Real Life Practice in

Asthma Management
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Current asthma guideline

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Definition of asthma
Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation
It is defined by the chestPMK
history of respiratory airway
symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time
and in intensity, together with variable
expiratory airflow limitation

GINA 2014

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?Asthma?

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GINA 2014, Box 1-1

Global Initiative for Asthma

Asthma Dx

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12% &
200 ml

Asthma

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Mechanisms Underlying the

Definition of Asthma
Risk Factors
(for development of asthma)

INFLAMMATION
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Airway
Hyperresponsiveness

Risk Factors
(for exacerbations)

Airflow Obstruction

Symptoms

Asthma treatment

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GINA 2015 changes to Steps 4 and 5

STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE

STEP 1

STEP 2

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Low dose ICS

Other
controller
options

RELIEVER

Consider low
dose ICS

Leukotriene receptor antagonists (LTRA)

Low dose theophylline*

As-needed short-acting beta2-agonist (SABA)

STEP 3

Low dose
ICS/LABA*

Med/high
ICS/LABA

Med/high dose ICS Add tiotropium#

Low dose ICS+LTRA High dose ICS
+ LTRA
(or + theoph*)
(or + theoph*)

Refer for
add-on
treatment
e.g.
anti-IgE

Add
tiotropium#
Add low
dose OCS

As-needed SABA or
low dose ICS/formoterol**

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of exacerbations;
it is not indicated in children <18 years.

GINA 2015, Box 3-5, Steps 4 and 5

Global Initiative for Asthma

ICS for asthma

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WELL CONTROLLED asthma

during Phase I

* P = 0.039
**P < 0.001

FP Phase I

Patients (%)

SFC Phase I

80
71%*

69%**

65%
60

52%

51%**

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40

33%

20

Steroid-naive (S1)

Low-dose ICS (S2)

Moderate-dose ICS (S3)

Bateman ED et al. The Gaining Optimal Asthma ControL Study. Am J Respir Crit Care Med 2004;170:836-44.

TOTAL CONTROL during Phase I

% of patients achieving
TOTAL CONTROL

FP Phase I
SFC Phase I

80

*P < 0.001

60
42%*

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40

32%*

31%
20%

20

19%*

8%
0

Steroid-naive (S1)

Low-dose ICS (S2)

Moderate-dose ICS (S3)

Bateman ED et al. The Gaining Optimal Asthma ControL Study. Am J Respir Crit Care Med 2004;170:836-44.

Time to achieve
*
Well-Controlled asthma

FP

SFC

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Week 2

Week 7

10

The week by which 50% of patients achieved their first WELL-CONTROLLED week
Patients previously on low-dose ICS (stratum 2)
*Well controlled defined as achieving at least 2 of the following 3 criteria every week; daytime symptoms < 2 days/week with
symptom score >1, use of rescue beta2 agonist for < 2 days/week and < 4 occasions/week or morning PEF>80% predicted
every day plus achieving all other criteria from GINA and NIH guidelines for at least 7 out of 8 weeks
Bateman et al. AJRCCM. 2004;170:83644

Time to achieve Total Control

FP

SFC

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Week 21

12

16

Week 45

20

24

28

32

36

40

44

The week by which 50% of patients achieved their first TOTAL CONTROL week
Patients previously on low-dose ICS (stratum 2)
*Total control defined as experiencing none of the 7 listed symptoms from GINA and NIH guidelines
for at least 7 out of 8 weeks
Bateman et al. AJRCCM. 2004;170:83644

48

52

HOW TO ASSESS ASTHMA CONTROL

1
2
3
4

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Global Initiative for Asthma

The control-based asthma management cycle

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GINA 2014, Box 3-2

Global Initiative for Asthma

INITIAL CONTROLLER TREATMENT

Regular low dose ICS is recommended for patients
with any of the following:
Asthma symptoms more than twice a month
Waking due to asthma more than once a month
Any asthma symptoms + any risk factor(s) for
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exacerbations ; (e.g.
needing OCS for asthma within
the last 12 months; low FEV1 or ever in ICU for
asthma
Consider starting at a higher step (e.g. medium/high
dose ICS, or ICS/LABA) if the patient
Has troublesome asthma symptoms on most days
Waking from asthma once or more a week, especially
if there are any risk factors for exacerbations.

Initial controller treatment

Before starting initial controller treatment
Record evidence for diagnosis of asthma, if possible
Record symptom control and risk factors, including
lung function
Consider factors affecting choice of treatment for
this patient
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Ensure that the patient
can use the inhaler correctly
Schedule an appointment for a follow-up visit
After starting initial controller treatment
Review response after 2-3 months, or according to
clinical urgency
Adjust treatment (including non-pharmacological
treatments)
Consider stepping down when asthma has been wellcontrolled
for 3 months
GINA 2014, Box 3-4 (2/2)

General principles for stepping down

controller treatment
Aim
To find the lowest dose that controls symptoms and exacerbations, and minimizes the
risk of side-effects

When to consider stepping down

When symptoms have been well controlled and lung function stable for
3 months
No respiratory infection, patient not travelling, not pregnant

Prepare for step-down

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Record the level of symptom control and consider risk factors

Make sure the patient has a written asthma action plan
Book a follow-up visit in 1-3 months

Step down through available formulations

Stepping down ICS doses by 2550% at 3 month intervals is feasible and safe for most
patients
See GINA 2014 report Box 3-7 for specific step-down options

Stopping ICS is not recommended in adults with asthma

GINA 2014, Box 3-7

Time Course for the improvement

of different endpoints
No night symptoms
100

% improvement

FEV1

PEF am

No SABA use
AHR

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Days

Weeks

Months

Years

Woolcock, ERS 2000

FP/salmeterol
250/50

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282 pt
1:1:1

Changes in treatment and dose

throughout the study period

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21% (49/229)

73% (168/229)

5% (12/229)

Treatment received to achieve

control
Fluticasone
FP/salmeterol
Salmeterol

% of patients
100

75

33%

21%
Adjustment to
achieve and
maintain control

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34%

73%

50

25

34%
5%

Start of study
(n=282)

End of study (n=229)

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Continuing
improvements in
airway
hyperresponsive
ness indicate
the importance
of maintaining
treatment after
clinical control
of symptoms and
lung function
are achieved

Other changes for clarification in

GINA 2015 update
Assessment of risk factors: over-usage of SABA
High usage of SABA is a risk factor for exacerbations (Patel et al, CEA 2013)
Very high usage (e.g. >200 doses/month) is a risk factor for asthmarelated death (Haselkom, JACI 2009)
Beta-blockers and acute coronary events
If cardioselective beta-blockers are indicated for acute coronary
events, asthma is not an absolute contra-indication.
These medications should only
be used under close medical
supervision by a specialist,chestPMK
with consideration of the risks for and
against their use
Asthma-COPD Overlap Syndrome (ACOS)
The aims of the chapter are mainly to assist clinicians in primary
care and non-pulmonary specialties in diagnosing asthma and COPD as
well as ACOS, and to assist in choosing initial treatment for efficacy
and safety
A specific definition cannot be provided for ACOS at present, because
of the limited populations in which it has been studied
ACOS is not considered to represent a single disease; it is expected
that further research will identify several different underlying
mechanisms

Choosing between controller options

individual patient decisions
Decisions for individual patients
Use shared decision-making with the patient/parent/carer to discuss the following:

1. Preferred treatment for symptom control and for risk reduction

2. Patient characteristics (phenotype)
Does the patient have any known predictors of risk or response?
(e.g. smoker, history of exacerbations, blood eosinophilia)

3. Patient preference

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What are the patients goals and concerns for their asthma?

4. Practical issues
Inhaler technique - can the patient use the device correctly after training?
Adherence: how often is the patient likely to take the medication?
Cost: can the patient afford the medication?

GINA 2014, Box 3-3 (2/2) Provided by H Reddel

Global Initiative for Asthma

Device

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60
40

46
60
(100%)

20
0

14
(23%)

MDI
Turbuhaler
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100

61.7

80

60
40
20
0
MDI

75

34
51
26
(43%)

No
Yes

9
(15%)

Accuhaler Handihaler

72.7

66.7

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Fink JB, Tobin MJ, Dhand R. Bronchodilator therapy in mechanically ventilated

patients. Respir Care 1999;44[1]: 5369

Dyspnea

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asth
ma

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