Transcript GINA

G lobal
INitiative for
A sthma
GINA Workshop Report
Topics:
Definition
 Burden of Asthma
 Risk Factors
 Mechanisms
 Diagnosis and Classification
 Education and Delivery of Care
 Six Part Asthma Management Plan
 Research Recommendations

Definition of Asthma

Asthma is a chronic inflammatory disorder of the
airways in which many cells and cellular elements play
a role

Chronic inflammation causes an associated increase in
airway hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest tightness,
and coughing, particularly at night or in the early
morning

These episodes are usually associated with
widespread but variable airflow obstruction that is often
reversible either spontaneously or with treatment
Mechanisms Underlying the
Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION
Airway
Hyperresponsiveness
Risk Factors
(for exacerbations)
Airflow Obstruction
Symptoms
Burden of Asthma

Asthma is one of the most common chronic
diseases worldwide

Prevalence increasing in many countries,
especially in children

A major cause of school/work absence

An overall increase in severity of asthma
increases the pool of patients at risk for
death
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
Worldwide
Variation in
Prevalence of
Asthma
Symptoms
International Study of
Asthma and Allergies in
Children (ISAAC)
Lancet 1998;351:1225
Increasing Prevalence of Asthma in
Children/Adolescents
{1966
1989
Sweden
{1979
1991
Japan
{1982
1992
Scotland
{1982
1992
UK
{1989
1994
USA
{1982
1992
New Zealand 1975
{1989
Australia
{1982
1992
Finland
(Haahtela et al)
(Aberg et al)
(Nakagomi et al)
(Rona et al)
(Omran et al)
(NHIS)
(Shaw et al)
(Peat et al)
0
5
10
15
20
Prevalence (%)
25
30
35
Trends in Prevalence of Asthma
By Age, U.S., 1985-1996
80
Rate/1,000 Persons
Age (years)
70
<18
18-44
60
45-64
50
65+
Total (All Ages)
40
30
20
85 86
87
88 89 90 91 92 93 94
Year
95 96
Hospitalization Rates for Asthma
by Age, U.S., 1974 - 1997
Rate/100,000 Persons
40
35
<15
15-44
45-64
65+
30
25
20
15
10
5
0
74
76
78
80
82
84
86
Year
88
90
92
94
96
Death Rates for Asthma
By Race, Sex, U.S., 1980-1998
Rate/100,000 Persons
5
Black Female
4
Black Male
3
White Female
2
White Male
1
0
1980
1985
1990
Year
1995
2000
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
Factors that Exacerbate Asthma







Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Risk Factors that Lead to
Asthma Development
Host Factors
Environmental Factors
 Genetic predisposition
 Atopy
 Airway hyperresponsiveness
 Gender
 Race/Ethnicity

Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Parasitic infections
 Socioeconomic factors
 Family size
 Diet and drugs
 Obesity
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
Asthma Diagnosis

History and patterns of symptoms

Physical examination

Measurements of lung function

Measurements of allergic status to
identify risk factors
Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
Nocturnal
Symptoms
Continuous
Limited physical
activity
Frequent
Daily
Attacks affect activity
> 1 time week
> 1 time a week
but < 1 time a day
 60% predicted
Asymptomatic
and normal PEF
between attacks
Variability > 30%
60 - 80% predicted
> 2 times a month
Variability > 30%
 80% predicted
Variability 20 - 30%
< 1 time a week
STEP 1
Intermittent
FEV1 or PEF
 2 times a month
 80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.
Six-Part Asthma Management
Program
1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for
Chronic Management: Adults and
Children
5. Establish Plans for Managing
Exacerbations
6. Provide Regular Follow-up Care
Six-Part Asthma Management
Program
1. Educate patients to develop a partnership in
asthma management
2. Assess and monitor asthma severity with
symptom reports and measures of lung
function as much as possible
3. Avoid exposure to risk factors
4. Establish medication plans for chronic
management in children and adults
5. Establish individual plans for managing
exacerbations
6. Provide regular follow-up care
Six-part Asthma Management Program
Goals of Long-term Management







Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Maintain pulmonary function as close to normal
levels as possible
Maintain normal activity levels, including
exercise
Avoid adverse effects from asthma medications
Prevent development of irreversible airflow
limitation
Prevent asthma mortality
Six-part Asthma Management Program
Control of Asthma

Minimal (ideally no) chronic symptoms

Minimal (infrequent) exacerbations

No emergency visits

Minimal (ideally no) need for “as needed” use of
β2-agonist

No limitations on activities, including exercise

PEF circadian variation of less than 20 percent

(Near) normal PEF

Minimal (or no) adverse effects from medicine
Six-Part Asthma Management
Program
.

The most effective management is to
prevent airway inflammation by
eliminating the causal factors

Asthma can be effectively controlled in
most patients, although it can not be
cured

The major factors contributing to asthma
morbidity and mortality are underdiagnosis and inappropriate treatment
Six-Part Asthma Management
Program

Any asthma more severe than
intermittent asthma is more effectively
controlled by treatment to suppress and
reverse airway inflammation than by
treatment only of acute
bronchoconstriction and symptoms
Six-part Asthma Management Program
Part 1: Educate Patients to
Develop a Partnership
 Aim is guided self-management – giving
patients the ability to control their asthma
 Interventions, including use of written
action plans, have been shown to reduce
morbidity in both children and adults
Six-part Asthma Management Program
Part 1: Educate Patients to
Develop a 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
Six-part Asthma Management Program
Factors Associated with
Non-Compliance in Asthma Care
Medication Usage
Patient/Physician
Misunderstanding/lack of
information

Difficulties associated
with inhalers


Complicated regimens

Underestimation of severity

Fears about, or actual
side effects

Attitudes toward ill health

Cultural factors

Poor communication

Cost
Six-part Asthma Management Program
Part 2: Assess and Monitor Asthma Severity
with Symptom Reports and Measures of Lung
Function
 Symptom



reports
Use of reliever medication
Nighttime symptoms
Activity limitations
 Spirometry
for initial assessment. Peak Expiratory Flow for
follow-up:


Assess severity
Assess response to therapy
 PEF




monitoring at home
Important for those with poor perception of symptoms
Daily measurement recorded in a diary
Assesses the severity and predicts worsening
Guides the use of a zone system for asthma self-management
 Arterial
blood gas for severe exacerbations
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
A Simple Index of PEF Variation
Highest PEF (670)
PEF (L/min)
800
700
600
500
Morning PEF
Evening PEF
Lowest morning PEF (570)
400
300
0
7
14
Days
Minimum morning PEF ( % recent best): 570/670 = 85%
(From Reddel, H.K. et al. 1995)
Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk
Factors
 Methods to prevent onset of asthma are
not yet available but this remains an
important goal
 Measures to reduce exposure to causes
of asthma exacerbations (e.g. allergens,
pollutants, foods and medications)
should be implemented whenever
possible
Six-part Asthma Management Program
Part 3: Avoid 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
Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management

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
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy
The choice of treatment should be guided by:

Severity of the patient’s asthma

Patient’s 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.
Part 4: Long-term Asthma Management
Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids
 Systemic glucocorticosteroids
 Cromones
 Methylxanthines
 Long-acting inhaled β2-agonists
 Long-acting oral β2-agonists
 Leukotriene modifiers
 Anti-IgE

Part 4: Long-term Asthma Management
Pharmacologic Therapy
Reliever Medications:

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Methylxanthines

Short-acting oral β2-agonists
Estimated Comparative Daily Dosages
for Inhaled Glucocorticosteroids
Drug
Low Daily Dose (g)
Adult
Child
Medium Daily Dose (g)
Adult
Child
High Daily Dose (g)
Adult
Child
BeclomethasoneCFC
200-500
100-250
500-1000
250-500
> 1000
> 500
BeclomethasoneHFA
100-250
50-200
250-500
200-400
> 500
> 400
Budesonide-DPI
200-600
100-200
600-1000
200- 600
> 1000
> 600
Budesonide-Neb
250-500
500-1000
>1000
Flunisolde
500-1000
500 -750
1000-2000
750-1250
> 2000
> 1250
Fluticasone
100- 250
100-200
250- 500
200- 400
> 500
> 400
Mometasone
furoate
200- 400
Triamcinolone
acetonide
400- 1000
400- 800
400-800
1000-2000
> 800
800-1200
> 2000
> 1200
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Best
Possible Results
Outcome: Asthma Control
Controller:

Controller:
Controller:
None
Controller:
Daily inhaled
corticosteroid



Daily inhaled
corticosteroid
plus
Daily longacting inhaled
β2-agonist


Daily inhaled
corticosteroid
plus
Daily long –
acting inhaled
β2-agonist
plus (if needed)
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor
Reliever: Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).
Recommended Asthma Medications
Step 1: Adults
Severity
Daily Controller
Medications
Step 1:
• None
Intermittent
Other Options (in order
of cost)
• None
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more
than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Recommended Asthma Medications
Step 2: Adults
Severity
Daily Controller
Medications
Other Options (in order
of cost)
Step 2:
Mild
Persistent
• Low-dose inhaled • Sustained-release
glucocorticosteroid theophylline, or
• Cromone, or
• Leukotriene modifier
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more
than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Recommended Asthma Medications
Step 3: Adults
Severity
Daily Controller
Medications
Other Options (in order of cost)
Step 3:
Moderate
persistent
• Low- to medium-dose
inhaled glucocorticosteroid plus long-acting
inhaled β2- agonist
• Medium-dose inhaled glucocorticosteroid
plus sustained- release theophylline, or
• Medium-dose inhaled glucocorticosteroid
plus long-acting inhaled β2- agonist, or
• High-dose inhaled glucocorticosteroid, or
• Medium-dose inhaled glucocorticosteroid
plus leukotriene modifier
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more
than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Recommended Asthma Medications
Step 4: Adults
Severity
Daily Controller Medications
Step 4
Severe
persistent
• High-dose inhaled glucocorticosteroid
plus long-acting inhaled β2- agonist
plus one or more of the following, if
needed:
-
Other Options
Sustained-release theophylline
Leukotriene modifier
Long-acting inhaled β2- agonist
Oral glucocorticosteroid
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more
than 3-4 times a day. Once control is achieved and maintained for at
least 3 months, gradual reduction of therapy should be tried.
Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in
Infants and Children
 Childhood and adult asthma share the
same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ
from those in adults.
Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in
Infants and Children
 Many asthma medications (e.g.
glucocorticosteroids, β2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in
Infants and Children
 Long-term treatment with inhaled
glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
 Studies including a total of over 3,500
children treated for periods of 1 – 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
Six-part Asthma Management Program
Part 4: Establish Medication Plans for
Long-Term Asthma Management in
Infants and Children
 Rapid-acting inhaled β2- agonists are
the most effective reliever therapy for
children
 These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
Six-part Asthma Management Program
Part 5: Establish Plans for
Managing 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
Six-part Asthma Management Program
Part 5: Establish Plans for
Managing 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
Six-part Asthma Management Program
Part 5: Managing Severe Asthma
Exacerbations
 Severe exacerbations are lifethreatening medical emergencies
 Care must be expeditious and treatment
is often most safely undertaken in a
hospital or hospital-based emergency
department
Emergency Department Management
Acute Asthma
Initial Assessment
History, Physical Examination, PEF or FEV1
Initial Therapy
Bronchodilators; O2 if needed
Good Response
Observe for at
least 1 hour
If Stable,
Discharge to
Home
Incomplete/Poor Response
Respiratory Failure
Add Systemic Glucocorticosteroids
Good Response
Poor Response
Discharge
Admit to Hospital
Admit to ICU
Six-part Asthma Management Program
Part 6: Provide Regular
Follow-up Care
Continual monitoring is essential to assure that
therapeutic goals are met. Frequent follow-up visits
are necessary to review:
 Home PEF and symptom records
 Techniques in use of medications
 Risk factors and their control
Once asthma control is established, follow-up
visits should be scheduled (at 1 to 6 month intervals
as appropriate)
Six-part Asthma Management Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Physical activity
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
Six-part Asthma Management
Program: Summary
 Asthma can be effectively controlled, although it
cannot be cured

Effective asthma management programs include
education, objective measures of lung function,
environmental control, and pharmacologic therapy

A stepwise approach to pharmacologic therapy is
recommended. The aim is to accomplish the
goals of therapy with the least possible medication
Six-part Asthma Management
Program: Summary (continued)

Anything more than mild, occasional asthma is
more effectively controlled by suppressing
inflammation than by only treating acute
bronchospasm

The availability of varying forms of treatment,
cultural preferences, and differing health care
systems need to be considered
http://www.ginasthma.com
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Best
Possible Results
Outcome: Asthma Control
Controller:

Controller:
Controller:
None
Controller:
Daily inhaled
corticosteroid



Daily inhaled
corticosteroid
Daily longacting inhaled
β2-agonist


Daily inhaled
corticosteroid
Daily long –
acting inhaled
β2-agonist
plus(if needed)
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

When
asthma is
controlled,
reduce
therapy

Monitor
Reliever: Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate
Persistent
STEP 4:
Severe
Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).
Stepwise Approach to Asthma Therapy: Adults
Step 1: Intermittent Asthma
Daily Controller
Medications
None required
Reliever
Medications
Rapid-acting inhaled 2-agonist
for symptoms (but < once a week)
Rapid-acting inhaled 2-agonist,
cromone, or leukotriene modifier
before exercise or exposure to
allergen




Continuously review medication technique, compliance and environmental control
Review treatment every three months.
Step up if control is not achieved; step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Stepwise Approach to Asthma Therapy: Adults
Step 2: Mild Persistent Asthma
Daily Controller
Medications
Reliever
Medications
Low-dose inhaled
glucocorticosteroid
Rapid-acting inhaled 2-agonist
for symptoms (but < 3-4 times/day)
Other options (order by cost):
 sustained-release theophylline, or
 Cromone, or
 leukotriene modifier
Other options:
 inhaled anticholinergic, or
 short-acting oral 2-agonist, or
 short-acting theophylline




Continuously review medication technique, compliance and environmental control.
Review treatment every three months
Step up if control is not achieved; Step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Stepwise Approach to Asthma Therapy: Adults
Step 3: Moderate Persistent Asthma
Daily Controller
Medications
Low- to medium-dose inhaled glucocorticosteroid, plus long-acting inhaled 2-agonist
Other options (order by cost):
 Medium-dose inhaled glucocorticosteroid plus
sustained-release theophylline, or
 Medium-dose inhaled glucocorticosteroid plus longacting inhaled β2- agonist, or
 High-dose inhaled glucocorticosteroid, or
 Medium-dose inhaled glucocorticosteroid plus
leukotriene modifier




Reliever
Medications
Rapid-acting inhaled
2-agonist for symptoms
(but < 3 - 4 times/day)
Other options:
 inhaled anticholinergic or
 short-acting oral
2-agonist or
 short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: Adults
Step 4: Severe Persistent Asthma
Daily Controller
Medications
High-dose inhaled glucocorticosteroid,
plus long-acting inhaled β2agonist
plus one or more of the following, if
needed (order by cost):
 sustained-release theophylline, or
 leukotriene modifier or
 oral glucocorticosteroid




Reliever
Medications
Rapid-acting inhaled
2-agonist for symptoms
(but < 3-4 times/day)
Other options:
 inhaled anticholinergic or
 short-acting oral
2-agonist or
 short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.