It has been estimated that approximately 20% of Americans suffer from seasonal allergies. This includes allergic rhinitus, hay fever, and bouts of sneezing and watery eyes and even asthma. However, numerous studies have demonstrated that both indoor and outdoor pollution have contributed to the rise of this condition. Numerous pollutants can oversensitize the tissue of the upper respiratory tract thereby releasing excessive amounts of inflammatory mediators from mast cells. When the upper respiratory tract is already over-sensitized, mast cells respond to allergens by producing and releasing an even greater abundance of inflammatory chemicals such as histamine. Histamine appears to be the major culprit in causing many of the symptoms associated with allergies as mentioned above. Mediators of inflammation such as prostaglandins also play an important role. Antihistamines and steroids are the accepted as the conventional course of therapy. However, while histamines successfully treat the physical symptoms by blocking the action of histamine at receptor sites they do have numerous unwanted side effects the most common being drowsiness, depression and extreme excitability. Frequent or long term steroid use frequently results in bone loss, immunosuppression, hypersensitivity and serious mental disturbance. Numerous human and animal studies have demonstrated that several dietary supplements may successfully treat seasonal allergies. What appears to make the supplements perhaps superior is their apparent lack of side effects.

BOTANICALS
Ephedra sinica(Ma huang) has been used in Traditional Chinese Medicine (TCM) for over 5,000 years. The active plant alkaloid - ephedrine has been well documented in treating asthma, allergies, allergic rhinitis and nasal congestion. Pseudoephedrine (its drug analogue) is found in numerous OTC drug preparations for cold, flu and allergy relief. There have been some reports of adverse effects due to Ephedra abuse. Some dietary supplements were augmented with either pseudoephedrine or ephedrine and marketed as giving a natural high. Abuse of these supplements has caused some deaths when extreme doses were taken. However, Ephedra has a long history of safe use when used appropriately. It is an approved herb in the German Commission E Monographs for diseases of the upper respiratory tract with mild bronchospasms in adults and children over the age of 6. In TCM, Ephedra is not used alone. Is it combined with other herbs that include Angelica sinensis (Dong quai), licorice root (Glycyrrhiza glabra),) Chinese skullcap (Scutellaria baicalensis) and ginger (Zingiber officinale). Allergy and sinus products that contain many of these herbs can be found as Chinese Patent Formulas (at Chinese apothecaries and some health food stores) as well as by dietary supplement companies at health food stores and some pharmacies. The combination of these herbs provides antihistamine, anti-inflammatory, decongestant and expectorant effects. Since products may differ slightly, label directions give the best guidance for use. I have personally seen excellent clinical effects of many of these preparations. Also, patients have generally reported better results and virtually no side effects. Few patients may feel a little hyper when taking products that contain Ephedra. The choices are: (1) reduce the dosage, (2) advise not taking it in the evening, (3) try a multi herb formulation that does not contain Ephedra. I recommend products that combine Ephedra with other herbs such as: Angelica sinensis, Glycyrrhiza glabra, Scutellaria baicalensis, and Zingiber officinale, in multi herb combination formulas. If a single herb is used, following label directions are important since potency and dosage form (e.g. tincture vs. capsule) will be different, even from brand to brand.

Angelica sinensis (Dong quai) has a long history of use in TCM, but like Ephedra, it is generally not used alone but in combination with other herbs as previously mentioned. Studies have shown that Angelica can decrease allergic antibody production levels that can be as much as ten times greater in those with allergies. A decrease in antibodies results in a reduced production and release of mediators from mast cells.

Licorice (Glycyrrhiza glabra) has an anti-inflammatory action similar to that of cortisone. Cautioned is warranted when licorice is used alone over a long period of time since it may result in potassium loss and elevate blood pressure in susceptible individuals. Once again, in TCM licorice is not used alone but in combination with other herbs. It has been safely used for thousands of years when used appropriately. It is an approved herb in the German Commission E Monographs for catarrhs of the upper respiratory tract. It is suggested that licorice not be taken for more than 4-6 weeks without medical advice. It would be prudent for patients to monitor their blood pressure during licorice root therapy.

Chinese skullcap (Scutellaria baicalensis) provides a rich source of flavonoids, which help reduce the production of leukotrienes (inflammatory prostaglandins) and favor the production of anti-inflammatory prostaglandins of the 3 series. Flavonids also act as natural antihistamines so this herb provides both cortisone -like action and antihistamine effect. In TCM it is combined with other herbs.

Ginger (Zingiber officinale) has been the focus of numerous studies demonstrating anti-inflammatory effects particularly in arthritis and in dyspepsia. However, it has long been used in TCM for its anti-inflammatory effects in allergy preparation that include the aforementioned herbs.

Gingko biloba contains gingkolides that antagonize platelet-activating factor (PAF) by competing it for binding sites. PAF induces an inflammatory and allergic process by neutrophil activation, increasing vascular permeability, smooth muscle contraction (e.g. bronchoconstriction) and reduced coronary blood flow. Studies with asthmatics have shown that at levels of 120 mg of pure gingkolides significantly improve respiratory function and reduce bronchial reactivity. Standardized supplements of Gingko provide 24% of the gingkolides. While achieving the high dose of 120 mg may be a bit expensive, combining a lower dose with other herbs may yield a synergistic effect. Common doses of Gingko biloba are 120-240 mg per day.

Ginseng appears to work in a similar fashion to Gingko by inhibiting PAF. It contains plant compounds known as ginsenosides, which inhibit PAF, mast cell mediator formation and mast cell degranulation triggered by antigen-antibody response. It is often found in combination with other herbs in cold/allergy/asthma preparations. However, it is one of the few herbs that are often used alone as a daily tonic not only in Asia, but all over the world. It can be found as teas, capsules, tablets and tinctures. Standardized preparations are the most reliable. Since potency differs from product to product, it is best to follow label directions.

While treatment of asthma was covered in a previous issue covered of this newsletter [1999;1(3)] it needs to be covered as one of the symptoms of seasonal allergies. Lobelia inflata contains lobeline an alkaloid that is a well documented expectorant. It has a long history of use in treating asthma. Its mechanism of action appears to be stimulation of the adrenal glands to release epinephrine, which binds to beta-2-receptors, and relax the airways. I have personally had excellent success using this herb clinically with various types of asthma. It is extremely safe and effective. Usual doses are 20 drops of an extract, 1-3 times daily or 2 capsules (or tablets) 2-3 times daily as needed. I prefer the extract as it works very quickly, almost as fast as an inhaler.

Quercetin at doses of 1-2 grams per day stabilizes mast cells and inhibits the release of inflammatory mediators and histamine. It also decreases leukotriene formation by inhibiting steps in eicosanoid metabolism and decreasing formation of arachidonic acid and inflammatory prostaglandins. It enhances the absorption of vitamin C and has a synergistic effect.

Stinging nettles (Urtica dioica) has become quite popular in the US for treating allergies. Studies have shown that it is effective for allergic rhinitis. In one study, 98 patients with allergic rhinitis received either nettles (300 mg) or a placebo twice daily for one week. Sixty-nine patients completed the study. In the treatment group, 58% reported it moderately effective vs. 37% in the placebo group. While the researchers conclude that a one week trial of two 300 mg capsules may be sufficient to identify those who respond favorably, personal experience reveals that some may need a higher dose to be effective, perhaps two 300 mg capsules twice daily.

VITAMINS
Numerous human and animal studies have shown that vitamins C and E are effective in the treatment of seasonal allergies. Vitamin C reduces elevated blood histamine levels by preventing the secretion of histamine by white blood cells. In one study, 16 patients with allergic rhinitis received 2 grams of vitamin C or placebo in a cross over study. In the placebo group, histamine caused a significant decrease in the maximal expiratory flow. Histamine did not decrease maximal expiratory flow in the vitamin C group. Studies have also shown that vitamin C and E work together synergistically. Vitamin E inhibits leukotriene function and both C and E are powerful antioxidants that protect the lung and respiratory tract against oxidative damage from air pollutants such as automobile exhaust, sulfur dioxide and other industrial chemicals. In one study asthmatics took 400 IU of vitamin E and 500 mg of vitamin C or placebo in a cross over study for separate 5-week periods. Participants were exposed to air and ozone and sulfur dioxide challenges. Those who took the antioxidants showed an overall decrease in sensitivity to ozone and improvements in pulmonary function were dramatic in six volunteers. Beta-carotene as well as other carotenoids are also powerful antioxidants that also decrease leukotriene formation, quench singlet oxygen, increase the integrity of the epithelial lining of the respiratory tract and specifically block the damage that may be caused by specific pollutants. Natural vitamin E with mixed tocopherols and natural beta-carotene with mixed carotenoids appear to be the most bioavailable, safe and effective forms of supplementation.

OMEGA-3 FATTY ACIDS
Much of the research has focused on fish oil and asthma, demonstrating that it effectively improves airway function and blocks inflammation. Fish oil effectively inhibits the formation of the formation pro-inflammatory prostaglandins by blocking the production of arachidonic acid since it provides a rich source of omega-3 fatty acids. Omega-3 fatty acids modulate the allergic response by inhibiting the production of pro-inflammatory prostaglandins and suppressing the responses of target cells and tissues. Eating fish several times per week may be effective for some. Common doses of fish oil supplements are 4 - 6 capsules per day,

SUMMARY
A combination herbal product that contains several of the herbs discussed including Ephedra can alleviate many of the symptoms associated with seasonal allergies. Addition of an antioxidant supplement has the additional benefit of protecting the upper respiratory tract and reducing oxidative stress due to pollutants and allergens. Fish oil may offer an added benefit of further reducing the inflammatory response.

SELECTED BIBLIOGRAPHY
1. Hatch GE. Asthma, inhaled oxidants and dietary antioxidants. Am J Clin Nutr 1995;61(Suppl):625S-630S.
2. Broughton KS et al. Reduced asthma symptoms with n-3 fatty acid ingestion are related to 5-series leukotriene production. Am J Clin Nutr 1997;65:1011-1017.
3. Trenga C et al. Sulfur dioxide sensitivity and plasma antioxidants in adult subjects with asthma. Occup Environ Med 1999;56(8):544-7.
4. Braquet P. The gingkolides: Potent platelet activating factor antagonists isolated from Gingko biloba: chemistry, pharmacology and clinical applications. Drugs Future 1987;12:643-649.
5. Jung KJ et al. Platelet activating factor antagonist activity of ginsenosides. Biol Pharm Bull 1998;21:79-80.
6. Mittman P. Randomized, double-blind study of freeze-dried Urtica dioica in the treatment of allergic rhinitis. Planta Med 1990;56:44-77.
7. The Encyclopedia of Natural Medicine, 2nd Edition. Murray M, Pizzorno P. 1998 Prima Publishing (Rocklin, CA), pgs 260-272.
8. Nutritional Influences on Illness, 2nd Edition. Werbach, M. 1993 Third Line Press (Tarzana, CA), pgs. 39-46.