Transcript Global Strategy for Asthma Management

Latest Guidelines for Asthma
Management
Global Initiative for Asthma
By: Dr. Mahmoud Taheri
Strategies for Asthma Management
and Prevention
Definition and Overview
 Diagnosis and Classification
 Asthma Medications
 Asthma Management and
Prevention Program
 Implementation of Asthma
Guidelines in Health
Systems

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
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Widespread, variable, and often reversible
airflow limitation
Asthma Inflammation: Cells and Mediators
Factors that Exacerbate Asthma

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Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
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
Is it Asthma?

Recurrent episodes of wheezing
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Troublesome cough at night
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Cough or wheeze after exercise
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Cough, wheeze or chest tightness
after exposure to airborne allergens
or pollutants
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Colds “go to the chest” or take more
than 10 days to clear
Asthma Diagnosis

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History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow

Measurement of airway responsiveness
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Measurements of allergic status to identify risk
factors
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
Measuring Variability of Peak
Expiratory Flow
Measuring Airway Responsiveness
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

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
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.
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
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
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
Asthma Management and Prevention Program
Factors Involved in Non-Adherence
Medication Usage
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Difficulties associated
with inhalers
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Complicated regimens
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Fears about, or actual
side effects
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Cost

Distance to pharmacies
Non-Medication Factors
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Misunderstanding/lack of
information
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Inappropriate expectations
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Underestimation of severity
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Attitudes toward ill health
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Cultural factors
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Poor communication
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors
 Measures to help reducing exposure to risk factors
should be implemented wherever possible.
 Asthma exacerbations are caused by a variety of
risk factors – allergens, viral infections, pollutants
and drugs.
 Reducing exposure to some risk factors improves
the control of asthma and reduces medications
needs.
Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors
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Reduce exposure to indoor allergens
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Avoid tobacco smoke
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Avoid vehicle emission

Identify irritants in the workplace

Explore role of infections on asthma
development
Asthma Management and Prevention Program
Influenza Vaccination
 Routine influenza vaccination of
children and adults with asthma does
not appear to protect them from
asthma exacerbations or improve
asthma control
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 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 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)
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)
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
*IMPORTANT*
Any exacerbation should
prompt review of
maintenance treatment
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
 Step 2 is the initial treatment for most
patients. If the patient is severely
uncontrolled, we start from step 3.
 Our approach includes:
- Assessing Asthma Control
- Treating to Achieve Control
Controller Medications
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Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled β2-agonists in combination
with inhaled glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones
Anti-IgE
Salbutamol (Albuterol)
Availability: Aerosol 90 mcg/inh.
 Brand Names: Ventolin
 Onset: 5-15 min
 Peak: 1 Hour
 Duration: 3-6 hrs.
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Salmeterol
Availability: Aerosol 25 mcg/inh.
 Brand Names: Serevent
 Onset: 10-25 min
 Peak: 3-4 hrs.
 Duration: 12 hrs.
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Beclomethasone
Availability: Aerosol 40 mcg/inh.
Aerosol 80 mcg/inh.
 Brand Names: Becotide, Beclazone, Qvar
 Onset: Within 24 hrs.
 Peak: 1-4 Weeks
 Duration: Unknown

Fluticasone
Availability: Aerosol 44 mcg/inh.
Aerosol 110 mcg/inh.
Aerosol 220 mcg/inh.
 Brand Names: Flovent
 Onset: Within 24 hrs.
 Peak: 1-4 Weeks
 Duration: Days after DC.

Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug
Low Daily Dose (g)
Medium Daily Dose (g)
High Daily Dose (g)
Beclomethasone
200-500
>500-1000
>1000
Budesonide
200-600
600-1000
>1000
Ciclesonide
80 – 160
>160-320
>320-1280
Flunisolide
500-1000
>1000-2000
>2000
Fluticasone
100-250
>250-500
>500
Mometasone furoate
200-400
> 400-800
>800-1200
Triamcinolone acetonide
400-1000
>1000-2000
>2000
Reliever Medications
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists
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
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Specific immunotherapy should be considered
only after strict environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
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
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)
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.
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
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)
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
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)
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)
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
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)
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)
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
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 effective 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)
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
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
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