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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
Global Initiative for Asthma
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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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Global Strategy for Asthma
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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Global Strategy for Asthma
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 Management andPrevention Program
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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Asthma Management andPrevention Program
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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Asthma Management and Prevention Program
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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 asthmaplanning teams
Clear communication between health
care professionals and asthma patientsis key to enhancing compliance
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Asthma Management and Prevention Program
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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
patients family Global Initiative for Asthma
Asthma Management and Prevention Program
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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
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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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Asthma Management and Prevention Program
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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Asthma Management and Prevention Program
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
Asthma Management and Prevention Program
Component 2: Identify and ReduceExposure to Risk Factors
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Asthma Management and Prevention Program
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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Asthma Management and Prevention Program
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Component 3: Assess, Treatand Monitor Asthma
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
Component 3: Assess, Treatand Monitor Asthma
Global Initiative for Asthma
Asthma Management and Prevention Program
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
Component 3: Assess, Treatand Monitor Asthma
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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
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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
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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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Shaded green - preferred controller options
TO STEP 4 TREATMENT,
ADD EITHER
TO STEP 3 TREATMENT,
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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Shaded green - preferred controller options
TO STEP 4 TREATMENT,
ADD EITHER
TO STEP 3 TREATMENT,
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
Treating to Achieve Asthma Control
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Shaded green - preferred controller options
TO STEP 4 TREATMENT,
ADD EITHER
TO STEP 3 TREATMENT,
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)
Treating to Achieve Asthma Control
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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)
Treating to Achieve Asthma Control
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TO STEP 3 TREATMENT,
SELECT ONE OR MORE:
TO STEP 4 TREATMENT,
ADD EITHER
Shaded green - preferred controller options
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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
Treating to Achieve Asthma Control
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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)
Treating to Achieve Asthma Control
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TO STEP 3 TREATMENT,SELECT ONE OR MORE: TO STEP 4 TREATMENT,ADD EITHER
Shaded green - preferred controller options
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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 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
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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 monitoredby the health care professional andby the patient
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Treating to Maintain Asthma Control
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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Treating to Maintain Asthma Control
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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Treating to Maintain Asthma Control
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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Treating to Maintain Asthma Control
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)
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Asthma Management and Prevention Program
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
Component 4: Manage Asthma
Exacerbations
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Asthma Management and Prevention Program
Component 4: Manage Asthma
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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
Component 4: Manage Asthma
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
Global Initiative for Asthma
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
Asthma Management and
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
Global Initiative for Asthma
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