Clinical Practice Guidelines On Asthma

CLINICAL PRACTICE GUIDELINES ON ASTHMA
GINA GUIDELINES
G lobal
itiative
for
IN
sthma
A
Global Initiative for Asthma
GINA 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 BOARD OF DIRECTORS
M. FitzGerald, Chair, Canada

E. Bateman, S. Africa P. Paggario, Italy
L.P. Boulet, Canada
A. Cruz, Brazil
S. Pedersen, Denmark
H. Reddel, Australia
M. Haahtela, Finland M. Soto-Quiroz, Costa

M. Levy, U.K.
G. Wong, Hong
Rica
Kong ROC
P. OByrne, Canada
GINA Structure
EXECUTIVE COMMITTEE
CHAIR: MARK FITZGERALD, MD
Dissemination
Committee
Science
Committee
Chair: L.P. Boulet, MD
Chair: H. Reddel, MD
GINA ASSEMBLY
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 to meet with the

GINA Executive Committee during the ATS and ERS
meetings
GLOBAL STRATEGY FOR ASTHMA

MANAGEMENT AND PREVENTION
Evidence-based
Implementation oriented
Diagnosis
Management
Prevention
Outcomes can be evaluated

MANAGEMENT AND PREVENTION
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


MANAGEMENT AND PREVENTION (2012)
Definition
Updated 2012
and Overview
Diagnosis and Classification
Asthma Medications
Asthma Management and
Prevention Program
Implementation of Asthma
Guidelines in Health Systems
DEFINITION OF ASTHMA
A chronic
Many
inflammatory disorder of the airways
cells and cellular elements play a role
Chronic
inflammation is associated with airway

hyperresponsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness, and coughing
Widespread,
variable, and often reversible airflow limitation

Asthma Inflammation: Cells and

Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma
Inflammation
Asthma Inflammation: Cells and

Mediators
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
Countries should enter their own data on burden

of asthma.
FACTORS THAT EXACERBATE

ASTHMA
Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxid
Food, additives, drugs
FACTORS THAT INFLUENCE ASTHMA

DEVELOPMENT AND EXPRESSION
Host Factors
Genetic
- Atopy
- Airway
hyperresponsiveness
Gender
Obesity
Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Diet
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 diagnose asthma in
children 5 years and younger and the elderly
Typical Spirometric (FEV11) 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
Asthma Management and Prevention Program
Goals of Long-term Management

Achieve
and maintain control of symptoms

Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels
as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
Asthma Management and Prevention

Program: Five Components
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to
Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Updated 2012
Guidelines on asthma management should be available but

ASTHMA
MANAGEMENT
AND
PREVENTION
PROGRAM
adapted and adopted
local use
by
local asthma
planning
ASTHMAfor
MANAGEMENT
AND
PREVENTION
PROGRAM
PART 1: EDUCATE PATIENTS TO DEVELOP A
teams
PARTNERSHIP
Clear communication between health care professionals and

asthma patients is key to enhancing compliance
ASTHMA
ASTHMA MANAGEMENT
MANAGEMENT AND
AND PREVENTION
PREVENTION PROGRAM
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
ASTHMA
ASTHMA MANAGEMENT
MANAGEMENT AND
AND PREVENTION
PREVENTION PROGRAM
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
ASTHMA
ASTHMA MANAGEMENT
MANAGEMENT AND
AND PREVENTION
PREVENTION PROGRAM
PROGRAM
FACTORS INVOLVED IN NON-ADHERENCE

Non-Medication Factors
Medication Usage
Difficulties associated with inhalers

Complicated regimens
Fears about, or actual side effects
Cost
Distance to pharmacies
Misunderstanding/lack of information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication

Prevention Program: Five
Interrelated Components
1. Develop Patient/Doctor
Partnership
Risk Factors
3. Assess, Treat and Monitor
Asthma
Asthma
Asthma Management
Management and Prevention Program
Component 2: Identify and Reduce 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
Asthma
Asthma Management
Influenza Vaccination
Influenza vaccination should be
provided to patients with asthma when
vaccination of the general population is
advised
However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control

Partnership
Risk Factors
Asthma
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
GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION
CLINICAL CONTROL OF ASTHMA
Determine the initial level of

control to implement
treatment
(assess patient impairment)
Maintain control once
treatment has been
implemented
LEVELS OF ASTHMA CONTROL

(ASSESS PATIENT IMPAIRMENT)
Characteristic
Daytime symptoms
Limitations of
activities
Controlled
(All of the following)
Twice or less
per week
Partly controlled
(Any present in any week)
More than
twice per week
None
Any
Nocturnal symptoms
None
/ awakening
Any
Need for rescue /

reliever treatment
Lung function
(PEF or FEV1)
Uncontrolled
Twice or less
per week
More than
twice per week
Normal
< 80% predicted or

personal best (if
known) on any day
3 or more
features of
partly
controlled
asthma
present in
any week
Assessment of Future Risk (risk of exacerbations, instability, rapid

decline in lung function, side effects)
Assess Patient Risk

Features that are associated with
increased risk of adverse events in the
future include:
Poor clinical control
Frequent exacerbations in past year
Ever admission to critical care for
asthma
Low FEV1, exposure to cigarette smoke,
high dose medications
Assessment of Future Risk

Risk of exacerbations, instability, rapid decline
in
lungexacerbation
function, side effects
Any
should prompt review

Features that are associated with increased
of maintenance
risk of adverse
events in the future include:
Poor clinical control
treatment
Frequent exacerbations in past year

Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke, high
dose medications
Asthma
Asthma Management
Component 3: Assess,
Treat and Monitor Asthma
Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
Asthma
Asthma Management
Component 3: Assess,
Treat and Monitor Asthma
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 care

systems need to be considered
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled -agonists in
2
combination with inhaled
glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones
Anti-IgE
Estimate Comparative Daily Dosages for

Inhaled Glucocorticosteroids by Age
Drug
Drug
Low
Low Daily
Daily Dose
Dose (g)
(g) Medium
Medium Daily
Daily Dose
Dose (g)
(g)
>> 55 yy Age
>> 55 yy Age
Age << 55 yy
Age << 55 yy
Beclomethasone
200-500
100-200
>500-1000
>200-400
Budesonide
200-600
200
100-
600-1000
>200-400
Budesonide-Neb
Inhalation Suspension
Ciclesonide
250-
High
High Daily
Daily Dose
Dose (g)
(g)
>> 55 yy Age
Age << 55 yy
>1000
>1000
500-1000
>400
>400
>1000
500
80 160
80-160
>160-320
>160-320
>320-1280
>750-1250
>2000
>1250
>200-500
>500
>500
Flunisolide
500-1000
750
500-
>1000-2000
Fluticasone
100-250
200
100-
>250-500
Mometasone furoate
200-400
200
100-
> 400-800
>200-400
>800-1200
Triamcinolone acetonide
400-1000
800
400-
>1000-2000
>800-1200
>2000
>320
>400
>1200
Reliever Medications
Rapid-acting inhaled 2agonists
Systemic
Anticholinergics
Theophylline
Short-acting oral 2-agonists
REDUCE
LEVEL OF CONTROL
TREATMENT OF ACTION
maintain and find lowest
controlling step
partly controlled
consider stepping up to
gain control
INCREASE
controlled
uncontrolled
exacerbation
step up until controlled

treat as exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
STEP
STEP
TO STEP 3 TREATMENT,
SELECT ONE OR MORE:
Shaded green - preferred controller options
ADD EITHER
Treating to Achieve Asthma

Control
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 2 or higher)
SELECT ONE OR MORE:
ADD EITHER

Control
Step 2 Reliever medication plus a single
controller
A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence
A)
Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
SELECT ONE OR MORE:
ADD EITHER

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

Control
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)
SELECT ONE OR MORE:
ADD EITHER

Control
Step 4 Reliever medication plus two or more
controllers
Selection of treatment at Step 4 depends

on prior selections at Steps 2 and 3
Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma

Control
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 added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled 2-agonist (Evidence B)
SELECT ONE OR MORE:
ADD EITHER

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 severe
side effects (Evidence A)
Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
Treating to Maintain Asthma

Control
Stepping down treatment when asthma is controlled
When controlled on medium- to highdose inhaled glucocorticosteroids: 50%

dose reduction at 3 month intervals
(Evidence B)
When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)

Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled

glucocorticosteroids and long-acting
inhaled 2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting 2-agonist
(Evidence B)
If control is maintained, reduce to lowdose inhaled glucocorticosteroids and
stop long-acting 2-agonist (Evidence D)

Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or longacting inhaled 2-agonist

bronchodilators provide temporary
relief.
Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy

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 an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
Doubling the dose of inhaled glucocorticosteroids is not effective, and is not
recommended (Evidence A)

Partnership
Risk Factors
Asthma
ASTHMA
ASTHMA MANAGEMENT
MANAGEMENT AND
AND PREVENTION
PREVENTION PROGRAM
PROGRAM
COMPONENT 4: MANAGE ASTHMA

EXACERBATIONS
Exacerbations of asthma are episodes of progressive increase

in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory
airflow that can be quantified and monitored by measurement
of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and
treatment requires close supervision
ASTHMA
ASTHMA MANAGEMENT
MANAGEMENT AND
AND PREVENTION
PREVENTION PROGRAM
PROGRAM
COMPONENT 4: MANAGE ASTHMA

EXACERBATIONS
Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled
2-agonist
Early introduction of systemic
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

Partnership
Risk Factors
Asthma
ASTHMA MANAGEMENT AND PREVENTION PROGRAM
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

Clinical Practice Guidelines On Asthma

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CLINICAL PRACTICE GUIDELINES ON ASTHMA

GINA PROGRAM OBJECTIVES

GINA BOARD OF DIRECTORS

M. FitzGerald, Chair, Canada

M. Haahtela, Finland M. Soto-Quiroz, Costa

Global Initiative for Asthma

Chair: L.P. Boulet, MD

A network of individuals participating in the dissemination

GINA Assembly members are invited to meet with the

GLOBAL STRATEGY FOR ASTHMA

Global Initiative for Asthma

GLOBAL STRATEGY FOR ASTHMA

Randomized clinical trials

Randomized clinical trials

Panel judgment consensus

GLOBAL STRATEGY FOR ASTHMA

inflammatory disorder of the airways

cells and cellular elements play a role

inflammation is associated with airway

variable, and often reversible airflow limitation

Asthma Inflammation: Cells and

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and

Source: Peter J. Barnes, MD

Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Countries should enter their own data on burden

FACTORS THAT EXACERBATE

Global Initiative for Asthma

FACTORS THAT INFLUENCE ASTHMA

and patterns of symptoms

Typical Spirometric (FEV11) Tracings

Asthma Management and Prevention Program

Goals of Long-term Management

and maintain control of symptoms

Asthma Management and Prevention

Global Initiative for Asthma

Guidelines on asthma management should be available but

Clear communication between health care professionals and

Global Initiative for Asthma

information about asthma

training on self-management skills

a partnership among health care providers, the

COMPONENT 1: DEVELOP PATIENT/DOCTOR

Key factors to facilitate communication:

FACTORS INVOLVED IN NON-ADHERENCE

Difficulties associated with inhalers

Global Initiative for Asthma

Asthma Management and

Component 2: Identify and Reduce Exposure to

Reduce exposure to indoor allergens

Global Initiative for Asthma

Asthma Management and

GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

CLINICAL CONTROL OF ASTHMA

The focus on asthma control is

GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

CLINICAL CONTROL OF ASTHMA

Determine the initial level of

LEVELS OF ASTHMA CONTROL

Need for rescue /

< 80% predicted or