[aberzoy]

Respiratory Medicine Volume 98, Issue 8 , August 2004, Pages 687-696
.....
The homeopathy review
Method

For the homeopathy review, we searched the Asthma and Wheez* database of the Cochrane Airways Group for all trials including the word homoeop* and homeop*. Additionally, we checked the trial database of the initiative for a Cochrane Complementary Medicine Field, the databases of the Glasgow Homeopathic Library (Scotland), the Centre for Complementary Medicine Research (University of Munich, Germany), and the reference lists of published reviews and papers.
Results

Differences in the interventions used in the trials raised many questions concerning how to analyse the findings of the studies. The studies could be divided into the following categories: (1) Individualized and formula; the approach to treatment differs sufficiently between these two to merit separation. This division would be helpful in addressing the question of package of care, as that associated with "individualized" differs greatly from that provided with "formula" homeopathy, which by its very nature is generic; (2) adults and children; and (3) homeopathy and isopathy. Six trials were included,[32., 33., 34., 35., 36. and 37.] detailed in Table 2.

Table 2. Studies included in the homeopathy review.

All of the included studies were described as randomized, double-blind, placebo-controlled, parallel group trials. Diagnosis was variously defined in terms of respiratory function,[32.] symptoms, [33.] clinical history and spirometry, [34.] clinical history, spirometry and medication usage, [35.] lung function, symptoms and medication usage, [36.] and general practitioner diagnosis and medication prescription. [37.]

Participants suffered from mild-to-moderate asthma[37.] or mixed severity (mild to severe). [33. and 36.] No attempt was made to grade severity in three of the studies. [32., 34. and 35.]

Two studies recruited children only (of 1–12 years[33.] or 4–16 years [37.]). The other four studies recruited adults only (>16 years; [32.] 24–48 years; [34.] 36–70 years; [35.] 18–55 years [36.]). Two studies [32. and 36.] used allergen-based homeopathic treatments (isopathy).

No details were given in one of the studies[33.] on the use of concomitant therapies. Most participants in all the remaining studies were described as taking medication to control their asthma.
Interventions

Active treatment was compared with placebo as an adjunct to usual care in all of the studies. Four studies used homeopathic dilutions, either single remedies (Blatta officianalis C6[33.]), individualized remedies (classical homeopathy [37.]), or a standardized combination (Engystol N containing Vincetoxin D6/D10/D30 and sulfur D4/D10; [34.] and Asthma H containing 14 different potencies of either D3, D4, D5 or D6 [35.]). Two studies [32. and 36.] used isopathy, both to 30C. Duration of treatment in the studies ranged from 1 day [36.] (plus 16-week follow-up) to 1 year [37.] (with up to six consultations over 1 year).
Methodological quality of included studies

The overall study quality was deemed to be mixed (see Table 2 for Jadad [17.] scores). All studies were double-blind.

Although the aim of the review was to establish the efficacy of homeopathy compared with placebo, all the studies administered homeopathic treatment in addition to usual care. In most instances, this was in addition to steroids or 2-agonists. The effects of these medications may have confounded potential benefits of homeopathy.

The reviewers felt that, across the studies, the severity of asthma was largely mild to moderate. This limits the applicability of this review to patients with more severe asthma.

Owing to the heterogeneity of trials (in terms of patients, interventions, and outcome assessment), quantitative meta-analysis of the studies was limited. We have only been able to assess homeopathic treatments in addition to usual care.
Formula homeopathy versus placebo (in addition to usual care)

One study[32.] found that the severity of symptoms quantified by a daily visual analogue scale differed significantly between the groups (P=0.003). No significant difference was observed for peak expiratory flow rate. Another study[36.] reported no significant difference between treatment and control either after treatment or at 15-weeks follow-up.

The data for morning peak expiratory flow could not be pooled because of differences in the studies. One study[34.] reported a significant difference between homeopathy and control in favour of homeopathy (no P value reported). Another study[36.] reported no significant difference after treatment and at 15-week follow-up.

The reported FEV1 data could be pooled for two of the studies.[35. and 36.] No significant difference was observed (−0.06 l; 95% CI −0.17 to 0.04). One study[32.] assessed the difference between the medians with 95% confidence intervals. No significant difference was detected.

One study[34.] reported that there was a "clear difference" between treatment and control, but no statistical analysis was presented.

For FVC, no data could be pooled due to differences in the studies. One study[32.] reported a significant difference between the medians of the groups (P=0.03). Another study[34.] reported a "clear difference" of 1.3 L, but again the results of statistical tests were not reported. A third study[35.] reported no significant differences in the treatment group compared with control.
Medication usage

Two studies[34. and 35.] reported steroid usage. One of them [34.] showed a "clear difference" between treatment and control in terms of oral steroid use (no P value reported). The other study[35.] reported inhaled triamcinolone usage with treatment leading to a significant reduction in medication use (P<0.01). No significant difference was reported in bronchodilator usage after treatment or at 15-week follow-up in a third study.[36.]
Exacerbations

One study[33.] measured intensity, frequency and duration of exacerbations in 86 children. No significant difference was reported between the groups in terms of intensity, frequency and duration of exacerbations.
Individualized homeopathy versus placebo (in addition to usual care)

One study measured individualized homeopathy.[37.] No significant difference was found between treatment and control on symptoms, lung function, quality of life, medication usage, global assessment, and adverse effects.
Discussion

There did seem to be substantial differences between the studies in terms of the package of care provided. For example, in one study,[37.] there was extensive telephone contact and changes in remedy in addition to six consultations. It is difficult to see how this can be assessed alongside some of the less extensive "one off" treatments offered in two of the studies. [32. and 36.]

The currently available evidence makes it difficult to reliably assess the possible role of homeopathy in the treatment of asthma. We did not have enough information to explore the effects of separate remedies and potencies. Although the scientific rationale behind homeopathy remains unproven, non-specific benefits associated with a "holistic" package of care may exist. The effect of homeopathy on asthma has yet to be proven in a randomized study.
Conclusion

There is currently not enough good evidence to recommend either acupuncture or homeopathy in the management of asthma as a front-line therapy. Nevertheless, the holistic approach adopted by the trialists featured in these reviews to patient care may make such alternative treatments appealing to patients and their carers. More research into both of these treatments is warranted, paying particular attention to the way these therapies are practiced.

The "package of care" issue in future trials is an important one and applies to both acupuncture and homeopathy. Acupuncture in practice is often one aspect of a complex package of treatments. In the absence of a scientific rationale for homeopathy, some would argue that any observed effect cannot be seen outside the context of the entire treatment package, which consists of one-on-one, in depth, "holistic" consultation, administration of homeopathic treatment, and follow-up. Until studies can adequately estimate the effect of a "package of care", the effects of these two alternative treatment strategies will be difficult to quantify and qualify. Studies conducted with two control treatment groups (i.e. one arm that receives the package and a placebo intervention, and another that only receives the placebo intervention) might offer some useful insights into patient expectations of this type of care, and how they respond to close attention from qualified specialists.