Global Initiative for Asthma (GINA)

GINA Global Strategy for Asthma

Management and Prevention

© Global Initiative for Asthma

Razões para as mudanças de 2019 –
Os riscos do tratamento único som SABA

 Uso regular ou frequente de SABA está associado a riscos adversos:

 Feedback negativo de receptores b, diminuição da broncoproteção,
hiperresponsividade de rebote, resposta diminuída aos broncodilatadores. (Hancox,
Respir Med 2000)
 Aumento da resposta aos alérgenos e aumento da inflamação eosinofílica das vias
aéreas. (Aldridge, AJRCCM 2000)

 Maior uso de SABA está associado a repercussões clínicas adversas:

 O uso de 3 ou mais frascos por ano (aproximadamente 1,7 puffs/dia) está
associado com maior risco da necessidade de buscar um serviço de emergência.
(Stanford, AAAI 2012)
 O uso de 12 ou mais frascos ao ano (aproximadamente 6,8 puffs/dia) está
associado a maior risco de óbito. (Suissa, AJRCCM 1994)

© Global Initiative for Asthma, www.ginasthma.org

 GINA 2018

Step 1 treatment is for

patients with symptoms
<twice/month and no risk
factors for exacerbations

Previously, no controller
was recommended for
Step 1, i.e. SABA-only
treatment was ‘preferred’

GINA 2018, Box 3-5 (2/8) (upper part) © Global Initiative for Asthma, www.ginasthma.org
GINA © Global Initiative for Asthma, www.ginasthma.org
 Abreviações

 SABA: agonistas dos receptores beta adrenérgicos de ação curta, ex

salbutamol.

 LABA: agonistas dos receptores beta adrenérgicos de ação longa, ex

formoterol.

 LTRA: antagonistas de leucotrienos.

 CI: corticóide inalatório.

 CO: corticóide oral.

© Global Initiative for Asthma, www.ginasthma.org

 STEP 1

 O tratamento no Step 1 está direcionado a pessoas que apresentem sintomas

<2 vezes/mês e sem fatores de risco para exacerbações.

 Por razões de segurança, o GINA não recomenda mais que o primeiro passo
consista apenas na utilização de SABA durante as crises.
 Isso se baseia nas evidências de que o uso de CI diminui significativamente o risco
de exacerbações graves.

 A recomendação atual é de que as crianças maiores de 12 anos e adultos

associem CI ou CI-LABA ao SABA quando apresentarem sintomas.

© Global Initiative for Asthma, www.ginasthma.org

 Box 3-5A Confirmation of diagnosis if necessary
Adults & adolescents 12+ years Symptom control & modifiable
risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Personalized asthma management: Patient goals
Assess, Adjust, Review response
Symptoms
Exacerbations
Side-effects
Lung function
Patient satisfaction Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
Asthma medications STEP 4
Refer for
individual patient needs STEP 3 Medium dose phenotypic
assessment
STEP 2 ICS-LABA
Low dose ± add-on
PREFERRED STEP 1 therapy,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA e.g.tiotropium,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IgE,
and control symptoms low dose anti-IL5/5R,
ICS-formoterol * anti-IL4R
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose ICS, add-on OCS, but
SABA is taken † ICS+LTRA # tiotropium, or consider
add-on LTRA # side-effects
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed
† Off-label; separate or combination ICS and SABA inhalers bud-form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with
© Global Initiative for Asthma, www.ginasthma.org allergic rhinitis and 1FEV >70% predicted
 STEP 2

É recomendado:

 Uso diário de baixas doses de CI + SABA durante as crises;

 Uso de CI-LABA sempre que for utilizado SABA;

 Uso de LTRA sempre que for utilizado SABA;

 Uso de baixas doses de CI sempre que for utilizado SABA.

© Global Initiative for Asthma, www.ginasthma.org

 Box 3-5A Confirmation of diagnosis if necessary
Adults & adolescents 12+ years Symptom control & modifiable
risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Personalized asthma management: Patient goals
Assess, Adjust, Review response
Symptoms
Exacerbations
Side-effects
Lung function
Patient satisfaction Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
Asthma medications STEP 4
Refer for
individual patient needs STEP 3 Medium dose phenotypic
assessment
STEP 2 ICS-LABA
Low dose ± add-on
PREFERRED STEP 1 therapy,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA e.g.tiotropium,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IgE,
and control symptoms low dose anti-IL5/5R,
ICS-formoterol * anti-IL4R
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose ICS, add-on OCS, but
SABA is taken † ICS+LTRA # tiotropium, or consider
add-on LTRA # side-effects
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed
† Off-label; separate or combination ICS and SABA inhalers bud-form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with
© Global Initiative for Asthma, www.ginasthma.org allergic rhinitis and 1FEV >70% predicted
 STEP 3

É recomendado:

 Uso regular de baixas doses de CI-LABA + SABA durante as crises;

 Uso diário regular de médias doses de CI + SABA durante as crises;

 Uso diário regular de baixas doses de CI-LTRA + SABA durante as crises.

 Obs: uso de CI-formoterol se necessário.

© Global Initiative for Asthma, www.ginasthma.org

 Box 3-5A Confirmation of diagnosis if necessary
Adults & adolescents 12+ years Symptom control & modifiable
risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Personalized asthma management: Patient goals
Assess, Adjust, Review response
Symptoms
Exacerbations
Side-effects
Lung function
Patient satisfaction Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
Asthma medications STEP 4
Refer for
individual patient needs STEP 3 Medium dose phenotypic
assessment
STEP 2 ICS-LABA
Low dose ± add-on
PREFERRED STEP 1 therapy,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA e.g.tiotropium,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IgE,
and control symptoms low dose anti-IL5/5R,
ICS-formoterol * anti-IL4R
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose ICS, add-on OCS, but
SABA is taken † ICS+LTRA # tiotropium, or consider
add-on LTRA # side-effects
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed
† Off-label; separate or combination ICS and SABA inhalers bud-form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with
© Global Initiative for Asthma, www.ginasthma.org allergic rhinitis and 1FEV >70% predicted
 STEP 4

É recomendado:

 Uso diário regular de médias doses de CI-LABA + SABA durante as crises;

 Uso regular de altas doses de CI + tiotrópio + SABA durante as crises;

 Uso regular de altas doses de CI + LTRA + SABA durante as crises.

 Obs: uso de CI-formoterol se necessário.

© Global Initiative for Asthma, www.ginasthma.org

 Box 3-5A Confirmation of diagnosis if necessary
Adults & adolescents 12+ years Symptom control & modifiable
risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Personalized asthma management: Patient goals
Assess, Adjust, Review response Step 4 treatment is
Symptoms medium dose ICS-LABA;
Exacerbations
Side-effects high dose now in Step 5
Lung function
Patient satisfaction Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
Asthma medications STEP 4
Refer for
individual patient needs STEP 3 Medium dose phenotypic
assessment
STEP 2 ICS-LABA
Low dose ± add-on
PREFERRED STEP 1 therapy,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA e.g.tiotropium,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IgE,
and control symptoms low dose anti-IL5/5R,
ICS-formoterol * anti-IL4R
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose ICS, add-on OCS, but
SABA is taken † ICS+LTRA # tiotropium, or consider
add-on LTRA # side-effects
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed
† Off-label; separate or combination ICS and SABA inhalers bud-form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with
© Global Initiative for Asthma, www.ginasthma.org allergic rhinitis and 1FEV >70% predicted
 STEP 5

 É recomendado uso regular de altas doses de CI-LABA + SABA durante as

crises. Também pode ser necessária a associação de terapia com tiotrópio, anti-
igE, anti interleucinas…

 Algumas fonts recomendam o uso de CO em baixas doses, porém deve-se

lembrar dos riscos sistêmicos desse tratamento.

 Obs: uso de CI-formoterol se necessário.

© Global Initiative for Asthma, www.ginasthma.org

 Box 3-5A Confirmation of diagnosis if necessary
Adults & adolescents 12+ years Symptom control & modifiable
risk factors (including lung function)
Comorbidities
Inhaler technique & adherence
Personalized asthma management: Patient goals
Assess, Adjust, Review response
See severe asthma
Symptoms Pocket Guide for
Exacerbations
Side-effects
details about Step 5
Lung function
Patient satisfaction Treatment of modifiable risk
factors & comorbidities STEP 5
Non-pharmacological strategies
Education & skills training High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
Asthma medications STEP 4
Refer for
individual patient needs STEP 3 Medium dose phenotypic
assessment
STEP 2 ICS-LABA
Low dose ± add-on
PREFERRED STEP 1 therapy,
CONTROLLER Daily low dose inhaled corticosteroid (ICS), ICS-LABA e.g.tiotropium,
to prevent exacerbations As-needed or as-needed low dose ICS-formoterol * anti-IgE,
and control symptoms low dose anti-IL5/5R,
ICS-formoterol * anti-IL4R
Other Low dose ICS Leukotriene receptor antagonist (LTRA), or Medium dose High dose Add low dose
controller options taken whenever low dose ICS taken whenever SABA taken † ICS, or low dose ICS, add-on OCS, but
SABA is taken † ICS+LTRA # tiotropium, or consider
add-on LTRA # side-effects
PREFERRED As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡
RELIEVER
Other As-needed short-acting β2 -agonist (SABA)
reliever option
* Off-label; data only with budesonide-formoterol (bud-form) ‡ Low-dose ICS-form is the reliever for patients prescribed
† Off-label; separate or combination ICS and SABA inhalers bud-form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with
© Global Initiative for Asthma, www.ginasthma.org allergic rhinitis and 1FEV >70% predicted