopathic/ conventional drugs [23]. However, randomized trials are mandatory to validate the efficacy of homeopathy in asthma. In addition to randomized trials, observational studies are also necessary to determine the homeopathic drugs prescribed and the patient's response [23]. Herbal treatment has been found to be an effective alternative treatment for asthma, but still, for the safe and effective prescription of herbal medications evidence-based studies, particularly clinical trials are required [24]. e current study reveals that patients preferred homeopathic and herbal treatments for controlling chronic symptoms of asthma as compared to acute attacks. Such findings increased reliance on homeopathic and herbal treatments for controlling chronic symptoms, which is in line with the findings of Clarke et al., where they found that because of the risk of possible adverse effects pertaining to long-term use of allopathic medications; many patients avoid allopathic or conventional medicines. Furthermore, nonadherence to conventional (allopathic) treatment might be due to complex treatment regimens and difficult inhalation techniques [19]. A study also found that improper use of inhalers affects the quality of life of an asthmatic patient and also results in nonadherence to allopathic treatment [25]. e current study data showed that from available and prescribed medications including allopathic, herbal, and homeopathic, the short-acting β-2 agonist is used by most of the patients for acute asthmatic episodes while the second most used drug was inhaled corticosteroid. For maintenance of relief from asthma, long-acting β-2 agonist and inhaled/ oral corticosteroid were the preferred choices by asthmatic patients.
e study findings are in line with previous findings; most asthmatic patients used short-acting β-2 agonist as a first-line treatment for acute asthmatic attacks [26] and provides quick relief from symptoms [27]. Controlling chronic symptoms of asthma, responses of the patients also coincided with the recommended guidelines that long-acting β-2 agonists and inhaled corticosteroids [28] are an effective treatment for long-term relief from asthma. It was also noted that some of the respondents were using both long-acting β-2 agonists and inhaled corticosteroids for relief from asthmatic symptoms; such a combination is reported to be effective in asthma control and preventing exacerbations [29]. ese treatment preferences also strengthen the patient's response that the main factor for selecting a specific treatment or medication is the effectiveness of the treatment. Route of drug administration might be another major contributing factor to the preference of patients for allopathic medicines. e survey findings verified that most of the medications used for asthma control belong to the allopathic medicine system; the inhalation route is found to be the most effective one with rapid onset of action for respiratory disorders [30].
e results of this study also showed that most of the patients using different treatments were satisfied with their chosen treatment for both acute attacks of asthma as well as for chronic relief from asthma. Although homeopathic and herbal treatments were used by a small number of patients, most of them were satisfied with their treatment for both acute and chronic relief. It shows that allopathic was the preferred treatment for asthma; however, homeopathic and herbal treatments were also found to be effective for both reducing acute asthmatic episodes and for chronic relief.
ese findings are contradictory to the results of Chen et al., which showed that the use of alternative and complementary therapies is associated with a lack of asthma control. However, the study also included many alternative treatments other than homeopathic and herbal treatments [18]. e study also focused on factors that patients considered important when choosing treatment for asthma. e majority of respondents rank the effectiveness of treatment as the most important factor for the choice of treatment type. In addition, the cost of treatment is also significantly considered by respondents while selecting a treatment. It was observed that patients understand the fact that asthma is a chronic disease, so they also consider minimal side effects and easy long-term management before choosing a treatment. ese findings of the study validate that allopathic is the most preferred treatment for asthma in terms of efficacy. e efficacy of allopathic medication has been proven by many research studies. However, current study results also support the outcome of Herman and his colleagues' study that further analysis of cost effectiveness should be performed on alternative treatments [31].
Another important finding of this study suggests that patients' basic needs are the positive outcome with any of the treatments they select. Patient preference or choice of a specific treatment may also be affected by many psychological factors such as motivation to recover; attitude towards asthma; the medication; the prescriber; attitudes; and views of surrounding individuals [32]. Various studies evaluated the role of the health care provider which holds a very significant position and can affect the patient's decision of acceptability to the treatment. If the exacerbated presentation of specific treatment benefits including efficacy, better tolerance, cost, and fewer side effects is presented by health care providers, it will definitely increase the adherence of patients to the prescribed treatment [33,34]. It is also necessary to highlight the increasing prevalence of alternative treatments; physicians, pharmacists, and clinicians should have knowledge and information to guide their patients about the use, benefits, and possible side effects of alternative therapies [35]. Physicians should regularly evaluate the triggers for individual patients, and support and educate patients to manage the effect of asthma triggers [36]. Pharmacists can also play a significant role in the education of patients about the disease as well as the types of drugs used.

Conclusion
e study found that allopathic treatment is the most preferred treatment for both acute asthmatic attacks and relief from chronic asthma. Effectiveness and cost of the treatment were the key factors for selecting a particular treatment.
e findings of the study may provide a way forward for understanding patients' values and preferences regarding their treatment and enhancing their satisfaction levels.

Recommendations
It is important that any treatment provided by healthcare providers should be prescribed only after the identification of a moderate, severe, or life-threatening exacerbation. ey should always first identify the symptoms, signs, and risk factors for severe and life-threatening exacerbations and then prescribe treatment that is better for patients in terms of effectiveness, safety, and economy. e ECHO (economic outcome, clinical outcome, and humanistic outcome) model should be applied. [37] Evidence-based studies and randomized clinical trials are required to confirm the efficacy and safety of alternative treatment methods for asthma in order to use them more with allopathic medications.

Data Availability
e datasets generated during the current study are not publicly available to maintain the confidentiality of participants but are available from the corresponding author on a reasonable request.

Conflicts of Interest
e authors declare that there are no conflicts of interest.

Authors' Contributions
JF conceived the idea, collected data, analyzed data and interpreted results, and drafted the initial manuscript. SAK designed the study, drafted the final manuscript, and approved the final version to be submitted. FG reviewed the study protocol and revised the manuscript. JS surveyed the literature, analyzed data, and reviewed the manuscript. IA is the supervisor of this study, he surveyed literature and approved the final version to be submitted. All authors read and approved the final manuscript.