GLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SET January 2013
GLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SET January 2013 This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA. © Global Initiative for Asthma G lobal INitiative for A sthma © 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 © Global Initiative for Asthma GINA Structure Executive Committee Chair: Mark FitzGerald, MD Dissemination Committee Science Committee Chair: L.B. Boulet, MD Chair: Helen Reddel, MD © Global Initiative for Asthma GINA Board of Directors M. FitzGerald, Chair, Canada E. Bateman, S. Africa P. Paggario, Italy L.P. Boulet, Canada S. Pedersen, Denmark A. Cruz, Brazil H. Reddel, Australia M. Haahtela, Finland M. Soto-Quiroz, Costa Rica M. Levy, U.K. G. Wong, Hong Kong ROC P. O’Byrne, Canada © Global Initiative for Asthma GINA Science Committee H. Reddel, Chair, Australia N. Barnes, UK M. FitzGerald, Canada P. Barnes, UK R. Lemanske, US A. Becker, Canada P. O’Byrne, Canada E. Bel, Netherlands E. Pizzichini, Brazil J. DeJongste, Netherlands S. Pedersen, Denmark J. Drazen, US H. Reddel, Australia © Global Initiative for Asthma GINA Structure Executive Committee Chair: Mark FitzGerald, MD Dissemination Committee Science Committee Chair: L.P. Boulet, MD Chair: H. Reddel, MD GINA ASSEMBLY © Global Initiative for Asthma 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 Initiative for Asthma Saudi Arabia Bangladesh Pakistan Israel Slovenia Germany Ireland Yugoslavia Croatia Australia Canada Brazil Austria United States Taiwan Portugal Thailand Philippines Malta Greece Mexico Moldova China Syria Egypt South Africa United Kingdom Hong Kong ROC Chile New Zealand Italy Venezuela Cambodia Argentina Lebanon Mongolia Poland Korea Switzerland GINA Assembly Russia Turkey Czech India Macedonia France Sweden Albania Netherlands Georgia Denmark Belgium Slovakia Republic Colombia Ukraine Romania Japan Singapore Kyrgyzstan Spain Vietnam GINA Documents Global Strategy for Asthma Management and Prevention (updated 2012) Pocket Guide: Asthma Management and Prevention (updated 2012) Global Strategy for Asthma Management and Prevention for Children 5 Years and Younger (2009) Pocket Guide: Asthma Management and Prevention in Children 5 Years and younger (2009) Guide for asthma patients and families All materials are available on GINA web site www.ginasthma.org © Global Initiative for Asthma Global Strategy for Asthma Management and Prevention Evidence-based Implementation oriented Diagnosis Management Prevention Outcomes can be evaluated © Global Initiative for Asthma 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 © Global Initiative for Asthma Global Strategy for Asthma Management and Prevention (2012) Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems Updated 2012 © Global Initiative for Asthma 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 © Global Initiative for Asthma Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD Mechanisms: Asthma Inflammation Source: Peter J. Barnes, MD Asthma Inflammation: Cells and Mediators Source: Peter J. Barnes, MD 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma Asthma Prevalence and Mortality Source: Masoli M et al. Allergy 2004 Countries should enter their own data on burden of asthma. 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 © Global Initiative for Asthma Factors that Exacerbate Asthma Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 Time (sec) 5 Note: Each FEV1 curve represents the highest of three repeat measurements © Global Initiative for Asthma Measuring Variability of Peak Expiratory Flow Measuring Airway Responsiveness © Global Initiative for Asthma 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 Updated 2012 5. Special Considerations © Global Initiative for Asthma 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 © Global Initiative for Asthma Asthma Management and Prevention Program: Five Interrelated 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 © Global Initiative for Asthma 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. © Global Initiative for Asthma 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 © Global Initiative for Asthma Asthma Management and Prevention 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes 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. © Global Initiative for Asthma 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 © Global Initiative for Asthma 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. © Global Initiative for Asthma Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for 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 Initiative for Asthma 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 (assess patient risk) © Global Initiative for Asthma Levels of Asthma Control (Assess patient impairment) Characteristic Controlled Partly controlled (All of the following) (Any present in any week) Daytime symptoms Twice or less per week More than twice per week Limitations of activities None Any Nocturnal symptoms / awakening None Any Need for rescue / “reliever” treatment Twice or less per week More than twice per week Normal < 80% predicted or personal best (if known) on any day Lung function (PEF or FEV1) Uncontrolled 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) © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 © Global Initiative for Asthma Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma 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 © Global Initiative for Asthma Asthma Management and Prevention Program 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 © Global Initiative for Asthma Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE © Global Initiative for Asthma Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (g) > 5 y Age < 5 y Medium Daily Dose (g) > 5 y Age < 5 y Beclomethasone 200-500 100-200 >500-1000 >200-400 Budesonide 200-600 100-200 600-1000 >200-400 Budesonide-Neb Inhalation Suspension Ciclesonide 250-500 80 – 160 High Daily Dose (g) > 5 y Age < 5 y >1000 >1000 500-1000 >400 >400 >1000 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 Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 © Global Initiative for Asthma >400 >1200 Reliever Medications Rapid-acting inhaled β2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral β2-agonists © Global Initiative for Asthma 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 © Global Initiative for Asthma 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 1 2 3 4 5 © Global Initiative for Asthma TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, 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 β2-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) © Global Initiative for Asthma TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER Treating to Achieve Asthma 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 © Global Initiative for Asthma TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER Treating to Achieve Asthma Control Step 3 – Reliever medication plus one or two controllers For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled longacting β2-agonist either in a combination inhaler device or as separate components (Evidence A) Inhaled long-acting β2-agonist must not be used as monotherapy For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A) © Global Initiative for Asthma Treating to Achieve Asthma 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) © Global Initiative for Asthma TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER Treating to Achieve Asthma 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 © Global Initiative for Asthma Treating to Achieve Asthma Control Step 4 – Reliever medication plus two or more controllers Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-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 β2-agonist (Evidence B) © Global Initiative for Asthma TO STEP 3 TREATMENT, SELECT ONE OR MORE: Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER 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) © Global Initiative for Asthma 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 © Global Initiative for Asthma 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) © Global Initiative for Asthma Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B) If control is maintained, reduce to lowdose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D) © Global Initiative for Asthma Treating to Maintain Asthma Control Stepping up treatment in response to loss of control Rapid-onset, short-acting or longacting 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 © Global Initiative for Asthma Treating to Maintain Asthma Control Stepping up treatment in response to loss of control Use of a combination rapid and long-acting inhaled β2-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) © Global Initiative for Asthma Asthma Management and Prevention 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 lifethreatening and treatment requires close supervision © Global Initiative for Asthma Asthma Management and Prevention Program Component 4: Manage Asthma 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 © Global Initiative for Asthma Asthma Management and Prevention Program Component 4: Manage Asthma Exacerbations Primary therapies for exacerbations: • Repetitive administration of rapid-acting inhaled β2-agonist • Early introduction of systemic glucocorticosteroids • Oxygen supplementation Closely monitor response to treatment with serial measures of lung function © Global Initiative for 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 © Global Initiative for Asthma Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger 2009 www.ginasthma.org © Global Initiative for Asthma Asthma Management and Prevention Program: Summary Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms 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 © Global Initiative for Asthma Asthma Management and Prevention Program: Summary A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered © Global Initiative for Asthma http://www.ginasthma.org © Global Initiative for Asthma
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