GINA GUIDELINES LONGTERM MANAGEMENT OF ASTHMA.pdf

Asthma guidelines

1. Longterm management of Asthma

2. Introduction
●Asthma diagnosis is mainly clinical
●Probability based diagnosis is the recommended
method for diagnosis in children less than 5 years.
●For older children we have objective diagnostic
tools,Spirometry and PEFR that can be used for
diagnosis ofAsthma.

3. .

4. Key Messages for pharmacotherapy of Asthma (Dos):
●Inhaled corticosteroids (ICS) are the mainstay to be used daily.
●Short acting Beta2 Agonists (SABAs) are for SOS use as relievers
particularly in under fives.
●Dose of ICS depends upon their age and severity of the
diseases.

5. ●For children more than 6 years we may add a Long Acting Beta2
Agonist(LABA)
●Children more than 12 years need to be treated with adult
dosages
●pMDI + Spacer with or without mask is the preferred inhalation
device for all children.

6. Key Messages for pharmacotherapy of Asthma (Don’ts)
●Montelukast has a limited role: only as add on to ICS.
●There is a serious warning against Montelukast due to risk of
neuropsychiatric side effects on long term use.
●Use of nebulizers is to be restricted to only a severe acute
exacerbation with desaturation.
●Nebulizers at home should be strictly discouraged.

7. ●GINA 2022 recommendation for children under 5 yrs, 6-11
years, adolescents and adults:-
●Every step of treatment, should receive an Inhaled
Corticosteroid either regularly or whenever a reliever is used .
●Reliever may be SABA or Formoterol + ICS

8. ICS Dosages as per GINA 2022
-

9. ●Monteleukast (LTRA) -
●2-5yrs age- 4mg/day, 6-14 yrs age – 5mg/day, >14yrs age
10mg/daily
●Ipratrpium bromide- nebulisation 250micrograms diluted in 2ml
of normal saline, given over 10 minutes F/b 250micrograms
every 2-4 hours.

10. Formoterol dosage
For inhalation dosage form (powder):
●For preventing an asthma attack:
●Adults and children 5 years of age and older - 12 micrograms (mcg) (1 capsule)
by oral inhalation every 12 hours.
●Usual Pediatric Dose for Asthma - Maintenance
●Formoterol 12 mcg inhalation capsule: (Less than 5 years: Not approved)
●5 years or older: 12 mcg (1 inhalation) orally every 12 hours using the
aerolizer inhaler
●Maximum dose: 24 mcg daily

11. ●Inhalation powder: (Less than 6 years: Not approved)
●6 to 16 years:
●6 mcg or 12 mcg inhaled orally every 12 hours Maximum dose:
12 mcg twice a day (total of 24 mcg daily)
●16 years or older:
●6 mcg or 12 mcg inhaled orally every 12 hours Maximum dose:
24 mcg twice a day (total of 48 mcg daily)

12. Low dose ICS whenever
SABA taken, or daily
LTRA, or add HDM SLIT
Medium dose ICS,
or add LTRA, or
add HDM SLIT
Add LAMA or LTRA
or HDM SLIT, or
switch to high dose
ICS
Add azithromycin (adults)
or LTRA. As last resort
consider adding low dose
OCS but consider side-
effects
RELIEVER: As-needed short-acting beta2-
agonist
STEP 1
Take ICS
whenever SABA
taken
STEP 2
Low dose
maintenance
ICS
STEP 3
Low dose
maintenanc
e ICS-LABA
STEP 4
Medium/high
dose
maintenance
ICS-LABA
STEP 5
Add-on LAMA
Refer for assessment
of phenotype.
Consider high dose
maintenance ICS-
LABA, ± anti-IgE,
anti-IL5/5R, anti-
IL4R, anti-TSLP
RELIEVER: As-needed low-dose ICS-
formoterol
STEPS 1 – 2
As-needed low dose ICS-
formoterol
STEP 3
Low dose
maintenance
ICS-
formoterol
STEP 4
Medium dose
maintenance
ICS-
formoterol
STEP 5
Add-on LAMA
Refer for assessment
of phenotype.
Consider high dose
maintenance ICS-
formoterol,
± anti-IgE, anti-
IL5/5R, anti-IL4R,
anti-TSLP
Treatment of modifiable risk
factors and comorbidities
Non-pharmacological
strategies
Asthma medications (adjust
down/up/between tracks)
Education & skills training
Adults &
adolescents 12+
years
Personalized asthma
management
Assess, Adjust, Review
for individual patient needs
Symptoms
Exacerbatio
ns Side-
effects Lung
function
Patient
satisfaction
Confirmation of diagnosis if
necessary Symptom control &
modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Patient preferences and goals
CONTROLLER and
PREFERRED RELIEVER
(Track 1). Using ICS-
formoterol as reliever
reduces the risk of
exacerbations compared
with using a SABA reliever
Other controller options for
either track (limited
indications, or less evidence
for efficacy or safety)
CONTROLLER and
ALTERNATIVE
RELIEVER
(Track 2). Before considering
a regimen with SABA reliever,
check if the patient is likely to
be adherent with daily
controller
See GINA
severe
asthma
guide

13. Step 1 –symptoms less than twice a month
Step 2 – symptoms twice a month or more but less than
4-5 days a week
Step 3 - Symptoms most days or waking with asthma once
a week or more.
Step 4 - daily symptoms or waking with asthma once a
week or more and low lung function

14. Add-on anti-IL5
or, as last resort,
consider add-on
low dose OCS,
but consider
side-effects
PREFERRED
CONTROLLER
to prevent
exacerbations
and control
symptoms
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
STEP 1
Low dose ICS
taken whenever
SABA taken
Consider daily
low dose ICS
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
STEP 2
Daily low dose inhaled corticosteroid (ICS)
Daily leukotriene receptor antagonist (LTRA), or
low dose ICS taken whenever SABA taken
STEP 3
Low dose ICS-
LABA, OR medium
dose ICS, OR
very low dose*
ICS-formoterol
maintenance and
reliever (MART)
STEP 4
Medium dose
ICS-LABA,
OR low dose
†
ICS-formoterol
maintenance
and reliever
therapy (MART).
Refer for expert
advice
STEP 5
Refer for
phenotypic
assessment
± higher dose
ICS-LABA or
add-on therapy,
e.g. anti-IgE,
anti-IL4R
Add tiotropium
or add LTRA
Low dose
ICS + LTRA
As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Lung function
Child and parent
satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Child and parent preferences and
goals
Treatment of modifiable risk factors
& comorbidities
Non-pharmacological strategies
Asthma medications (adjust down
or up) Education & skills training

15. PREFERRED
CONTROLLER
CHOICE
Other controller options
(limited indications, or
less evidence for efficacy
or safety)
RELIEVER
CONSIDER THIS
STEP FOR
CHILDREN WITH:
STEP 1
Children 5 years and younger
Personalized asthma management:
Assess, Adjust, Review response
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Infrequent viral
wheezing and no
or few interval
symptoms
Asthma diagnosis, and
asthma not well-controlled
on low dose ICS
Asthma not
well-controlled
on double ICS
Before stepping up, check for alternative diagnosis,
check inhaler skills, review adherence and exposures
As-needed short-acting beta2-agonist
Symptom pattern not consistent with asthma but wheezing
episodes requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
Symptom pattern consistent with asthma, and asthma
symptoms not well-controlled or ≥3 exacerbations per year.
STEP 2
Daily low dose inhaled corticosteroid (ICS)
STEP 3
Double ‘low
dose’ ICS
Low dose ICS + LTRA
Consider specialist
referral
STEP 4
Continue
controller & refer
for specialist
assessment
Add LTRA, or increase
ICS frequency, or add
intermittent ICS
Daily leukotriene receptor antagonist (LTRA), or
intermittent short course of ICS at onset of
respiratory illness
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Exclude alternative diagnoses
Symptom control & modifiable
risk factors
Comorbidities
Inhaler technique & adherence
Parent preferences and goals
Treat modifiable risk factors
and comorbidities
Non-pharmacological
strategies Asthma
medications
Education & skills training
Consider intermittent
short course ICS at
onset of viral illness

16. -

17. Simple questions to ask to assess level
of asthma control
●Asthma symptom control :
●In the past 4 weeks patient had -
●1. day time asthma symptoms > twice a week?
●2. Any night wakenings ?
●3. Releiver(SABA) use for symptoms > twice a week ?
●4. Any activity limitation due to asthma ?
●Level of symptom control – well controlled (0),
● Partly controlled(1-2), Uncontrolled ( 3-4).

18. When to consider step down of treatment?
●1. Assess symptom control over past 4 weeks
●2. Assess future risk for poor asthma outcomes
●Risk factors for asthma exacerbations in next few months:
●Uncontrolled symptoms
●Severe exacerbation in past year
●Start of child’s usual flare-up season
Exposure to trigger (or likelihood of trigger like Festivals, Exam etc.),
●Poor adherence
●If well controlled for 3 months and no immediate risk for poor asthma outcomes: Step
down treatment

19. Stepping down treatment:
• While using ICS alone (med to high doses):
• 50% reduction at 3 months interval
• Control achieved at low dose ICS, switch to OD.
While using ICS+LABA:
• Reduce ICS by 50% while continuing LABA.
• Control maintained at low dose ICS+LABA, switch to OD

20. Aims of treatment
●To relieve airflow obstruction and hypoxemia as quickly as
possible, &
●To plan the prevention of future relapses.
●Prevent Asthma exacerbation
●Prevent Loss of lung function
●Minimal side effects of medications such as palpitations and
tremors.

21. Stopping treatment
Good control. No symptoms for 6-12 m & No risk factors.
● Stop controller regimen
● Trigger avoidance continues
● Written Home management plan for acute episodes (Step 1
regime)
●Follow up 3-6 monthly for 1-2 years
●Counsel regarding possible future resumption of controller, if
recurrences.

22. Very Important:
●Give Asthma Action plan
●Always prescribe for long term
●Demonstrate technique
●Green – breathing is good, no cough or wheeze, sleep through the night, can work
and play.
●Yellow – first signs of cold, exposure to known trigger, cough, mild wheeze, tight
chest, coughing at night.
●Red – Asthma is getting worse fast, medicine is not helping, breathing is hard and
fast, nose opens wide and ribs show, cannot talk well.

23. .

24. THANK YOU