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G lobal
INitiative for
A sthma
Revised 2006
Juan Sancha-Cadiz 24 Mayo 2007
Novedades GINA 2006
• En la definición,clínica y patogenia
• Diagnóstico: clínico, funcional, alergológico y diagº
diferencial
• Clasificación : De etiología y gravedad ....al
CONTROL
• Tratamiento: Nuevo escalonamiento.Aumento de
protagonismo de los antileucotrienos
• Manejo y prevención: (5 componentes:
medico/paciente-factores de riesgovaloración/tto/monitorización del asma-manejo de
exacerbaciones-consideraciones especiales)
Definición
• Importancia de la variabilidad clínica
• La obstrucción y los síntomas son variables,
pero la inflamación siempre existe.
• Por primera vez se habla del ASMA
DIFICIL DE TRATAR: “Aquel que afecta a
pacientes relativamente insensibles a los
Glucocorticoides y por lo tanto difíciles de que
logren el mismo nivel de control con estos
fármacos, que otros pacientes”
Clasificación : De etiología y gravedad
....al CONTROL
• CONTROL DEL ASMA:
–
–
–
–
–
Ausencia de síntomas durante el día (=/< 2 v/s)
No limitación de actividades incluido ejercicio
Ausencia de síntomas y despertares nocturnos.
No uso de medicación de rescate (=/< 2 v/s)
Función pulmonar normal o cerca de la
normalidad
– Ausencia de exacerbaciones
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
Global Strategy for Asthma
Management and Prevention
 Evidence-based
 Implementation oriented
Diagnosis
Management
Prevention
 Outcomes can be evaluated
Global 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
Definition 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
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
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
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
Factors 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
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Diet
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
Clinical Control of Asthma
 No (or minimal)* daytime symptoms
 No limitations of activity
 No nocturnal symptoms
 No (or minimal) need for rescue medication
 Normal lung function
 No exacerbations
_________
* Minimal = twice or less per week
Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure
to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma Exacerbations
Revised 2006
5. Special Considerations
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.
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

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 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
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
Levels of Asthma Control
Partly controlled
Characteristic
Controlled
Daytime symptoms
None (2 or less /
week)
More than
twice / week
Limitations of
activities
None
Any
Nocturnal
symptoms /
awakening
None
Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation
None
One or more / year
(Any present in any week)
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any week
Component 4: Asthma Management and Prevention Program
Controller Medications









Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β2-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral β2-agonists
Anti-IgE
Systemic glucocorticosteroids
Component 4: Asthma Management and Prevention Program
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

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
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest
controlling step
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
step up until controlled
treat as exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
1
2
3
4
5
Treating to Achieve Asthma Control
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
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
Nivel central
A ver si vas
acabando
Juanito
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled longacting 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
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 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 lowdose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
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 glucocorticosteroids is not effective, and is not
recommended (Evidence A)
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
 Long-term treatment with inhaled
glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
 Studies including a total of over 3,500
children treated for periods of 1 – 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
 Rapid-acting inhaled β2-agonists are the
most effective reliever therapy for
children
 These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
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
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations
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 serial
measures of lung function
Hasta la próxima amigos
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