G lobal INitiative for A sthma

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: Tim Clark, MD

Dissemination Committee
Chair: Martyn Partridge, MD

Science Committee
Chair: Paul OByrne, MD

GINA reports prepared during workshops conducted in cooperation with the U.S. National Heart, Lung, and Blood Institute, NIH and the World Health Organization.

GINA Sponsors
AstraZeneca
Aventis Bayer Byk Gulden Chiesi GlaxoSmithKline

Merck, Sharp & Dohme

Mitsubishi Pharma Nikken Chemicals Schering-Plough Sepracor Viatris Yamanouchi

Boehringer Ingelheim Novartis

Executive Committee
T. Clark, UK, Chair J. Bousquet, France W. Busse, USA S. Holgate, UK C. Lenfant, USA P. OByrne, Canada K. Ohta, Japan M. Partridge, UK S. Pedersen, Denmark R. Singh, India A. Sheffer, USA W. Tan, Singapore

Science Committee
P. OByrne, Canada, Chair P. Barnes, UK P. Gibson, Australia E. Bateman, S. Africa S. Holgate, UK J. Bousquet, France J. Kips, Belgium W. Busse, USA K. Ohta, Japan J. Drazen, USA S. Pedersen, Denmark M. FitzGerald, Canada E. von Mutius, Germany

Science Committee: Objectives

Develop methods to track and evaluate new scientific research on asthma Develop a process to evaluate impact of new scientific findings on GINA documents

Science Committee: Objectives (continued)

Identify a network of individuals to

serve as ongoing reviewers

With the Dissemination Committee, develop methods to disseminate new scientific findings that impact on GINA documents

Dissemination Committee
M. Partridge, UK, chair G. Anabwani, Botswana R. Beasley, N. Zealand H. Campos, Brazil Y. Chen, China F. Gallefoss, Norway M. Haida, Japan J. Khan, Pakistan R. Neville, UK A. Sheffer, USA J. Sinnadurai, Malaysia R. Singh, India W. Tan, Singapore R. Tomlins, Australia O. van Schyack, Netherlands H. Zar, S. Africa

Dissemination Committee: Objectives

Enhance dissemination of GINA reports
Ensure that all concerned with care of patients with asthma are knowledgeable about recommendations Evaluate methods to alter health professional behaviour Recommend methods to assess and monitor outcomes

GINA Documents
Workshop Report: Global Strategy for
Asthma Management and Prevention
(updated 2002)

Pocket guide for health care providers Pocket guide for management of pediatric
asthma (available mid-2002)

Guide for asthma patients and their

families
All materials are available on GINA web site www.ginasthma.com

GINA Workshop Report

Developed during workshops conducted in cooperation with the National Heart, Lung, and Blood Institute, NIH and the World Health Organization Evidence-based Implementation oriented Diagnosis Management Prevention Outcomes can be evaluated

GINA Workshop Report

Evidence Category Sources of Evidence

Randomized clinical trials Rich body of data Randomized clinical trials Limited body of data Non-randomized trials Observational studies Panel judgment consensus

B
C D

GINA Workshop Report

Topics:
Definition Burden of Asthma Risk Factors Mechanisms Diagnosis and Classification Education and Delivery of Care Six Part Asthma Management Plan Research Recommendations

Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role Chronic inflammation leads to an increase in airway hyperresponsiveness with recurrent episodes of wheezing, coughing, and shortness of breath

Widespread, variable, and often reversible airflow limitation

Definition of Asthma

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role
Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning

These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment

Mechanisms Underlying the Definition of Asthma

Risk Factors (for development of asthma)

INFLAMMATION
Airway Hyperresponsiveness Airflow Obstruction

Risk Factors (for exacerbations)

Symptoms

Burden of Asthma

Asthma is one of the most common chronic diseases worldwide

Prevalence increasing in many countries, especially in children A major cause of school/work absence

An overall increase in severity of asthma increases the pool of patients at risk for death

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

Worldwide Variation in Prevalence of Asthma Symptoms

International Study of Asthma and Allergies in Children (ISAAC)
Lancet 1998;351:1225

Increasing Prevalence of Asthma in Children/Adolescents

{1966 1989 Sweden {1979 1991 Japan {1982 1992 Scotland {1982 1992 UK {1989 1994 USA {1982 1992 New Zealand 1975 {1989 Australia {1982 1992
Finland
(Haahtela et al) (Aberg et al) (Nakagomi et al) (Rona et al)

(Omran et al)
(NHIS)

(Shaw et al)
(Peat et al)

10

15

20

25

30

35

Prevalence (%)

Countries should enter their own data on burden of asthma. The following three slides are US data on prevalence, hospitalization rates and mortality.

Trends in Prevalence of Asthma By Age, U.S., 1985-1996

80 70 60 50 40 30 20 85 86 87 88 89 90 91 92 93 94 Year 95 96 Rate/1,000 Persons

Age (years)
<18 18-44

45-64
65+ Total (All Ages)

Hospitalization Rates for Asthma

by Age, U.S., 1974 - 1997
Rate/100,000 Persons 40 35 <15 15-44 45-64 65+

30
25 20

15
10 5 0 74 76 78 80 82 84 86 Year 88 90 92 94 96

Death Rates for Asthma

By Race, Sex, U.S., 1980-1998
Rate/100,000 Persons 5 Black Female 4 3 White Female 2 1 0 1980 White Male Black Male

1985

1990 Year

1995

2000

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 Air Pollutants Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Risk Factors that Lead to Asthma Development

Host Factors
Genetic predisposition Atopy Airway hyperresponsiveness Gender Race/Ethnicity

Environmental Factors
Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Parasitic infections Socioeconomic factors Family size Diet and drugs Obesity

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

Physical examination

Measurements of lung function

Measurements of allergic status to identify risk factors

Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms STEP 4 Severe Persistent STEP 3 Continuous Limited physical activity Daily Attacks affect activity Nocturnal Symptoms FEV1 or PEF 60% predicted

Frequent

Variability > 30% 60 - 80% predicted

> 1 time week

Moderate Persistent STEP 2

Mild Persistent STEP 1 Intermittent

Variability > 30%

80% predicted

> 1 time a week but < 1 time a day < 1 time a week Asymptomatic and normal PEF between attacks

> 2 times a month

Variability 20 - 30%

2 times a month

80% predicted

Variability < 20%

The presence of one feature of severity is sufficient to place patient in that category.

Six-Part Asthma Management Program

1. Educate Patients

2. Assess and Monitor Severity

3. Avoid Exposure to Risk Factors 4. Establish Medication Plans for Chronic Management: Adults and Children 5. Establish Plans for Managing Exacerbations 6. Provide Regular Follow-up Care

Six-Part Asthma Management Program

1. Educate patients to develop a partnership in asthma management 2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible 3. Avoid exposure to risk factors 4. Establish medication plans for chronic management in children and adults 5. Establish individual plans for managing exacerbations 6. Provide regular follow-up care

Six-part Asthma Management Program

Goals of Long-term Management

Achieve and maintain control of symptoms Prevent asthma episodes or attacks Maintain pulmonary function as close to normal levels as possible Maintain normal activity levels, including exercise Avoid adverse effects from asthma medications Prevent development of irreversible airflow limitation Prevent asthma mortality

Six-part Asthma Management Program

Control of Asthma

Minimal (ideally no) chronic symptoms

Minimal (infrequent) exacerbations

No emergency visits Minimal (ideally no) need for as needed use of No limitations on activities, including exercise PEF circadian variation of less than 20 percent (Near) normal PEF Minimal (or no) adverse effects from medicine

2-agonist

Six-Part Asthma Management Program

The most effective management is to prevent airway inflammation by eliminating the causal factors Asthma can be effectively controlled in most patients, although it can not be cured The major factors contributing to asthma morbidity and mortality are underdiagnosis and inappropriate treatment

Six-Part Asthma Management Program

Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms

Six-part Asthma Management Program

Part 1: Educate Patients to Develop a Partnership Patient education involves a partnership between the patient and health care professional(s) with frequent revision and reinforcement
Aim is guided self-management giving patients the ability to control their asthma

Interventions, including use of written action plans, have been shown to reduce morbidity in both children and adults

Six-part Asthma Management 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 asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance

Six-part Asthma Management Program

Part 1: Educate Patients to Develop a 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

Six-part Asthma Management Program

Factors Associated with Non-Compliance in Asthma Care

Medication Usage

Patient/Physician
Misunderstanding/lack of information

Difficulties associated with inhalers

Complicated regimens
Fears about, or actual side effects

Underestimation of severity Attitudes toward ill health Cultural factors

Cost

Poor communication

Six-part Asthma Management Program

Part 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function
Symptom

reports

Use of reliever medication Nighttime symptoms Activity limitations

Spirometry

for initial assessment. Peak Expiratory Flow for

follow-up:

Assess severity Assess response to therapy

PEF

monitoring at home

Important for those with poor perception of symptoms Daily measurement recorded in a diary Assesses the severity and predicts worsening Guides the use of a zone system for asthma self-management

Arterial

blood gas for severe exacerbations

Typical Spirometric (FEV1) Tracings

Volume FEV1

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

2 3 4 Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements

A Simple Index of PEF Variation

800 700 600 500 400 300

Highest PEF (670)

PEF (L/min)

Lowest morning PEF (570)

Morning PEF Evening PEF

14

Days

Minimum morning PEF ( % recent best): 570/670 = 85%

(From Reddel, H.K. et al. 1995)

Six-part Asthma Management Program

Part 3: Avoid Exposure to Risk Factors Methods to prevent onset of asthma are not yet available but this remains an important goal Measures to reduce exposure to causes of asthma exacerbations (e.g. allergens, pollutants, foods and medications) should be implemented whenever possible

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
At present, inhaled glucocorticosteroids are the most effective controller medications and are recommended for persistent asthma at any step of severity Long-term treatment with inhaled glucocorticosteroids markedly reduces the frequency and severity of exacerbations

Six-part Asthma Management Program

Part 3: Avoid 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

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management

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

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy

The choice of treatment should be guided by:

Severity of the patients asthma

Patients 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.

Part 4: Long-term Asthma Management

Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids Systemic glucocorticosteroids Cromones Methylxanthines Long-acting inhaled 2-agonists Long-acting oral 2-agonists Leukotriene modifiers

Part 4: Long-term Asthma Management

Pharmacologic Therapy
Reliever Medications:

Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids

Anticholinergics
Methylxanthines Short-acting oral 2-agonists

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy - Adults

Outcome: Asthma Control
Outcome: Best Possible Results

Controller:

Controller: Controller:
None

Controller:
Daily inhaled corticosteroid

Daily inhaled corticosteroid Daily longacting inhaled 2-agonist

Daily inhaled corticosteroid Daily long acting inhaled 2-agonist plus (if needed)

When asthma is controlled, reduce therapy Monitor

-Theophylline-SR -Leukotriene -Long-acting inhaled 2- agonist -Oral corticosteroid

Reliever: Rapid-acting inhaled 2-agonist prn

STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down

Alternative controller and reliever medications may be considered (see text).

Recommended Asthma Medications Step 1: Adults

Severity Daily Controller Medications Other Options (in order of cost)
None

Step 1: None Intermittent

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 2: Adults

Severity
Step 2: Mild Persistent

Daily Controller Medications

Inhaled glucocorticosteroid (< 500 g BDP or equivalent)

Other Options (in order of cost)

Sustained-release theophylline, or Cromone, or Leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 3: Adults

Severity Step 3: Moderate persistent Daily Controller Medications Inhaled glucocorticosteroid (200 1000 g BDP or equivalent) plus long-acting inhaled 2- agonist Other Options (in order of cost) Inhaled glucocorticosteroid (500 1000 g BDP or equivalent) plus sustainedrelease theophylline, or Inhaled glucocorticosteroid (500 1000 g BDP or equivalent) plus long-acting inhaled 2- agonist, or Inhaled glucocorticosteroid at higher doses (> 1000 g BDP or equivalent), or Inhaled glucocorticosteroid (500 1000 g BDP or equivalent) plus leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 4: Adults

Severity Step 4 Severe persistent Daily Controller Medications Inhaled glucocorticosteroid ( > 1000 g BDP or equivalent) plus long-acting inhaled 2- agonist plus one or more of the following, if needed: - Sustained-release theophylline - Leukotriene modifier - Long-acting inhaled 2- agonist - Oral glucocorticosteroid Other Options

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Part 4: Long-term Asthma Management

Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

A number of questions must be addressed regarding the role of specific immunotherapy in asthma therapy

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

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
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.

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Many asthma medications (e.g. glucocorticosteroids, 2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
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

Six-part Asthma Management Program

Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Rapid-acting inhaled 2- 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

Recommended Asthma Medications Step 1: Children

Severity Daily Controller Medications Other Options (in order of cost)
None

Step 1: None Intermittent

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 2: Children

Severity
Step 2: Mild Persistent

Daily Controller Medications

Inhaled glucocorticosteroid (100 400 g budesonide or equivalent)

Other Options (in order of cost)

Sustained-release theophylline, or Cromone, or

Leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 3: Children

Severity Daily Controller Medications Other Options (in order of cost)

Step 3: Moderate persistent

Inhaled glucocorticosteroid Inhaled glucocorticosteroid (< 800 g ( 400 800 g budesonide budesonide or equivalent) plus sustained-release theophylline, or or equivalent) Inhaled glucocorticosteroid (< 800 g budesonide or equivalent) plus longacting inhaled 2- agonist, or Inhaled glucocorticosteroid at higher doses (> 800 g budesonide or equivalent), or Inhaled glucocorticosteroid (< 800 g budesonide or equivalent) plus leukotriene modifier

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Recommended Asthma Medications Step 4: Children

Severity Step 4 Severe persistent Daily Controller Medications Inhaled glucocorticosteroid ( > 800 g budesonide or equivalent) plus one or more of the following, if needed: - Sustained-release theophylline - Leukotriene modifier - Long-acting inhaled 2- agonist - Oral glucocorticosteroid Other Options

Reliever Medication: Rapid-acting inhaled 2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.

Six-part Asthma Management Program

Part 5: Establish Plans for Managing 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

Six-part Asthma Management Program

Part 5: Establish Plans for Managing Exacerbations Primary therapies for exacerbations: Repetitive administration of rapid-acting inhaled 2-agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

Six-part Asthma Management Program

Part 5: Managing Severe Asthma Exacerbations Severe exacerbations are lifethreatening medical emergencies
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department

Emergency Department Management

Acute Asthma
Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if needed Good Response Observe for at least 1 hour Incomplete/Poor Response Add Systemic Glucocorticosteroids Good Response If Stable, Discharge to Home Poor Response Respiratory Failure

Discharge

Admit to Hospital

Admit to ICU

Six-part Asthma Management Program

Part 6: Provide Regular Follow-up Care

Continual monitoring is essential to assure that therapeutic goals are met. Frequent follow-up visits are necessary to review: Home PEF and symptom records Techniques in use of medications Risk factors and their control Once asthma control is established, follow-up visits should be scheduled (at 1 to 6 month intervals as appropriate)

Six-part Asthma Management Program

Special Considerations
Special considerations are required to manage asthma in relation to: Pregnancy Surgery Physical activity Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma

Six-part Asthma Management Program: Summary

Asthma can be effectively controlled, although it

cannot be cured

Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

Six-part Asthma Management Program: Summary (continued)

Anything more than mild, occasional asthma is more effectively controlled by suppressing inflammation than by only treating acute bronchospasm The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

http://www.ginasthma.com

Optional Therapy Slides

Part 4: Long-term Asthma Management

Stepwise Approach to Asthma Therapy - Adults

Outcome: Asthma Control
Outcome: Best Possible Results

Controller:

Controller: Controller:
None

Controller:
Daily inhaled corticosteroid

Daily inhaled corticosteroid Daily longacting inhaled 2-agonist

Daily inhaled corticosteroid Daily long acting inhaled 2-agonist plus(if needed)

When asthma is controlled, reduce therapy Monitor

-Theophylline-SR -Leukotriene -Long-acting inhaled 2- agonist -Oral corticosteroid

Reliever: Rapid-acting inhaled 2-agonist prn

STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down

Alternative controller and reliever medications may be considered (see text).

Stepwise Approach to Asthma Therapy: Adults

Step 1: Intermittent Asthma

Daily Controller Medications
None required

Reliever Medications
Rapid-acting inhaled 2-agonist for symptoms (but < once a week) Rapid-acting inhaled 2-agonist, cromone, or leukotriene modifier before exercise or exposure to allergen

Continuously review medication technique, compliance and environmental control Review treatment every three months. Step up if control is not achieved; step down if control is sustained for at least 3 months Preferred treatments are in bold print

Stepwise Approach to Asthma Therapy: Adults

Step 2: Mild Persistent Asthma

Daily Controller Medications
Inhaled glucocorticosteroid (< 500 g BDP or equivalent) Other options (order by cost): sustained-release theophylline, or Cromone, or leukotriene modifier

Reliever Medications
Rapid-acting inhaled 2-agonist for symptoms (but < 3-4 times/day) Other options: inhaled anticholinergic, or short-acting oral 2-agonist, or short-acting theophylline

Continuously review medication technique, compliance and environmental control. Review treatment every three months Step up if control is not achieved; Step down if control is sustained for at least 3 months Preferred treatments are in bold print

Stepwise Approach to Asthma Therapy: Adults

Step 3: Moderate Persistent Asthma

Daily Controller Medications Reliever Medications

Inhaled glucocorticosteroid, (200 1000 g BDP or Rapid-acting inhaled equivalent) plus long-acting inhaled 2agonist 2-agonist for symptoms Other options (order by cost): (but < 3 - 4 times/day) Inhaled glucocorticosteroid (500 1000 g BDP equivalent) plus sustained-release theophylline, or Other options: Inhaled glucocorticosteroid (500 1000 g BDP inhaled anticholinergic or equivalent) plus long-acting inhaled 2- agonist, or short-acting oral inhaled glucocorticosteroid at higher doses 2-agonist or (> 1000 g BDP equivalent), or short-acting theophylline Inhaled glucocorticosteroid (500 1000 g BDP
equivalent) plus leukotriene modifier

Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print.

Stepwise Approach to Asthma Therapy: Adults

Step 4: Severe Persistent Asthma

Daily Controller Medications
Inhaled glucocorticosteroid, (> 1000 g BDP or equivalent) plus long-acting inhaled 2agonist

Reliever Medications
Rapid-acting inhaled 2-agonist for symptoms (but < 3-4 times/day)

plus one or more of the following, if needed (order by cost): sustained-release theophylline, or leukotriene modifier or oral glucocorticosteroid

Other options: inhaled anticholinergic or short-acting oral 2-agonist or short-acting theophylline

Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print.