Download Step 3

G lobal
INitiative for
A sthma
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
GINA Structure
Executive Committee
Chair: Paul O’Byrne, MD
Science
Dissemination/Implementation
Committee
Task Group
Chair: Eric Bateman, MD
Chair: Wan Tan, MD
GINA Executive Committee
P. O’Byrne, Chair, Canada
E. Bateman, S. Africa
J. Bousquet, France
T. Clark, UK
K. Ohta, Japan
P. Paggario, Italy
S. Pedersen, Denmark
R. Singh, India
M. Soto-Quiroz, Costa Rica
W. Tan, Canada
GINA Science Committee
E. Bateman, Chair, S. Africa
P. Barnes, UK
J. Bousquet, France
J. Drazen, US
M. FitzGerald, Canada
P. Gibson, Australia
P. O’Byrne, Canada
K. Ohta, Japan
S. Pedersen, Denmark
E. Pizzichini, Brazil
S. Sullivan, US
S. Wenzel, US
H. Zar, S. Africa
GINA Structure
Executive Committee
Chair: Paul O’Byrne, MD
Science
Dissemination/Implementation
Committee
Task Group
Chair: Eric Bateman, MD
Chair: Wan Tan, MD
GINA ASSEMBLY
GINA 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
Saudi Arabia
Bangladesh
Slovenia
Germany
Ireland
Yugoslavia Croatia
Australia
Canada
Brazil
Austria
Taiwan ROC
United States
Thailand Portugal
Malta
Greece
Mexico
Moldova
China
Syria
South Africa
United Kingdom
Hong Kong ROC
New Zealand
Italy
Argentina
Pakistan
Lebanon
Guatemala
Poland Korea
Switzerland
Turkey
India
GINA Assembly
Russia
Czech Republic
Chile
Venezuela
Macedonia
France
Belgium
Slovakia
Japan
Netherlands
Georgia
Denmark
Singapore Spain
Costa Rica
Ukraine
Sweden
Kyrgyzstan Vietnam
Albania
Romania
GINA Documents
 Global Strategy for Asthma Management
and Prevention (revised 2006)
 Pocket Guide: Asthma Management and
Prevention
(revised 2006)
 Pocket Guide: Asthma Management and
Prevention in Children (revised 2006)
 Guide for asthma patients and families
All materials are available on GINA web site www.ginasthma.org
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
Global Strategy for Asthma
Management and Prevention (2006)
Definition and Overview
 Diagnosis and
Classification
 Asthma Medications
 Asthma Management and
Prevention Program
 Implementation of Asthma
Guidelines in Health
Systems

Revised 2006
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
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, MD
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
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
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
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
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
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
1
2
3
4
Time (sec)
5
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak
Expiratory Flow
Measuring Airway Responsiveness
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
Levels of Asthma Control
Characteristic
Controlled
Partly controlled
(All of the following)
(Any present in any week)
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
Uncontrolled
3 or more
features of
partly
controlled
asthma
present in
any week
1 in any 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: 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
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

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 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
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 TREATMENT
Assess your level of Asthma Control
In 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
Yes
If 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 TREATMENT
STEP-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 CONTROL
If 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-Adherence
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
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
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

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
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
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 care
systems need to be considered
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
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug
Low Daily Dose (g)
> 5 y Age < 5 y
Medium Daily Dose (g)
> 5 y Age < 5 y
Beclomethasone
200-500
100-200
>500-1000
>200-400
Budesonide
200-600
100-200
600-1000
>200-400
Budesonide-Neb
Inhalation Suspension
Ciclesonide
250-500
80 – 160
High Daily Dose (g)
> 5 y Age < 5 y
>1000
>1000
>500-1000
>400
>400
>1000
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
Triamcinolone acetonide
400-1000
400-800
>1000-2000
>800-1200
>2000
>400
>1200
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
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 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 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
 Rapid-onset, short-acting or longacting 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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
Childhood and adult asthma share the
same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ
from those in adults.
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger
Many asthma medications (e.g.
glucocorticosteroids, β2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
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
 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 lifethreatening and treatment requires close
supervision
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
Asthma Management and Prevention Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
 Anaphylaxis and Asthma
Asthma Management and
Prevention Program: Summary


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: 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
http://www.ginasthma.org
Alternate Slides for
Asthma Treatment
Levels of Asthma Control
Characteristic
Controlled
(All of the
following)
Partly Controlled
(Any measure
present in any week)
Daytime symptoms
None (twice or less/week)
More than twice/week
Limitations of
activities
None
Any
Nocturnal
symptoms/awakening
None
Any
Need for reliever/
rescue treatment
None (twice or less/week)
More than twice/week
Lung function (PEF or
FEV1)
Normal
< 80% predicted or
personal best (if known)
Exacerbations
None
One or more/year*
Uncontrolled
Three or more
features of
partly controlled
asthma present
in any week
One in any week†
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
† By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Asthma Control: Treatment Steps
Children Older than Five Years, Adolescents, Adults
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 TREATMENT
Assess your level of Asthma Control
In 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
Yes
If 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 TREATMENT
STEP-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 CONTROL
If 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.