Global Initiative for AsthmaGLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SETJanuary 2013

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G IN Alobal itiative for sthma Global Initiative for Asthma

GINA Program ObjectivesIncrease appreciation of asthma as a global public health problemPresent key recommendations for diagnosis and management of asthmaProvide strategies to adapt recommendations to varying health needs, services, and resourcesIdentify areas for future investigation of particular significance to the global community

Global Initiative for Asthma

Executive CommitteeChair: Mark FitzGerald, MD

Dissemination CommitteeChair: L.B. Boulet, MDGINA StructureScience CommitteeChair: Helen Reddel, MD Global Initiative for Asthma

GINA Board of DirectorsM. FitzGerald, Chair, CanadaE. Bateman, S. Africa P. Paggario, ItalyL.P. Boulet, Canada S. Pedersen, Denmark A. Cruz, Brazil H. Reddel, Australia M. Haahtela, Finland M. Soto-Quiroz, Costa Rica M. Levy, U.K. G. Wong, Hong Kong ROCP. OByrne, Canada Global Initiative for Asthma

GINA Science CommitteeH. Reddel, Chair, AustraliaN. Barnes, UK M. FitzGerald, CanadaP. Barnes, UK R. Lemanske, US A. Becker, Canada P. OByrne, CanadaE. Bel, NetherlandsE. Pizzichini, BrazilJ. DeJongste, NetherlandsS. Pedersen, DenmarkJ. Drazen, USH. Reddel, Australia

Global Initiative for Asthma

Executive CommitteeChair: Mark FitzGerald, MD

Dissemination CommitteeChair: L.P. Boulet, MDGINA StructureScience CommitteeChair: H. Reddel, MDGINA ASSEMBLY Global Initiative for Asthma

GINA AssemblyA network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional levelGINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings Global Initiative for Asthma

United StatesUnited KingdomArgentinaAustraliaBrazilAustriaCanadaChileBelgiumChinaDenmarkColombiaCroatiaGermanyGreeceIrelandItalySyriaHong Kong ROCJapanIndiaKoreaKyrgyzstanMoldovaMacedoniaMaltaNetherlandsNew ZealandPolandPortugalGeorgiaRomaniaRussiaSingaporeSlovakiaSloveniaSaudi ArabiaSouth AfricaSpainSwedenThailandSwitzerlandUkraineTaiwanVenezuelaVietnamYugoslaviaAlbaniaBangladeshFranceMexicoTurkeyCzech RepublicLebanonPakistanGINA AssemblyIsraelPhilippinesCambodiaMongoliaEgypt

GINA DocumentsGlobal Strategy for Asthma Management and Prevention (updated 2012)Pocket Guide: Asthma Management and Prevention (updated 2012)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 familiesAll materials are available on GINA web site www.ginasthma.org Global Initiative for Asthma

Global Strategy for Asthma Management and Prevention Evidence-based Implementation oriented Diagnosis Management Prevention Outcomes can be evaluated Global Initiative for Asthma

Global Strategy for Asthma Management and PreventionEvidence 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 Initiative for Asthma

Global Strategy for Asthma Management and Prevention (2012)Definition and OverviewDiagnosis and ClassificationAsthma MedicationsAsthma Management and Prevention ProgramImplementation of Asthma Guidelines in Health SystemsUpdated 2012 Global Initiative for Asthma

Definition of AsthmaA chronic inflammatory disorder of the airwaysMany cells and cellular elements play a roleChronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughingWidespread, variable, and often reversible airflow limitation Global Initiative for Asthma

Source: Peter J. Barnes, MDAsthma Inflammation: Cells and Mediators

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MDAsthma Inflammation: Cells and Mediators

Burden of AsthmaAsthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individualsPrevalence increasing in many countries, especially in childrenA major cause of school/work absence Global Initiative for Asthma

Burden of AsthmaHealth care expenditures very highDeveloped economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demandPoorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care Global Initiative for Asthma

Asthma Prevalence and MortalitySource: Masoli M et al. Allergy 2004

Countries should enter their own data on burden of asthma.

Risk Factors for AsthmaHost factors: predispose individuals to, or protect them from, developing asthmaEnvironmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Global Initiative for Asthma

Factors that Exacerbate AsthmaAllergensRespiratory infectionsExercise and hyperventilationWeather changesSulfur dioxideFood, additives, drugs Global Initiative for Asthma

Factors that Influence Asthma Development and ExpressionHost FactorsGenetic - Atopy - Airway hyperresponsiveness GenderObesityEnvironmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet Global Initiative for Asthma

Is it Asthma?Recurrent episodes of wheezingTroublesome cough at nightCough or wheeze after exerciseCough, wheeze or chest tightness after exposure to airborne allergens or pollutantsColds go to the chest or take more than 10 days to clear Global Initiative for Asthma

Asthma DiagnosisHistory and patterns of symptomsMeasurements of lung function - Spirometry - Peak expiratory flowMeasurement of airway responsiveness Measurements of allergic status to identify risk factorsExtra measures may be required to diagnose asthma in children 5 years and younger and the elderly Global Initiative for Asthma

Typical Spirometric (FEV1) Tracings1Time (sec)2345FEV1VolumeNormal SubjectAsthmatic (After Bronchodilator)Asthmatic (Before Bronchodilator)Note: Each FEV1 curve represents the highest of three repeat measurements Global Initiative for Asthma

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness Global Initiative for Asthma

1. Develop Patient/Doctor Partnership2. Identify and Reduce Exposure to Risk Factors3. Assess, Treat and Monitor Asthma4. Manage Asthma Exacerbations5. Special ConsiderationsAsthma Management and PreventionProgram: Five Components Global Initiative for Asthma

Asthma Management and Prevention ProgramGoals of Long-term ManagementAchieve and maintain control of symptomsMaintain normal activity levels, including exerciseMaintain pulmonary function as close to normal levels as possiblePrevent asthma exacerbationsAvoid adverse effects from asthma medicationsPrevent asthma mortality Global Initiative for Asthma

Asthma Management and Prevention Program: Five Interrelated Components1. Develop Patient/Doctor Partnership2. Identify and Reduce Exposure to Risk Factors3. Assess, Treat and Monitor Asthma4. Manage Asthma Exacerbations5. Special Considerations Global Initiative for Asthma

Asthma Management and Prevention ProgramAsthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptomsEarly intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.. Global Initiative for Asthma

Asthma Management and Prevention ProgramAlthough 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

Global Initiative for Asthma

Asthma Management and Prevention ProgramPart 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 teamsClear communication between health care professionals and asthma patients is key to enhancing compliance Global Initiative for Asthma

Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership Educate continuallyInclude the familyProvide information about asthmaProvide training on self-management skillsEmphasize a partnership among health care providers, the patient, and the patients family Global Initiative for Asthma

Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor PartnershipKey factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review

Global Initiative for Asthma

Global Initiative for Asthma

Example Of Contents Of An Action Plan To Maintain Asthma ControlYour 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 ? NoYes Activity or exercise limited by asthma? NoYes Waking at night because of asthma? NoYes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? NoYesIf 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 dont 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 ProgramFactors Involved in Non-AdherenceMedication UsageDifficulties associated with inhalersComplicated regimensFears about, or actual side effectsCostDistance to pharmaciesNon-Medication FactorsMisunderstanding/lack of informationFears about side-effects Inappropriate expectationsUnderestimation of severityAttitudes toward ill healthCultural factorsPoor communication Global Initiative for Asthma

Asthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk FactorsMeasures 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. Global Initiative for Asthma

Reduce exposure to indoor allergensAvoid tobacco smokeAvoid vehicle emissionIdentify irritants in the workplaceExplore role of infections on asthma development, especially in children and young infantsAsthma Management and Prevention ProgramComponent 2: Identify and Reduce Exposure to Risk Factors Global Initiative for Asthma

Asthma Management and Prevention ProgramInfluenza VaccinationInfluenza vaccination should be provided to patients with asthma when vaccination of the general population is advisedHowever, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control Global Initiative for Asthma

Asthma Management and Prevention ProgramComponent 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 Global Initiative for Asthma

Global Strategy for Asthma Management and PreventionClinical Control of AsthmaThe focus on asthma control isimportant because:the attainment of control correlates with a better quality of life, and reduction in health care use Global Initiative for Asthma

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 PreventionClinical Control of Asthma Global Initiative for Asthma

Levels of Asthma Control(Assess patient impairment)

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects) Global Initiative for Asthma

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 asthmaLow FEV1, exposure to cigarette smoke, high dose medications Global Initiative for Asthma

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 medicationsAny exacerbation should prompt review of maintenance treatment Global Initiative for Asthma

Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor AsthmaDepending on level of asthma control, the patient is assigned to one of five treatment stepsTreatment 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 Global Initiative for Asthma

A stepwise approach to pharmacological therapy is recommended The aim is to accomplish the goals of therapy with the least possible medicationAlthough in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommendedAsthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma Global Initiative for Asthma

The choice of treatment should be guided by: Level of asthma controlCurrent treatmentPharmacological properties and availability of the various forms of asthma treatmentEconomic considerationsCultural preferences and differing health caresystems need to be considered

Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma Global Initiative for Asthma

Controller Medications Inhaled glucocorticosteroids Leukotriene modifiersLong-acting inhaled 2-agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE Global Initiative for Asthma

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeDrug 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 Global Initiative for Asthma

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide200-600 100-200 600-1000 >200-400 >1000 >400 Budesonide-Neb Inhalation Suspension 250-500 500-1000 >1000 Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320Flunisolide500-1000 500-750 >1000-2000 >750-1250 >2000 >1250 Fluticasone100-250 100-200 >250-500 >200-500 >500 >500 Mometasone furoate200-400 100-200 > 400-800 >200-400>800-1200 >400Triamcinolone acetonide400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

Reliever Medications Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral 2-agonists

Global Initiative for Asthma

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 rhinitisThe role of specific immunotherapy in asthma is limitedSpecific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthmaPerform only by trained physician Global Initiative for Asthma

Global Initiative for Asthma

Shaded green - preferred controller options Global Initiative for Asthma

Shaded green - preferred controller optionsTO STEP 4 TREATMENT, ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global Initiative for Asthma

Step 1 As-needed reliever medicationPatients with occasional daytime symptoms of short durationA rapid-acting inhaled 2-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 Global Initiative for Asthma

Shaded green - preferred controller optionsTO STEP 4 TREATMENT, ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global Initiative for Asthma

Step 2 Reliever medication plus a single controllerA 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 glucocorticosteroidsTreating to Achieve Asthma Control Global Initiative for Asthma

Shaded green - preferred controller optionsTO STEP 4 TREATMENT, ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global Initiative for Asthma

Step 3 Reliever medication plus one or two controllersFor adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting 2-agonist either in a combination inhaler device or as separate components (Evidence A) Inhaled long-acting 2-agonist must not be used as monotherapy For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)Treating to Achieve Asthma Control Global Initiative for Asthma

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 Global Initiative for Asthma

Shaded green - preferred controller options Global Initiative for Asthma

Step 4 Reliever medication plus two or more controllersSelection of treatment at Step 4 depends on prior selections at Steps 2 and 3Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthmaTreating to Achieve Asthma Control Global Initiative for Asthma

Step 4 Reliever medication plus two or more controllersMedium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-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 2-agonist (Evidence B)Treating to Achieve Asthma Control Global Initiative for Asthma

Shaded green - preferred controller options Global Initiative for Asthma

Treating to Achieve Asthma ControlStep 5 Reliever medication plus additional controller optionsAddition 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) Global Initiative for Asthma

Treating to Maintain Asthma ControlWhen 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 Global Initiative for Asthma

Treating to Maintain Asthma ControlStepping down treatment when asthma is controlledWhen 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) Global Initiative for Asthma

Treating to Maintain Asthma ControlStepping down treatment when asthma is controlledWhen controlled on combination inhaled glucocorticosteroids and long-acting inhaled 2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting 2-agonist (Evidence B)If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting 2-agonist (Evidence D) Global Initiative for Asthma

Treating to Maintain Asthma ControlStepping up treatment in response to loss of controlRapid-onset, short-acting or long-acting inhaled 2-agonist bronchodilators provide temporary relief.Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy Global Initiative for Asthma

Treating to Maintain Asthma ControlStepping up treatment in response to loss of controlUse of a combination rapid and long-acting inhaled 2-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) Global Initiative for Asthma

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightnessExacerbations 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 supervisionAsthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations Global Initiative for Asthma

Asthma Management and Prevention ProgramComponent 4: Manage Asthma ExacerbationsTreatment of exacerbations depends on:The patientExperience of the health care professionalTherapies that are the most effective for the particular patientAvailability of medicationsEmergency facilities Global Initiative for Asthma

Primary therapies for exacerbations:Repetitive administration of rapid-acting inhaled 2-agonistEarly introduction of systemic glucocorticosteroidsOxygen supplementationClosely monitor response to treatment with serialmeasures of lung function

Asthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations Global Initiative for Asthma

Asthma Management and Prevention ProgramSpecial ConsiderationsSpecial considerations are required tomanage asthma in relation to:PregnancySurgeryRhinitis, sinusitis, and nasal polypsOccupational asthmaRespiratory infectionsGastroesophageal refluxAspirin-induced asthmaAnaphylaxis and Asthma Global Initiative for Asthma

Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger2009

www.ginasthma.org Global Initiative for Asthma

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptomsAlthough 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 controlAsthma Management and Prevention Program: Summary Global Initiative for Asthma

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: Summary Global Initiative for Asthma

http://www.ginasthma.org Global Initiative for Asthma

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