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GOOD MORNING~

Key changes in GINA Strategy Report


2014

oDiagnosis

o A new definition of asthma for clinical

practice
o Emphasis on confirming the diagnosis of
asthma, to avoid both under- and overtreatment

oAsthma control

o Two domains - symptom control + risk


factors for adverse outcomes

Key changes in GINA Strategy Report


2014
o A practical and comprehensive
approach to management
o Treating asthma to control symptoms and
minimize risk
o Cycle of care: Assess, Adjust treatment and
Review response
o Before considering step-up, maximize the
benefit of existing medications by checking
inhaler technique
and adherence
o Non-pharmacological treatments, modifiable
risk factors, comorbidities

Key changes in GINA Strategy Report


2014
o Continuum of care for worsening
asthma and
exacerbations

o New flow-charts, and revised

recommendations for written action


plans

o Diagnosis of asthma, COPD and


Asthma-

COPD overlap (ACOS)

What is

Definition

heterogeneous disease

characterized by chronic
airway inflammation

Definition
Wheeze

Chest
Tightnes
s

Shortne
ss of
Breath

Cough

variable
expiratory
airflow
limitation

PATHOGENESIS OF

FACTORS INFLUENCING THE


DEVELOPMENT AND EXPRESSION OF
ASTHMA

o HOST FACTORS
o Genetic

predisposing to atopy
predisposing to airway hyperresponsiveness

o Obesity
o Sex

FACTORS INFLUENCING THE


DEVELOPMENT AND EXPRESSION OF
ASTHMA

o ENVIRONMENTAL FACTORS
o Allergens
o Infections (predominantly viral)
o Occupational sensitizers
o Tobacco smoke
o Air pollution
o Diet

MECHANISMS OF ASTHMA

o Airway inflammation is a

consistent feature

o persistent even if symptoms are

episodic
o affects all airways but is more
pronounced in the medium-sized
bronchi

NE
W

Patterns of Respiratory
Symptoms that are
characteristic of asthma

More than one symptom (wheeze,


shortness of
breath, cough, chest
tightness) especially in adults

Symptoms often worse at night or early


in the morning

Patterns of Respiratory
Symptoms that are
characteristic of asthma

Symptoms vary over time and in


intensity

Symptoms are triggered by viral


infections
(colds), exercise,
allergen exposure, changes in the
weather, laughter, irritants such as
car exhaust fumes, smoke or strong
smells.

Features that decrease that


the probability of the
respiratory symptoms are
due to asthma

Isolated cough with no other


respiratory symptoms

Chronic production of sputum

Chest pains

Features that decrease that


the probability of the
respiratory symptoms are
due to asthma

Shortness of breath associated with


dizziness and light-headedness or
peripheral tingling (paresthesia)

Exercise-induced dyspnea with noisy


inspiration

Step 2. Low-dose controller and


as- needed SABA

o Other options

o Leukotriene receptor antagonists


(LTRA) with as-needed SABA

Less effective than low dose ICS


May be used for some patients with both
asthma and allergic rhinitis, or if patient
will not use ICS

Step 2. Low-dose controller and


as- needed SABA

o Other options

o Combination low dose ICS/long-

acting beta2-agonist (LABA) with


as-needed SABA

Reduces symptoms and increases lung


function compared with ICS

More expensive, and does not further


reduce exacerbations

STEP 3. One or two controllers


and as-needed SABA

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

STEP 3. One or two controllers and


as-needed SABA
o

Before considering step-up, check inhaler


technique and adherence, confirm diagnosis

o ADULTS/ADOLESCENTS

o either combination low dose ICS/LABA


maintenance with as-needed SABA
OR
o combination low dose ICS/formoterol
maintenance and reliever regimen

STEP 3. One or two controllers and


as-needed SABA

o Adding LABA reduces symptoms


and exacerbations and increases
FEV1, while allowing lower dose
of ICS

STEP 3. One or two controllers and


as-needed SABA

o In at-risk patients, maintenance

and reliever regimen significantly


reduces exacerbations with similar
level of symptom control and
lower ICS doses compared with
other regimens

STEP 4. Two or more controllers


and as-needed SABA

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

STEP 4. Two or more controllers


and as-needed SABA

o ADULTS/ADOLESCENTS
o low dose ICS/formoterol as
maintenance
regimen*

and reliever

OR

o combination medium dose ICS/LABA


with as-

needed SABA

STEP 4. Two or more controllers


and as-needed SABA

oTrial of high dose combination

ICS/LABA, but little extra benefit and


increased risk of side- effects
o Increase dosing frequency (for
budesonide- containing inhalers)
o Add-on LTRA or low dose theophylline

STEP 5. Higher level care


and/or add-on treatment

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

STEP 5. Higher level care and/or


add-on treatment

o Add-on omalizumab (anti-IgE) for

moderate
or severe allergic asthma
(uncontrolled on Step 4 treatment)
o Add-on low dose oral corticosteroids
(7.5mg/day prednisone equivalent)

REVIEWING RESPONSE AND


ADJUSTING TREATMENT

o How often should asthma be


reviewed?

o 1-3 months after treatment started, then


every 3- 12 months
o During pregnancy, every 4-6 weeks
o After an exacerbation, within 1 week

REVIEWING RESPONSE AND


ADJUSTING TREATMENT

o Stepping-up asthma treatment

o Sustained step-up: for at least 2-3 months if


asthma poorly controlled
o Short-term step-up: for 1-2 weeks, e.g. with
viral infection or allergen
o Day-to-day adjustment

For patients prescribed low-dose ICS/formoterol


maintenance and reliever regimen*

TIOTROPIUM IN
ASTHMA

oTiotropium increased time to first

severe exacerbation and first


episode of asthma worsening in
patients who remain symptomatic
despite treatment with
ICS and
LABA.
Primo TinA-asthmaclinical
trials

Kerstjens HAM, et al. Tiotropium in asthma poorly controlled


with standard combination therapy. N Engl J Med 2012 Sep
27; 367; 1198

THANK YOU~