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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
Chair: L.B. Boulet, MD
Science Committee
Chair: Helen Reddel, MD
GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD
Dissemination Committee
Chair: L.P. Boulet, MD
Science Committee
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
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 Italy New Zealand
Lebanon
Saudi Arabia
Bangladesh
Argentina
Mongolia
Poland Korea
GINA Assembly
Macedonia France
Belgium
Switzerland
Russia
Georgia
Denmark Spain Vietnam
Turkey Czech
India
Singapore
Kyrgyzstan
GINA Documents
Global Strategy for Asthma Management and
Prevention (updated 2012)
A B
C
D
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
Definition of Asthma
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
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
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
Global Initiative for Asthma
Is it 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
Normal Subject
2 3 4 Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
Global Initiative for Asthma
5. Special Considerations
Global Initiative for Asthma
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 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
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
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
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
Global Initiative for Asthma
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.
Non-Medication Factors
Complicated regimens
Fears about, or actual side effects Cost Distance to pharmacies
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
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
the attainment of control correlates with a better quality of life, and reduction in health care use
Global Initiative for Asthma
Maintain control once treatment has been implemented (assess patient risk)
Global Initiative for Asthma
Characteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment
Partly controlled
(Any present in any week)
Uncontrolled
Any More than twice per week < 80% predicted or personal best (if known) on any day
Normal
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Global Initiative for Asthma
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
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
Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled 2-agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE
Reliever Medications
Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral 2-agonists
Global Initiative for Asthma
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
LEVEL OF CONTROL
controlled partly controlled
REDUCE INCREASE
TREATMENT OF ACTION
maintain and find lowest controlling step consider stepping up to gain control
uncontrolled exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
3
Global Initiative for Asthma
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
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
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)
Global Initiative for Asthma
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
Asthma control should be monitored by the health care professional and by the patient
Global Initiative for Asthma
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
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)
Global Initiative for Asthma
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
Global Initiative for Asthma
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)
Global Initiative for Asthma
Severe exacerbations are potentially lifethreatening and treatment requires close supervision
Global Initiative for Asthma
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
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 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