GINA - Global initiative for Asthma
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Transcript of GINA - Global initiative for Asthma
G INA
G INA
lobal
itiative for
sthma
lobal
itiative for
sthma
GINA Program Objectives
GINA Program Objectives
Increase appreciation of asthma as a global public health problem
Present key recommendations for diagnosis and management of asthma
Provide strategies to adapt recommendations to varying health needs, services, and resources
Identify areas for future investigation of particular significance to the global community
Increase appreciation of asthma as a global public health problem
Present key recommendations for diagnosis and management of asthma
Provide strategies to adapt recommendations to varying health needs, services, and resources
Identify areas for future investigation of particular significance to the global community
Executive CommitteeExecutive CommitteeChair: Eric Bateman, MDChair: Eric Bateman, MDExecutive CommitteeExecutive CommitteeChair: Eric Bateman, MDChair: Eric Bateman, MD
Dissemination Dissemination CommitteeCommittee
Chair: L.B. Boulet, MDChair: L.B. Boulet, MD
GINA Structure
Science Science CommitteeCommittee
Chair: Mark FitzGerald, MDChair: Mark FitzGerald, MD
GINA Executive CommitteeGINA Executive Committee
E, Bateman, Chair, S. Africa
L.P. Boulet, Canada K. Ohta, Japan
A. Cruz, Brazil P. Paggario, Italy
M. FitzGerald, Canada S. Pedersen, Denmark
M. Haahtela, U.K. M. Soto-Quiroz, Costa Rica
P. O’Byrne, Canada G. Wong, Hong Kong ROC
E, Bateman, Chair, S. Africa
L.P. Boulet, Canada K. Ohta, Japan
A. Cruz, Brazil P. Paggario, Italy
M. FitzGerald, Canada S. Pedersen, Denmark
M. Haahtela, U.K. M. Soto-Quiroz, Costa Rica
P. O’Byrne, Canada G. Wong, Hong Kong ROC
GINA Science CommitteeGINA Science Committee
M. Fitzgerald, Chair, Canada
N. Barnes, UK P. O’Byrne, Canada
P. Barnes, UK K. Ohta, Japan
E. Bateman, S. Africa E. Pizzichini, Brazil
A. Becker, Canada S. Pedersen, Denmark
J. Drazen, US H. Reddel, Australia
R. Lemanske, US S. Sullivan, US S. Wenzel, US
M. Fitzgerald, Chair, Canada
N. Barnes, UK P. O’Byrne, Canada
P. Barnes, UK K. Ohta, Japan
E. Bateman, S. Africa E. Pizzichini, Brazil
A. Becker, Canada S. Pedersen, Denmark
J. Drazen, US H. Reddel, Australia
R. Lemanske, US S. Sullivan, US S. Wenzel, US
Executive CommitteeExecutive CommitteeChair: Eric Bateman, MDChair: Eric Bateman, MDExecutive CommitteeExecutive CommitteeChair: Eric Bateman, MDChair: Eric Bateman, MD
Dissemination Dissemination CommitteeCommittee
Chair: L.P. Boulet, MDChair: L.P. Boulet, MD
GINA Structure
Science Science CommitteeCommittee
Chair: M. FitzGerald, MDChair: M. FitzGerald, MD
GINA ASSEMBLY
GINA AssemblyGINA Assembly
A network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional level
GINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings
A network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional level
GINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings
United StatesUnited States
United Kingdom
ArgentinaArgentina
AustraliaAustraliaBrazilBrazil Austria
CanadaCanada
Chile
Belgium
ChinaChina
DenmarkDenmark
ColumbiaColumbia
CroatiaCroatiaGermany
Greece
IrelandIreland
ItalyItaly
SyriaSyria
Hong Kong ROC
Japan
IndiaIndia
KoreaKorea
Kyrgyzstan
MoldovaMoldova
Macedonia
Malta
Netherlands
New Zealand
PolandPoland
Portugal
GeorgiaGeorgia
Romania
Russia
SingaporeSlovakia
Slovenia Saudi ArabiaSaudi Arabia
South AfricaSouth Africa
Spain
SwedenSweden
ThailandThailand
SwitzerlandSwitzerland
UkraineUkraine
Taiwan
VenezuelaVenezuela
Vietnam
Yugoslavia
Albania
Bangladesh
France
Mexico
Turkey Czech Republic
Lebanon Pakistan
GINA Assembly
IsraelIsrael
PhilippinesPhilippines
CambodiaCambodia
Mongolia
Egypt
GINA DocumentsGINA Documents
Global Strategy for Asthma Management and Prevention (revised 2009)
Pocket Guide: Asthma Management and Prevention (revised 2009)
Global Strategy for Asthma Management and Prevention for Children 5 Years and Younger (2009)
Pocket Guide: Asthma Management and Prevention in Children 5 Years and younger (2009)
Guide for asthma patients and families
All materials are available on GINA web site www.ginasthma.org
Global Strategy for Asthma Management and Prevention (revised 2009)
Pocket Guide: Asthma Management and Prevention (revised 2009)
Global Strategy for Asthma Management and Prevention for Children 5 Years and Younger (2009)
Pocket Guide: Asthma Management and Prevention in Children 5 Years and younger (2009)
Guide for asthma patients and families
All materials are available on GINA web site www.ginasthma.org
Global Strategy for Asthma Management and PreventionGlobal Strategy for Asthma Management and Prevention
Evidence-based Implementation oriented
Diagnosis Management Prevention
Outcomes can be evaluated
Evidence-based Implementation oriented
Diagnosis Management Prevention
Outcomes can be evaluated
Global Strategy for Asthma Management and PreventionGlobal Strategy for Asthma Management and Prevention
Evidence Category Sources of Evidence
A Randomized clinical trials Rich body of data
B Randomized clinical trials
Limited body of data
C Non-randomized trials Observational studies
D Panel judgment consensus
Evidence Category Sources of Evidence
A Randomized clinical trials Rich body of data
B Randomized clinical trials
Limited body of data
C Non-randomized trials Observational studies
D Panel judgment consensus
Global Strategy for Asthma Management and Prevention (2009)Global Strategy for Asthma Management and Prevention (2009)
Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and
Prevention Program Implementation of Asthma
Guidelines in Health Systems
Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and
Prevention Program Implementation of Asthma
Guidelines in Health Systems
Updated 2009Updated 2009
Definition of AsthmaDefinition of Asthma
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD
Asthma Inflammation: Cells and Mediators
Burden of Asthma
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
Burden of Asthma
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Asthma Prevalence and Mortality
SourceSource: Masoli M et al. Allergy 2004: Masoli M et al. Allergy 2004
Countries should enter their own data on burden of asthma.
Countries should enter their own data on burden of asthma.
Risk Factors for Asthma
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Factors that Exacerbate AsthmaFactors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
Factors that Influence Asthma Development and Expression
Host Factors Genetic - Atopy - Airway
hyperresponsiveness Gender Obesity
Host Factors Genetic - Atopy - Airway
hyperresponsiveness Gender Obesity
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
Is it Asthma?Is it Asthma?
Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after
exposure to airborne allergens or pollutants
Colds “go to the chest” or take more than 10 days to clear
Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry - Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk factors
Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
History and patterns of symptoms
Measurements of lung function
- Spirometry - Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk factors
Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings
11Time (sec)Time (sec)22 33 44 55
FEV1FEV1
VolumeVolume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak Expiratory Flow
Measuring Airway Responsiveness
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and PreventionProgram: Five ComponentsAsthma Management and PreventionProgram: Five Components
Updated 2009
Asthma Management and Prevention Program
Goals of Long-term Management
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Asthma Management and Prevention Program: Five Interrelated Components
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and Prevention Program
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
.
Asthma Management and Prevention Program
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma Management and Prevention Program
Part 1: Educate Patients to Develop a Partnership
Asthma Management and Prevention Program
Part 1: Educate Patients to Develop a Partnership
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.
Asthma Management and Prevention Program
Factors Involved in Non-AdherenceAsthma Management and Prevention Program
Factors Involved in Non-Adherence
Medication Usage Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Medication Usage Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Non-Medication Factors
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.
Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.
Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.
Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma
development, especially in children and young infants
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Influenza VaccinationAsthma Management and Prevention Program
Influenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised
However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
The focus on asthma control is
important because:
the attainment of control correlates with a better quality of life, and
reduction in health care use
Determine the initial level of control to implement treatment
(assess patient impairment)
Maintain control once treatment has been implemented
(assess patient risk)
Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
Levels of Asthma Control(Assess patient impairment)
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Assess Patient Risk
Features that are associated with increased risk of adverse events in the future include:
Poor clinical control
Frequent exacerbations in past year
Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke, high dose medications
Assessment of Future Risk Risk of exacerbations, instability, rapid decline
in lung function, side effects
Features that are associated with increased risk of adverse events in the future include: Poor clinical control Frequent exacerbations in past year Ever admission to critical care for asthmaLow FEV1, exposure to cigarette smoke, high dose medications
Any exacerbation should prompt
review of maintenance
treatment
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Depending on level of asthma control, the patient is assigned to one of five treatment steps
Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in
combination with inhaled glucocorticosteroids
Systemic glucocorticosteroids Theophylline Cromones Anti-IgE
Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200
600-1000 >200-400 >1000 >400
Budesonide-Neb Inhalation Suspension
250-500
500-1000 >1000
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750
>1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200
>250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200
> 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800
>1000-2000 >800-1200 >2000 >1200
Reliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy
Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest controlling step
consider stepping up to gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
Shaded green - preferred controller options
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Shaded green - preferred controller options
TO STEP 4 TREATMENT, ADD EITHER
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Treating to Achieve Asthma Control
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
Step 4 – Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)
Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
When control as been achieved, ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored by the health care professional and by the patient
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)
When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.
Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)
Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)
Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and treatment requires close supervision
Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and treatment requires close supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for
the particular patient Availability of medications Emergency facilities
Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for
the particular patient Availability of medications Emergency facilities
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled β2-agonist
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serialmeasures of lung function
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled β2-agonist
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serialmeasures of lung function
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention ProgramAsthma Management and Prevention Program
Special ConsiderationsAsthma Management and Prevention ProgramAsthma Management and Prevention Program
Special Considerations
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Global Strategy for
the Diagnosis and
Management of Asthma in Children 5 Years and Younger
2009
www.ginasthma.org
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication
The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication
The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary
http://www.ginasthma.orghttp://www.ginasthma.org