GINA Slideset 2013

8/12/2019 GINA Slideset 2013

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Global Initiative for Asthma

GLOBAL INITIATIVE FOR ASTHMA (GINA)

TEACHING SLIDE SET

January 2013

This slide set is restricted for academic andeducational purposes only. Use of the slide set,

or of individual slides, for commercial orpromotional purposes requires approval from

GINA.


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G

IN

A

lobal

itiative for

sthma



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GINA Program Objectives

Increase appreciation of asthma as a global public

health problem

Present key recommendations for diagnosis andmanagement 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



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Executive CommitteeChair: Mark FitzGerald, MD

DisseminationCommittee

Chair: L.B. Boulet, MD

GINA Structure

ScienceCommittee

Chair: Helen Reddel, MD



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GINA Board of Directors

M. FitzGerald, Chair, Canada

E. Bateman, S. Africa P. Paggario,Italy

L.P. Boulet, Canada S. Pedersen, Denmark

A. Cruz, Brazil H. Reddel, Australia

M. Haahtela, Finland M. Soto-Quiroz, Costa RicaM. Levy, U.K. G. Wong, Hong Kong ROC

P. OByrne, Canada



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GINA Science Committee

H. Reddel, Chair,Australia

N. Barnes, UK M. FitzGerald, Canada

P. Barnes, UK R. Lemanske, US

A. Becker, Canada P. OByrne, Canada

E. Bel, Netherlands E. Pizzichini, Brazil

J. DeJongste, Netherlands S. Pedersen, Denmark

J. Drazen, US H. Reddel,Australia



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Executive CommitteeChair: Mark FitzGerald, MD

DisseminationCommittee

Chair: L.P. Boulet, MD

GINA Structure

ScienceCommittee

Chair: H. Reddel, MD

GINA ASSEMBLY Global Initiative for Asthma


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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 tomeet with the GINA Executive Committee

during the ATS and ERS meetings



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United States

United Kingdom

Argentina

AustraliaBrazil

AustriaCanada

Chile

Belgium

China

Denmark

Colombia

Croatia

Germany

Greece

Ireland

Italy

Syria

Hong Kong ROC

Japan

India

Korea

Kyrgyzstan

Moldova

Macedonia

Malta

Netherlands

New Zealand

Poland

Portugal

Georgia

Romania

Russia

SingaporeSlovakia

Slovenia Saudi Arabia

South Afr ica

Spain

Sweden

Thailand

Switzerland

Ukraine

Taiwan

Venezuela

Vietnam

Yugoslavia

Albania

Bangladesh

France

Mexico

Turkey CzechRepublic

Lebanon Pakistan

GINA Assembly

Israel

Philippines

Cambodia

Mongolia

Egypt


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GINA Documents

Global Strategy for Asthma Management andPrevention (updated 2012)

Pocket Guide: Asthma Management and Prevention

(updated 2012)

Global Strategy for Asthma Management andPrevention 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



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Global Strategy for Asthma

Management and Prevention

Evidence-based

Implementation oriented

Diagnosis

Management

PreventionOutcomes can be evaluated



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Management and Prevention

Evidence Category Sources of Evidence

A Randomized clinical trials

Rich body of data

B Randomized clinical trialsLimited body of data

C Non-randomized trialsObservational studies

D Panel judgment consensus Global Initiative for Asthma


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Management and Prevention (2012)

Definition and Overview

Diagnosis and Classification

Asthma Medications

Asthma Management andPrevention Program

Implementation of AsthmaGuidelines in HealthSystems

Updated 2012



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Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airwayhyperresponsiveness that leads to recurrentepisodes of wheezing, breathlessness, chesttightness, and coughing

Widespread, variable, and often reversibleairflow limitation



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Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation


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Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators


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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



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Burden of Asthma

Health care expenditures very high

Developed economies might expect to

spend 1-2 percent of total health careexpenditures 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



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Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004


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Countries should enter theirown data on burden of

asthma.


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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 topersist



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Factors that Exacerbate Asthma

Allergens

Respiratory infections

Exercise and hyperventilation

Weather changes

Sulfur dioxide Food, additives, drugs



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Factors that Influence Asthma

Development and Expression

Host Factors

Genetic

- Atopy- Airway

hyperresponsiveness

Gender

Obesity

Environmental Factors

Indoor allergens

Outdoor allergensOccupational sensitizers

Tobacco smoke

Air Pollution

Respiratory InfectionsDiet



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Is it Asthma?

Recurrent episodes of wheezing

Troublesome cough at night

Cough or wheeze after exercise

Cough, wheeze or chest tightnessafter exposure to airborne allergensor pollutants

Colds go to the chestor take morethan 10 days to clear



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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 diagnoseasthma in children 5 years and younger and theelderly



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Typical Spirometric (FEV1)Tracings

1Time (sec)

2 3 4 5

FEV1

Volume

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

Note: Each FEV1curve represents the highest of three repeat measurements



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Measuring Variability of PeakExpiratory Flow


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Measuring Airway Responsiveness



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1. Develop Patient/DoctorPartnership

2. Identify and Reduce Exposureto Risk Factors

3.Assess, Treat and MonitorAsthma

4. Manage Asthma Exacerbations

5. Special Considerations

Asthma Management and PreventionProgram: Five Components

Updated 2012



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Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, includingexercise

Maintain pulmonary function as close tonormal levels as possible

Prevent asthma exacerbations

Avoid adverse effects from asthmamedications

Prevent asthma mortality Global Initiative for Asthma


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Asthma Management and PreventionProgram: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure toRisk Factors

3.Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations Global Initiative for Asthma


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Asthma can be effectively controlled in

most patients by intervening to suppress

and reverse inflammation as well astreating bronchoconstriction and related

symptoms

Early intervention to stop exposure to therisk factors that sensitized the airway may

help improve the control of asthma and

reduce medication needs.

.



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Although there is no cure for asthma,appropriate management that includes

a partnership between the physicianand the patient/family most oftenresults in the achievement of control




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Part 1: Educate Patients to

Develop a Partnership

Guidelines on asthma management

should be available but adapted and

adopted for local use by local asthmaplanning teams

Clear communication between health

care professionals and asthma patientsis key to enhancing compliance




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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

patients family Global Initiative for Asthma



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Component 1: Develop

Patient/Doctor Partnership

Key factors to facilitate communication:

Friendly demeanor

Interactive dialogue

Encouragement and praise

Provide appropriate information

Feedback and review



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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

I f you answered YES to thr ee or more of these questions, your asthma is uncontr olled 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.



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Factors Involved in Non-Adherence

Medication Usage

Difficulties associatedwith inhalers

Complicated regimens

Fears about, or actualside effects

Cost

Distance to pharmacies

Non-Medication Factors

Misunderstanding/lack of

information Fears about side-effects

Inappropriate expectations

Underestimation of severityAttitudes toward ill health

Cultural factors

Poor communication Global Initiative for Asthma

A th M t d P ti P


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Component 2: Identify and ReduceExposure 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. Global Initiative for Asthma

A th M t d P ti P


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Reduce exposure to indoor allergens

Avoid tobacco smoke

Avoid vehicle emission

Identify irritants in the workplace

Explore role of infections on asthmadevelopment, especially in children andyoung infants


Component 2: Identify and ReduceExposure to Risk Factors



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Influenza Vaccination

Influenza vaccination should beprovided to patients with asthma whenvaccination of the general population is

advised

However, routine influenza vaccinationof children and adults with asthmadoes not appear to protect them fromasthma exacerbations or improveasthma control




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g g

Component 3: Assess, Treatand Monitor Asthma

The goal of asthma treatment, toachieve and maintain clinical

control, can be achieved in amajority of patients with apharmacologic intervention strategy

developed in partnership betweenthe patient/family and the healthcare professional



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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



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Levels of Asthma Control


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Levels of Asthma Control(Assess patient impairment)

Characteristic

Controlled

(All of the following)

Partly controlled

(Any present in any week) Uncontrolled

DaytimesymptomsTwice or less

per week

More than

twice per week

3 or more

features ofpartly

controlled

asthma

present in

any week

Limitations of

activitiesNone Any

Nocturnal symptoms

/ awakeningNone Any

Need for rescue /

reliever treatment

Twice or less

per week

More than

twice per week

Lung function

(PEF or FEV1)Normal

< 80% predicted or

personal best (if

known) on any day

Assessment of Future Risk (risk of exacerbations, instability, rapid

decline in lung function, side effects) Global Initiative for Asthma


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Assess Patient Risk

Features that are associated with increasedrisk of adverse events in the future include:

Poor clinical control

Frequent exacerbationsin past year

Ever admission to critical care for asthma

Low FEV1, exposure to cigarette smoke,high dose medications



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Depending on level of asthma control,the patient is assigned to one of fivetreatment steps

Treatment is adjusted in a continuouscycle driven by changes in asthmacontrol status. The cycle involves:

- Assessing Asthma Control

- Treating to Achieve Control

- Monitoring to Maintain Control Global Initiative for Asthma



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A stepwise approach to pharmacologicaltherapy is recommended

The aim is to accomplish the goals oftherapy with the least possible medication

Although in many countries traditionalmethods of healing are used, their efficacyhas not yet been established and their usecan therefore not be recommended




C 3 A T


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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




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Controller Medications

Inhaled glucocorticosteroids

Leukotriene modifiers

Long-acting inhaled 2-agonists in combinationwith inhaled glucocorticosteroids

Systemic glucocorticosteroids

Theophylline

Cromones

Anti-IgE


Estimate Comparative Daily Dosages for


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Estimate 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

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 80160 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



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Reliever Medications

Rapid-acting inhaled 2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral 2-agonists



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Component 4: Asthma Management and PreventionProgramAllergen-specific Immunotherapy

Greatest benefit of specific immunotherapyusing allergen extracts has been obtained inthe treatment of allergic rhinitis

The role of specific immunotherapy in asthma islimited

Specific immunotherapy should be consideredonly after strict environmental avoidance and

pharmacologic intervention, including inhaledglucocorticosteroids, have failed to controlasthma

Perform only by trained physician


E


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controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROL

maintain and find lowest

controlling step

consider stepping up to

gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTION

TREATMENT STEPS

REDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

REDUCE

INCRE

ASE



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Shaded green - preferred controller options

TO STEP 3 TREATMENT,SELECT ONE OR MORE:

TO STEP 4 TREATMENT,ADD EITHER


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TO STEP 4 TREATMENT,

ADD EITHER


SELECT ONE OR MORE:

T ti t A hi A th C t l


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Step 1 As-needed reliever medication

Patients with occasional daytime symptoms of

short duration A 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 2or higher)

Treating to Achieve Asthma Control



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ADD EITHER


SELECT ONE OR MORE:



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Step 2

Reliever medication plus a singlecontroller

A low-dose inhaled glucocorticosteroid is

recommended as the initial controller

treatment for patients of all ages (Evidence A)

Alternative controller medications includeleukotriene modifiers (Evidence A)

appropriate for patients unable/unwilling to

use inhaled glucocorticosteroids




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ADD EITHER


SELECT ONE OR MORE:



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Step 3

Reliever medication plus one or twocontrollers

For 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 usedas monotherapy

For children, increase to a medium-dose inhaled

glucocorticosteroid (Evidence A)





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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)




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SELECT ONE OR MORE:


ADD EITHER




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Step 4

Reliever medication plus two or morecontrollers

Selection of treatment at Step 4depends

on prior selections at Steps 2 and 3

Where possible, patients not controlled on

Step 3treatments should be referred to a

health professional with expertise in the

management of asthma





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Step 4

Reliever medication plus two or more controllers

Medium- 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 addedto medium- or high-dose inhaled

glucocorticosteroid combined with a long-acting

inhaled 2-agonist (Evidence B)




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TO STEP 3 TREATMENT,SELECT ONE OR MORE: TO STEP 4 TREATMENT,ADD EITHER




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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 severeside 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 Control


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When control as been achieved,ongoing monitoring is essential to:

-maintain control

-establish lowest step/dose treatment

Asthma control should be monitoredby the health care professional andby the patient




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Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose

inhaled glucocorticosteroids: 50% dosereduction at 3 month intervals (Evidence

B)

When controlled on low-dose inhaledglucocorticosteroids: switch to once-daily

dosing (Evidence A) Global Initiative for Asthma



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Stepping down treatment when asthma is controlled

When controlled on combination inhaledglucocorticosteroids and long-acting

inhaled 2-agonist, reduce dose of inhaledglucocorticosteroid by 50% whilecontinuing the long-acting 2-agonist(Evidence B)

If control is maintained, reduce to low-dose inhaled glucocorticosteroids andstop long-acting 2-agonist (Evidence D)




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Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-

acting inhaled 2-agonistbronchodilators provide temporaryrelief.

Need for repeated dosing over morethan one/two days signals need forpossible increase in controller therapy




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Stepping up treatment in response to loss of control Use of a combination rapid and long-acting

inhaled 2-agonist (e.g.,formoterol) and aninhaled glucocorticosteroid (e.g.,budesonide)in a single inhaler both as a controller andreliever is effecting in maintaining a high levelof asthma control and reduces exacerbations

(Evidence A) Doubling the dose of inhaled glucocortico-

steroids is not effective, and is notrecommended (Evidence A)



Component 4: Manage Asthma


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Exacerbations of asthma are episodes ofprogressive increase in shortness of breath,cough, wheezing, or chest tightness

Exacerbations are characterized by decreasesin expiratory airflow that can be quantified andmonitored by measurement of lung function

(FEV1or PEF) Severe exacerbations are potentially life-

threatening and treatment requires closesupervision


Exacerbations



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Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled2-agonist

Early introduction of systemicglucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serial

measures of lung function


Exacerbations




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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



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Global Strategyfor the Diagnosisand Management

of Asthma inChildren 5 Years

and Younger

2009

www.ginasthma.org


Asthma Management and


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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 thepatient/family most often results in theachievement of control


Prevention Program: Summary




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A stepwise approach to pharmacologictherapy is recommended. The aim is to

accomplish the goals of therapy with theleast possible medication

The availability of varying forms oftreatment, cultural preferences, anddiffering health care systems need to beconsidered

g

Prevention Program: Summary



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http://www.ginasthma.org



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