Asthma GINA 2014

GINA 2014

1. G
IN
A
lobal
itiative for
sthma

2. 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

3. 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

4. United States
United Kingdom
Argentina
Australia
Brazil
Austria
Canada
Chile
Belgium
China
Denmark
Colombia
Croatia
Germany
Greece
Ireland
Italy
Syria
Hong Kong
Japan
India
Korea
Kyrgyzstan
Moldova
Macedonia
Malta
Netherlands
New Zealand
Poland
Portugal
Georgia
Romania
Russia
Singapore
Slovenia
Saudi Arabia
South Africa
Spain
Sweden
Thailand
Switzerland
Ukraine
Taiwan ROC
Venezuela
Vietnam
Yugoslavia
Albania
Bangladesh
France
Mexico
Turkey
Czech
Republic
Lebanon Pakistan
GINA Assembly
IsraelIsrael
Slovakia

5. GINA Documents
Global Strategy for Asthma Management
and Prevention (revised 2006)
Pocket Guide: Asthma Management and
Prevention (revised 2006)
Pocket Guide: Asthma Management and
Prevention in Children (revised 2006)
Guide for asthma patients and families
All materials are available on GINA web site www.ginasthma.org

6. Global Strategy for Asthma
Management and Prevention
 Evidence-based
 Implementation oriented
Diagnosis
Management
Prevention
 Outcomes can be evaluated

7. Global Strategy for Asthma
Management and Prevention
Evidence Category Sources of Evidence
A Randomized clinical trials
Rich body of data

B Randomized clinical trials
Limited body of data

C Non-randomized trials
Observational studies

D Panel judgment consensus

8. Global Strategy for Asthma
Management and Prevention (2006)
Definition and Overview
Diagnosis and
Classification
Asthma Medications
Asthma Management and
Prevention Program
Implementation of Asthma
Guidelines in Health
Systems
Revised 2006Revised 2006

9. Definition of Asthma
A chronic inflammatory disorder of the airways
Many 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

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

11. Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation

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

13. 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

14. Asthma Prevalence and Mortality
SourceSource: Masoli M et al. Allergy 2004: Masoli M et al. Allergy 2004

15. 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

16. Factors that Exacerbate Asthma
Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

17. 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

18. 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

19. 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

20. Typical Spirometric (FEV
1
)
Tracings
11
Time (sec)
22 33 4455
FEV
1
Volume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV
1
curve represents the highest of three repeat measurements

21. Measuring Variability of Peak
Expiratory Flow

22. Measuring Airway
Responsiveness

23. Intermittent
Symptoms less than once a week
Brief exacerbations
Nocturnal symptoms not more than twice a month
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20%
Mild Persistent
Symptoms more than once a week but less than once a day
Exacerbations may affect activity and sleep
Nocturnal symptoms more than twice a month
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20 – 30%

24. Moderate Persistent
Symptoms daily
Exacerbations may affect activity and sleep
Nocturnal symptoms more than once a week
Daily use of inhaled short-acting 2-agonist
• FEV1 or PEF 60-80% predicted
• PEF or FEV1 variability > 30%
Severe Persistent
Symptoms daily
Frequent exacerbations
Frequent nocturnal asthma symptoms
Limitation of physical activities
• FEV1 or PEF ≤ 60% predicted
• PEF or FEV1 variability > 30%

25. Levels of Asthma
Control
Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Uncontrolled
Daytime symptoms
None (2 or less /
week)
More than
twice / week
3 or more
features of
partly
controlled
asthma
present in
any week
Limitations of
activities
None Any
Nocturnal
symptoms /
awakening
None Any
Need for rescue /
“reliever” treatment
None (2 or less /
week)
More than
twice / week
Lung function
(PEF or FEV
1
)
Normal
< 80% predicted or
personal best (if
known) on any day
Exacerbation None One or more / year 1 in any week

26. 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
Asthma Management and Prevention
Program: Five Components
Revised 2006

27. 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

28. Asthma Management and
Prevention Program
Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
Early intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
.

29. Asthma Management and
Prevention Program
Although there is no cure for asthma,
appropriate management that includes
a partnership between the physician
and the patient/family most often
results in the achievement of control

30. 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
Asthma Management and Prevention Program
Component 1: Develop
Patient/Doctor Partnership

31. 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 patient’s
family

32. 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

33. 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 ? NoYes
Activity or exercise limited by asthma? NoYes
Waking at night because of asthma? NoYes
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
If you answered YES to three or more of these questions, your asthma is uncontrolled and
you may need to step up your treatment.
HOW TO INCREASE TREATMENT
STEP-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 don’t respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL
If 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.

34. Asthma Management and Prevention Program
Factors Involved in Non-Adherence
Medication Usage
Difficulties associated
with inhalers
Complicated regimens
Fears about, or actual
side effects
Cost
Distance to pharmacies
Non-Medication Factors
Misunderstanding/lack of
information
Fears about side-effects
Inappropriate expectations
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication

35. Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure 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.

36. 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 Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

37. Asthma Management and Prevention Program
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

38. Asthma Management and Prevention Program
Component 3: Assess, Treat
and Monitor Asthma
The goal of asthma treatment, to
achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional

39. Asthma Management and Prevention Program
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

40. 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
Asthma Management and Prevention Program
Component 3: Assess, Treat
and Monitor Asthma

41. 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
Asthma Management and Prevention Program
Component 3: Assess, Treat
and Monitor Asthma

42. 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
Asthma Management and Prevention Program
Component 3: Assess, Treat
and Monitor Asthma

43. Component 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β
2
-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral β
2
-agonists
Anti-IgE
Systemic glucocorticosteroids

44. Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug

Low Daily Dose (mg) Medium Daily Dose (mg) High Daily Dose (mg)
> 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 80 – 160 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 acetonide400-1000 400-
800
>1000-2000 >800-1200 >2000 >1200

45. Component 4: Asthma Management and Prevention Program
Reliever Medications
Rapid-acting inhaled β
2
-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β
2
-agonists

46. Component 4: Asthma Management and Prevention Program
Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is
limited
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

47. controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest
controlling step
consider stepping up to
gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1
STEP
2
STEP
3
STEP
4
STEP
5
R
E
D
U
C
E
I
N
C
R
E
A
S
E

50. Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of
short duration
A rapid-acting inhaled β
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)
Treating to Achieve Asthma
Control

52. 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
Treating to Achieve Asthma
Control

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

55. 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

57. 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
Treating to Achieve Asthma
Control

58. Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled β
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 β
2
-agonist (Evidence B)
Treating to Achieve Asthma
Control

60. 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 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)

61. 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 monitored
by the health care professional and
by the patient

62. Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on medium- to high-
dose 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)

63. Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled β
2
-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting β
2
-agonist
(Evidence B)
If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting β
2
-agonist (Evidence D)

64. Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-
acting inhaled β2-agonist
bronchodilators provide temporary
relief.
Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy

65. Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting
inhaled β
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 glucocortico-
steroids is not effective, and is not
recommended (Evidence A)

66. 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.
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

67. Many asthma medications (e.g.
glucocorticosteroids, β
2
- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

68. 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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

69. Rapid-acting inhaled β
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
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor
Asthma – Children 5 Years and Younger

70. 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
(FEV
1
or PEF)
Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

71. Primary therapies for exacerbations:
•Repetitive administration of rapid-acting inhaled
β
2
-agonist
•Early introduction of systemic
glucocorticosteroids
•Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
Asthma Management and Prevention Program
Component 4: Manage Asthma
Exacerbations

72. Asthma Management and Prevention ProgramAsthma 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

73. THANK YOU