GINA 2021 baru.pdf

Panduan baru asma bronkiale

1. Thomas Jefferson University Thomas Jefferson University
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Department of Family & Community Medicine
Presentations and Grand Rounds
Department of Family & Community Medicine
7-22-2021
Global Initiative for Asthma (GINA): What’s New in GINA 2021? Global Initiative for Asthma (GINA): What’s New in GINA 2021?
Christopher Chambers, MD
Follow this and additional works at: https://jdc.jefferson.edu/fmlectures
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2. ©GlobalInitiativeforAsthma
GINAGlobalStrategyforAsthma
Managementand Prevention
Thisslideset isrestrictedforacademicandeducationalpurposesonly. Noadditions
orchangesmaybemadetoslides.Useof theslideset orof individualslidesfor
commercialorpromotionalpurposesrequiresapprovalfromGINA.
GlobalInitiativeforAsthma(GINA)
What’sNewinGINA2021?

3. §Otherconsiderationsin making recommendations
▪Patient prioritiesandpreferences
▪Patient behavior, includingadherence
▪Current understandingof underlyingdiseaseprocesses
▪Feasibilityforimplementationinclinicalpractice
©GlobalInitiativefor Asthma, www.ginasthma.org
AboutGINARecommendations

4. ©GlobalInitiativeforAsthma
GINAGlobalStrategy forAsthma
ManagementandPrevention
www.ginasthma.org
GINAguidanceabout
COVID-19andasthma
Updated26April 2021

5. §Arepeoplewithasthmaat increasedriskof COVID-19, orsevereCOVID-19?
▪Peoplewithasthmadonotappear tobeatincreasedrisk ofacquiringCOVID-19,andsystematic reviews have
notshownanincreasedrisk ofsevereCOVID-19inpeoplewithwell-controlled,mild-to-moderateasthma
§Arepeoplewithasthmaat increasedriskof COVID-19-relateddeath?
▪Overall,peoplewithwell-controlledasthmaarenotatincreasedrisk ofCOVID-19-relateddeath
(Williamson,Nature2020;LiuetalJACIIP 2021)
▪However,therisk ofCOVID-19deathwas increasedinpeoplewhohadrecently neededoralcorticosteroids
(OCS) for their asthma(Williamson,Nature2020)andinhospitalizedpatients withsevereasthma(Bloom,Lancet
Respir Med2021).
Updated26April2021 ©GlobalInitiativefor Asthma, www.ginasthma.org
COVID-19 and Asthma

6. Advisepatientstocontinuetakingtheirprescribedasthmamedications,particularlyinhaled
corticosteroids(ICS)
▪For patients withsevereasthma,continuebiologic therapy or oralcorticosteroids ifprescribed
AreICSprotectiveinCOVID-19?
▪In onestudy ofhospitalizedpatients aged≥50years withCOVID-19,ICSuseinthosewithasthmawas
associatedwithlower mortality thaninpatients withoutanunderlyingrespiratory condition(Bloom,LancetRM 2021)
Makesurethat allpatientshaveawrittenasthmaactionplan, advisingthemto:
▪Increasecontroller andreliever medicationwhenasthmaworsens (seeGINAreportBox 4-2)
▪TakeashortcourseofOCSwhenappropriatefor severeasthmaexacerbations
Avoidnebulizerswherepossible, toreducetheriskof spreadingvirus
▪Pressurizedmetereddoseinhaler viaaspacer is preferredexceptfor life-threateningexacerbations
▪Addamouthpieceor mask tothespacer ifrequired
Updated26April2021 ©GlobalInitiativefor Asthma, www.ginasthma.org
COVID-19 and Asthma -Medications

7. Areminder–AKey Change in Asthma Management
Reddeletal,ERJ2019;53:1901046 ©GlobalInitiativefor Asthma, www.ginasthma.org

8. §Recommendsagainst SABA-onlytreatmentforStep 1 in adultsand adolescents
▪SABA-onlytreatment increasestheriskof severe exacerbations,andthat addinganyICS
significantlyreducestherisk
§Alladultsand adolescentswith asthma should receive ICS-containing controller
treatment,to reduce the riskofseriousexacerbations
▪TheICScanbedeliveredbyregulardailytreatment or, inmildasthma, byas-neededlowdose
ICS-formoterol
ICS:inhaledcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
GINA2019–Landmark Changes in Asthma Management

9. §Patientswith apparentlymild asthma are stillatriskofseriousadverse events
▪30–37% of adultswithacuteasthma
▪16% of patientswithnear-fatalasthma
▪15–20% of adultsdyingof asthma
§Exacerbation triggersare unpredictable (viruses,pollens,pollution,pooradherence)
Background -The Risks of‘Mild’Asthma
hadsymptomslessthanweeklyinprevious
3months(Dusser,Allergy 2007)
SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org

10. Background-TheRisks ofSABA-Only Treatment
OCS:oralcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
§Regularuse ofSABA,even for1–2 weeks,isassociated with adverse effects
▪b-receptordownregulation, decreasedbronchoprotection, reboundhyperresponsiveness,
decreasedbronchodilatorresponse
§Higher use of SABA is associated with adverse clinical outcomes
§Inhaled corticosteroidsreduce the riskofasthma deaths,hospitalization and exacerbations
requiring oralcorticosteroids(OCS)
▪BUT adherence is poor, particularly in patients withmildorinfrequent symptoms
§Asafe and effective alternative wasneeded formild asthma

11. Original Article
As-Needed Budesonide–Formoterol versus
Maintenance Budesonide in Mild Asthma
Eric D. Bateman,M.D., Helen K. Reddel,M.B., B.S., Ph.D., Paul M. O’Byrne,M.B.,
Peter J. Barnes,M.D., Nanshan Zhong,Ph.D., Christina Keen,M.D., Carin
Jorup,M.D., Rosa Lamarca,Ph.D., Agnieszka Siwek-Posluszna,M.D., and J. Mark
FitzGerald,M.D.
N Engl J Med
Volume 378(20):1877-1887
May 17, 2018

12. Study Overview
•Inhaled glucocorticoid plus β-agonist in a single inhaler was compared
with maintenance inhaled glucocorticoid for exacerbation risk among
patients with mild asthma.
•Combination therapy was noninferior to maintenance therapy.

13. Annualized Rate of Severe Asthma Exacerbations and Time to First Severe Exacerbation.
Bateman ED et al. N Engl J Med 2018;378:1877-1887

14. O’Byrne PM et al. N Engl J Med 2018;378:1865-1876

15. O’Byrne PM et al. N Engl J Med 2018;378:1865-1876

16. §Track 1,withlowdose ICS-formoterolas the reliever,isthe preferredapproach
▪UsingICS-formoterolasrelieverreducestheriskofexacerbationscomparedwithusing
aSABAreliever, withsimilarsymptomcontrolandsimilarlungfunction
§Track 2,withSABAas the reliever,is analternative approach
▪UsethisifTrack1isnot possible, orisnot preferredbyapatient withnoexacerbationsontheir
current controllertherapy
▪BeforeconsideringaregimenwithSABAreliever, considerwhetherthepatient islikelytobe
adherent withdailycontroller–if not, theywillbeexposedtotherisksof SABA-onlytreatment
ICS:inhaledcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
The GINA2021 TreatmentFigure forAdults and Adolescents

17. RELIEVER:As-neededlow-doseICS-formoterol
RELIEVER:As-neededshort-actingβ2-agonist
CONTROLLERand
PREFERREDRELIEVER
(Track1).UsingICS-formoterol
asrelieverreduces therisk of
exacerbationscomparedwith
usingaSABAreliever
Othercontrolleroptions
foreithertrack
STEPS1–2
As-neededlowdoseICS-formoterol
STEP3
Lowdose
maintenance
ICS-formoterol
STEP4
Mediumdose
maintenance
ICS-formoterol
Treatmentofmodifiableriskfactors andcomorbidities
Non-pharmacologicalstrategies
Asthmamedications(adjustdown/up/betweentracks)
Education&skillstraining
STEP5
Add-onLAMA
Referforphenotypic
assessment±anti-IgE,
anti-IL5/5R, anti-IL4R
Considerhighdose
ICS-formoterol
LowdoseICSwhenever
SABAtaken,ordailyLTRA,
oraddHDMSLIT
MediumdoseICS,or
addLTRA,oradd
HDMSLIT
AddLAMAorLTRAor
HDMSLIT,orswitchto
highdoseICS
Addazithromycin(adults)or
LTRA;addlowdoseOCS
but considerside-effects
STEP1
Take ICSwhenever SABAtaken
STEP2
Lowdose
maintenanceICS
STEP3
Lowdose
maintenance
ICS-LABA
STEP4
Medium/high dose
maintenance ICS-
LABA
STEP5
Add-onLAMA
Referforphenotypic
assessment±anti-IgE,
anti-IL5/5R, anti-IL4R
Considerhighdose
ICS-LABA
CONTROLLERand
ALTERNATIVERELIEVER
(Track2). Beforeconsideringa
regimenwithSABAreliever,
check ifthepatientislikelytobe
adherentwithdailycontroller
Adults&adolescents
12+years
Personalizedasthmamanagement
Assess,Adjust, Review
forindividualpatientneedsSymptoms
Exacerbations
Side-effects Lung
function Patient
satisfaction
Confirmationofdiagnosisifnecessary
Symptomcontrol&modifiableriskfactors(includinglungfunction)
Comorbidities
Inhalertechnique&adherence
Patientpreferencesand goals
GINA2021,Box3-5A ©GlobalInitiativefor Asthma,www.ginasthma.org

18. §Whyisthispreferred foradultsand adolescents?
▪BecauseusinglowdoseICS-formoterolasrelieverreducestheriskof severeexacerbations
comparedwithregimenswithSABAasreliever, withsimilarsymptomcontrol
§Howisitused?
▪Whenapatient at anytreatment stephasasthmasymptoms,theyuselowdoseICS-formoterol
inasingleinhalerforsymptomrelief
▪InSteps3–5, patientsalsotakeICS-formoterolastheirdailycontrollertreatment.Together, this
iscalled‘maintenanceandrelievertherapy’or‘MART’
§When should itnotbe used?
▪ICS-formoterolshouldnot beusedastherelieverinpatientsprescribedadifferent ICS-LABAfor
theircontrollertherapy
ICS:inhaledcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
GINATrack 1(preferred):TheReliever is LowDoseICS-Formoterol

19. §When should thisbe used?
▪ThisisanalternativeapproachforadultsandadolescentsifTrack1isnot possible, orisnot
preferredbyapatient withnoexacerbationsontheircurrent therapy
§When should itnotbe used?
▪BeforeprescribingaregimenwithSABAreliever, considerwhetherthepatient islikelytobe
adherent withtheirprescribedICS-containingcontrollertherapy. If theyarepoorlyadherent, they
willbeat higherriskof exacerbations
ICS:inhaledcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
GINATrack 2(Alternative):TheReliever is SABA

20. Mean and individual values of subepithelial layer thickness in patients with
severe, moderate, and mild asthma, and healthy subjects
30
25
20
15
10
5
0
Severe
(n=6)
Moderate
(n=14)
Mild
(n=14)
Healthy Subjects
(n=8)
P<0.003
#
P<0.01
Subepithelial Layer Thickness (µm)
# P < 0.001, healthy vs.
patients with asthma
Chetta et al. CHEST. 1997; 111:852-857.
Airway Remodeling is Airway Scarring:
An Issue Even in Mild Asthma

21. A 23-year-old woman with intermittent asthma managed with PRN inhaler use only presents with an acute asthma flare brought on by a URI. She improves but is not totally clear after two neb treatments. The most appropriate discharge treatment plan is:
A.Continue PRN inhaler use but follow-up if symptoms recur.
B.Use the inhaler until the URI resolves.
C.Use the inhaler BID and “as needed”.
D.Prescribe a 5-day steroid burst and continue the inhaler both BOD and “as needed”.

22. §Systematic review of six trials (374
participants)
§RR = 0.38 relapse within one week
§RR = 0.35 subsequent hospitalization (21
days)
Cochrane Rev 2007
Steroids or No Steroids
for Acute Exacerbation

23. More on Steroids
§Early (within one hour) benefit
§Systematic review of 12 studies (863
participants)
§OR of hospitalization = 0.40
Cochrane 2001

24. RELIEVER:As-neededshort-actingβ2-agonist
RELIEVER:As-neededlow-doseICS-formoterol
STEP1
TakeICSwhenever SABAtaken
STEP2
Lowdose
maintenanceICS
STEP3
Lowdose
maintenance
ICS-LABA
STEP4
Medium/high
dosemaintenance
ICS-LABA
STEP5
Add-onLAMA Refer
forphenotypic
assessment±anti-IgE,
anti-IL5/5R,anti-IL4R
Considerhighdose
ICS-LABA
CONTROLLERand
ALTERNATIVERELIEVER
(Track2).Beforeconsidering
aregimenwithSABAreliever,
checkifthepatientislikely
tobeadherentwithdaily
controllertherapy
CONTROLLERand
PREFERREDRELIEVER
(Track1).UsingICS-formoterol
asrelieverreducestheriskof
exacerbationscomparedwith
usingaSABAreliever
STEPS1–2
As-neededlowdoseICS-formoterol
STEP3
Lowdose
maintenance
ICS-formoterol
STEP4
Mediumdose
maintenance
ICS-formoterol
STEP5
Add-onLAMA Refer
forphenotypic
assessment±anti-IgE,
anti-IL5/5R,anti-IL4R
Considerhighdose
ICS-formoterol
Symptomsmost
days,orwaking
withasthmaonce
aweekormoreSTART
HEREIF:
Symptomsless
than4–5days
aweek
Dailysymptoms,
orwakingwith
asthmaoncea
weekormore,
andlowlung
function
ShortcourseOCS
mayalsobeneeded
forpatientspresenting
withseverely
uncontrolledasthma
Symptomsmost
days,orwaking
withasthmaonce
aweekormore
START
HEREIF: Symptomsless
thantwice a
month
Dailysymptoms,
orwakingwith
asthmaoncea
weekormore,
andlowlung
function
ShortcourseOCS
mayalsobeneeded
forpatientspresenting
withseverely
uncontrolledasthmaSymptomstwice
a month ormore,
but less than 4–5
daysaweek
•Confirmdiagnosis
•Symptomcontrol
andmodifiablerisk
factors,including
lungfunction
•Comorbidities
•Inhalertechnique
andadherence
•Patientpreferences
andgoals
FIRST
ASSESS:
STARTINGTREATMENT
inadultsandadolescentswithadiagnosisof asthma
Track1 ispreferredif the patient islikelytobepoorlyadherent withdailycontroller
ICS-containing therapyisrecommended evenifsymptomsareinfrequent,asit
reduces the risk ofsevere exacerbationsandneedfor OCS.
GINA2021,Box3-4Bi ©GlobalInitiativefor Asthma,www.ginasthma.org

25. Medium/high
doseICS-LABA
+as-neededSABA
Lowdose
ICS-LABA
+as-neededSABA
LowdoseICS
+as-neededSABA
Takelowdose
ICSwhenever
SABAistaken
TRACK1
(preferred)
Mediumdose
ICS-formoterol
maintenanceand
reliever(MART)
Lowdose
ICS-formoterol
maintenanceand
reliever(MART)
As-needed lowdose
ICS-formoterol
As-needed lowdose
ICS-formoterol
Dailysymptoms,waking at
nightonceaweekormore
andlowlungfunction?
Symptomsmostdays,
orwakingatnightonce
aweekormore?
Symptomstwicea
monthor more?
YES
NO
YES
IF:
STEP1
STEP2
STEP4
Shortcourse OCSmay
alsobeneededforpatients
presentingwithseverely
uncontrolledasthma
NO
STEP3
STARTWITH:
NO
YES
FIRSTASSESS:
Confirmation ofdiagnosis
Symptomcontrol
&modifiablerisk factors (including lungfunction)
Comorbidities
Inhalertechnique
&adherence
Patientpreferences
&goals
TRACK2OR
As-neededICS-formoterol
ispreferredifthepatientis
likelytobepoorlyadherent
withdailyICS
ICS-containing therapy
isrecommendedevenif
symptomsareinfrequent,
asitreducesthe riskof
severeexacerbationsand
needfor OCS.
STARTINGTREATMENT
inadultsandadolescents12+yearswithadiagnosisof asthma
GINA2021,Box3-4Bii ©GlobalInitiativefor Asthma,www.ginasthma.org

26. §Maintenance and relievertherapy(MART)with ICS-formoterolrelieverreducesthe
riskofsevere exacerbationscompared with regimenswith SABAreliever
▪ComparedwithsamedoseorhigherdoseICS-LABA,inpatientswithhistoryof severe
exacerbations(Sobieraj,JAMA2018)
▪Comparedwithconventionalbestpractice, inbroadpopulations(Cates,Cochrane2013,Demoly
Respir Med2009)
§Maintenance and relievertherapy(MART)in Step 4
▪ICSresponsivenessvaries,andsomepatientswhoseasthmaisuncontrolledonMARTwithlow
doseICS-formoteroldespitegoodadherenceandcorrectinhalertechniquemaybenefit from
increasingthetotaldailymaintenancedosetomedium
§Maintenance and relievertherapy(MART)in Step 5
▪ThereisnodirectevidenceaboutinitiatingMARTinpatientsreceivingadd-ontreatmentsuchas
LAMAorbiologictherapy,butifapatientisalreadytakingMART,switchingthemtoconventional
ICS-LABAplusas-neededSABAmayincreasetheriskofexacerbations
ICS:inhaledcorticosteroids;LABA:long-actingbeta2-agonist;OCS:oralcorticosteroids;SABA:short-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
Maintenance and RelieverTherapy (MART)in Steps 3–5

27. §Step 5 recommendationsforadd-on LAMAhave been expanded to include combination
ICS-LABA-LAMA,ifasthma ispersistentlyuncontrolled despite ICS-LABA
▪Add-ontiotropiuminseparateinhaler(ages≥6years)
▪Triplecombinations(ages≥ 18years): beclometasone-formoterol-glycopyrronium; fluticasone
furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium
ICS:inhaledcorticosteroids;LABA:long-actingbeta2-agonist;LAMA:long-actingmuscarinicantagonist;OCS:oralcorticosteroids
©GlobalInitiativefor Asthma, www.ginasthma.org
Add-On Long-Acting Muscarinic Antagonists (LAMA)

28. §Add-on azithromycin three daysa weekhasbeen confirmed asan option for
consideration afterspecialistreferral
▪SignificantlyreducesexacerbationsinpatientstakinghighdoseICS-LABA
▪Significantlyreducesexacerbationsinpatientswitheosinophilicornon-eosinophilicasthma
▪NospecificevidencepublishedforazithromycininpatientstakingmediumdoseICS-LABA
(Hiles etal,ERJ 2019)
§Before considering add-on azithromycin
▪Checksputumforatypicalmycobacteria
▪CheckECGforlongQTc(andre-checkafteramonthof treatment)
▪Considertheriskof increasingantimicrobialresistance(populationorpersonal)
ICS:inhaledcorticosteroids;LABA:long-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
Add-On Azithromycin

29. §When assessing eligibility,repeatblood eosinophilsiflowatfirstassessment
▪Onestudyfoundthat 65% patientsonmediumorhighdoseICS-LABAshiftedtheireosinophil
categoryduring12months’follow-up(Lugogoetal,AnnAllergyAsthmaImmunol2020)
§Additionalindicationsforthese therapiesin Europe and/orUSAhave been listed
▪Omalizumab: chronicidiopathicurticaria, nasalpolyposis
▪Mepolizumab: hypereosinophilicsyndrome, eosinophilicgranulomatosiswithpolyangiitis(EGPA)
▪Benralizumab: noadditionalindicationsat present
▪Dupilumab: chronicrhinosinusitiswithnasalpolyposis(CRSwNP); atopicdermatitis
§Checklocalregulatoryapprovalsand eligibilitycriteria
ICS:inhaledcorticosteroids;LABA:long-actingbeta2-agonist
©GlobalInitiativefor Asthma, www.ginasthma.org
Add-On Biologic Therapy forSevereType 2 Asthma

30. A 30 year old man with moderate persistent asthma
is in the ED with an acute exacerbation. After 3 nebs
(albuterol plus ipratropium) and a loading dose of 60
mg prednisone his PEFR has improved from 180 to
260 l/min (PEF predicted=600 l/min).
Of the following, the most appropriate step is:
A.Discharge to home.
B.Add montelukast PO.
C.Give an IV loading dose of theophylline.
D.Give IV magnesium.

32. A 45 year old former smoker is currently being treated with
an ICS/LABA and an LTRA. He reports that he still requires
his rescue inhaler 3 or 4 times a day.
An appropriate next step would be:
A.Add ipratropium.
B.Add tiotropium.
C.Add theophylline.
D.Add cromolyn.

33. Tiotropium (Spiriva)
§Approved by the FDA for
long-term maintenance in asthma
§2 inhalations of 1.25 mcg per day.
Ann Am Thor Soc (2016) 13:173

34. LAMAs in Severe Asthma
§Adding LAMA vs. placebo to ICS/LABA
Systematic review of 4 trials (1197 parts.)
OR (for exacerbation) = 0.76 (CI, 0.57 –1.02)
Cochrane 2016
BUT…
§Systematic review 15 trials (7122 parts.)
LAMA + ICSRR hosp = 0.67 (0.48 –0.92)
LAMA + ICS/LABARR hosp = 0.87 (0.53 –1.42)
JAMA (2018) 319:1473

35. Asthma/COPD Overlap Syndrome
(ACOS)
§Persistent airflow limitation, partially
reversible
§Typically 40+ years old with smoking hx
§Need clinical suspicion, PFTs

36. ©GlobalInitiativeforAsthma
GINAGlobalStrategyforAsthma
Managementand Prevention
GINA2021:TreatmentofAsthma
inChildren

37. PREFERRED
CONTROLLER
topreventexacerbations
andcontrolsymptoms
Other controller
options
RELIEVER
STEP1
LowdoseICS
takenwhenever
SABAtaken
Considerdaily
lowdoseICS
Children6-11years
Personalizedasthmamanagement:
Assess,Adjust, Review
Asthmamedicationoptions:
Adjust treatment upanddownfor
individualchild’sneeds
STEP2
Dailylowdoseinhaledcorticosteroid(ICS)
(seetableofICSdoserangesforchildren)
Dailyleukotrienereceptorantagonist (LTRA),or
lowdoseICStaken wheneverSABAtaken
STEP3
LowdoseICS-
LABA,ORmedium
doseICS, OR very
lowdose* ICS-
formoterol
maintenanceand
reliever(MART)
Treatmentofmodifiableriskfactors
& comorbidities
Non-pharmacologicalstrategies
Asthmamedications(adjustdownorup)
Education &skillstraining
STEP5
Referfor
phenotypic
assessment
±higherdose
ICS-LABAor
add-on therapy,
e.g.anti-IgE
Add-onanti-IL5,
oradd-onlow
doseOCS,
butconsider
side-effects
Addtiotropium
oraddLTRA
Lowdose
ICS+LTRA
As-neededshort-actingbeta2-agonist(orICS-formoterolrelieverforMARTasabove)
Symptoms
Exacerbations
Side-effects
Lungfunction
Childandparent
satisfaction
Confirmationof diagnosisifnecessary
Symptomcontrol&modifiable
riskfactors(includinglungfunction)
Comorbidities
Inhalertechnique& adherence
Childandparentpreferencesandgoals
STEP4
Mediumdose
ICS-LABA,
ORlowdose†
ICS-formoterol
maintenance
andreliever
therapy (MART).
Referforexpert
advice
*Verylowdose:BUD-FORM100/6mcg
†Lowdose:BUD-FORM200/6mcg(metereddoses).
©GlobalInitiativefor Asthma,www.ginasthma.orgGINA2021,Box3-5B

38. PREFERRED
CONTROLLER
topreventexacerbations
andcontrolsymptoms
Other controller
options
RELIEVER
STEP1
LowdoseICS
takenwhenever
SABAtaken
Considerdaily
lowdoseICS
STEP2
Dailylowdoseinhaledcorticosteroid(ICS)
(seetableofICSdoserangesforchildren)
Dailyleukotrienereceptorantagonist (LTRA),or
lowdoseICStaken wheneverSABAtaken
STEP3
LowdoseICS-
LABA,ORmedium
doseICS, OR very
lowdose* ICS-
formoterol
maintenanceand
reliever(MART)
STEP4
Mediumdose
ICS-LABA,
ORlowdose†
ICS-formoterol
maintenance
andreliever
therapy (MART).
Referforexpert
advice
STEP5
Referfor
phenotypic
assessment
±higherdose
ICS-LABAor
add-on therapy,
e.g.anti-IgE
Add-onanti-IL5,
oradd-onlow
doseOCS,
butconsider
side-effects
Addtiotropium
oraddLTRA
Lowdose
ICS+LTRA
As-neededshort-acting beta2-agonist(orICS-formoterolrelieverforMARTasabove)
STARTINGTREATMENT
Children6–11yearswithadiagnosisofasthma
Symptoms mostdays, or wakingwith asthmaoncea weekormore
Confirmationofdiagnosis
Symptomcontrol&modifiableriskfactors (including lungfunction)
Comorbidities
Inhalertechnique& adherence
Childandparentpreferencesandgoals
ASSESS:
START
HEREIF:
Symptoms most days, orwaking withasthma onceaweekor
more,andlow lungfunction
Shortcourse OCS
mayalsobeneeded
forpatientspresenting
withseverely
uncontrolledasthma
Symptoms lessthantwice amonth
Symptoms twiceamonthor more,butlessthandaily
*Verylowdose:BUD-FORM100/6mcg
†Lowdose:BUD-FORM200/6mcg(metereddoses).
©GlobalInitiativefor Asthma,www.ginasthma.orgGINA2021,Box3-4Di