To the Editor:  

The article by Nicholas L. Rider, DO, and Timothy J. Craig, DO,¹ in the September 2006 issue of JAOA—The Journal of the American Osteopathic Association, about long-acting β₂-agonists and inhaled corticosteroids, shows the benefits of standard therapy in the treatment of patients with asthma. At the same time, however, the article raises questions in my osteopathic-oriented mind about the wisdom of using intranasal steroids to put the immune system “to sleep.” 

In the September 2006 edition of The DO, the late John A. Strosnider, DO,² (2006-2007 President of the American Osteopathic Association) encouraged us to remember our roots. One of the issues that helped me decide to pursue osteopathic medicine as a career was the success rate of osteopathic physicians in treating patients with influenza after World War I. According to the United States Centers for Disease Control and Prevention,³ the mortality rate of patients with “Spanish flu” who were treated with conventional medical therapy was more than 2.5%, while records reported at the time suggest that the mortality rate of patients who were treated by osteopathic physicians may have been as low as 0.25%.⁴ 

Even if the statistics then reported in the JAOA⁴ were not entirely accurate, the difference in outcomes for osteopathically treated patients versus allopathically treated patients was still likely to have been significant. 

As Harold I. Magoun, Jr, DO,⁵ pointed out in a letter in the October 2004 JAOA, this difference in outcomes probably centered on the realization by osteopathic physicians that the symptoms of fever and cough exhibited by patients with influenza—symptoms that MDs addressed pharmaceutically with aspirin and cough suppressants—were actually the immune system's protective responses to illness. In the language of evolutionary biology, those symptoms were defenses that were expressed because they conveyed a survival benefit that was lost when they were suppressed. In the language of sports, hobbling your defense means the other side scores. 

Most triggers for asthma are recognized in the nose. The “one airway hypothesis” posits that when the immune system recognizes a substance in the nose (ie, upper airway) that could cause greater problems in the lungs (ie, lower airway)—where the body's defenses are less robust—the system protects the lungs by constricting the connection between the two airways.⁶ This constriction is one of the actions of histamine as it triggers the washing defense that is rhinorrhea. Both common sense and ultramicrographic studies point to the fact that histamine's action in triggering rhinorrhea is just as much of a defense as is a fever or a cough.⁷ 

Just as blocking other evolutionary defenses handicaps our ability to deal with threats, stopping rhinorrhea risks an increase to nasal-related problems. The up to 20-fold increases that have been reported in hospitalizations for asthma stem from the early 1970s.⁸ That was the same time at which antihistamines and decongestants were made available on an over-the-counter basis—and the same time at which these medications were advertised on television and supplied in bulk for physicians to give to needy patients. Although this sequence of events does not satisfy the logic of causality, it should at least raise the question of causality. 

If the osteopathic medical profession is serious about looking to its roots, we ought to look at treatments that honor the natural defenses of the immune system and observe how doing so would impact the incidence and severity of asthma. Then, it is likely, we would not have to put our immune systems to sleep with steroids.