G IN A: Lobal Itiative For Sthma

G lobal
INitiative for
A sthma
© Global Initiative for Asthma
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
 Widespread, variable, and often reversible
airflow limitation

Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation

Asthma Inflammation: Cells and Mediators

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

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
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
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs

Factors that Influence Asthma
Development and Expression
Host Factors Environmental Factors

 Genetic  Indoor allergens
 Outdoor allergens
- Atopy
 Occupational sensitizers
- Airway
 Tobacco smoke
hyperresponsiveness
 Air Pollution
 Gender
 Respiratory Infections
 Obesity  Diet

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
 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
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)
1 2 3 4 5
Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure
to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma Exacerbations
Updated 2012
5. Special Considerations
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
 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

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
Component 1: Develop
Patient/Doctor Partnership
Key factors to facilitate communication:

 Friendly demeanor
 Interactive dialogue
 Encouragement and praise
 Provide appropriate information
 Feedback and review
Factors Involved in Non-Adherence
Medication Usage Non-Medication Factors

 Difficulties associated  Misunderstanding/lack of
with inhalers information
 Complicated regimens  Fears about side-effects
 Fears about, or actual  Inappropriate expectations
side effects
 Cost  Underestimation of severity
 Distance to pharmacies  Attitudes toward ill health

 Cultural factors
 Poor communication
Component 2: Identify and Reduce
Exposure to Risk Factors
 Measures to prevent the development of asthma,

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
 Asthma exacerbations may be caused by a variety
of risk factors – allergens, viral infections,
pollutants and drugs.
 Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
Component 2: Identify and Reduce
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
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
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)
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)
Twice or less More than

Daytime symptoms
per week twice per week
Limitations of 3 or more
None Any
activities features of
partly
Nocturnal symptoms controlled
None Any
/ awakening asthma
present in
Need for rescue / Twice or less More than any week
“reliever” treatment per week twice per week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day
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

and Monitor Asthma
 Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
 Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control

and Monitor 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

and Monitor Asthma
The choice of treatment should be guided by:
 Level of asthma control
 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
Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers
 Long-acting inhaled β2-agonists in combination

with inhaled glucocorticosteroids
 Systemic glucocorticosteroids
 Theophylline
 Cromones
 Anti-IgE

Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400
Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb 250-500 500-1000 >1000

Inhalation Suspension
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250
Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500
Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400
Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

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
 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
REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION
maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control
INCREASE
uncontrolled step up until controlled
exacerbation treat as exacerbation
REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER
Shaded green - preferred controller options


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)

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

Step 3 – Reliever medication plus one or two

controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting 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
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
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)

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
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)

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
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)
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 low-
dose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
Stepping up treatment in response to loss of control

 Rapid-onset, short-acting or long-
acting 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
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 effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
 Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended (Evidence A)
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 life-
threatening and treatment requires close
supervision
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
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

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

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G lobal

 A chronic inflammatory disorder of the airways

© Global Initiative for Asthma

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

 Asthma is one of the most common chronic

© Global Initiative for Asthma

 Health care expenditures very high

 Host factors: predispose individuals to, or

 Environmental factors: influence

© Global Initiative for Asthma

© Global Initiative for Asthma

Host Factors Environmental Factors

© Global Initiative for Asthma

 Recurrent episodes of wheezing

Asthmatic (After Bronchodilator)

Goals of Long-term Management

 Achieve and maintain control of symptoms

 Avoid adverse effects from asthma

1. Develop Patient/Doctor Partnership

 Although there is no cure for asthma,

© Global Initiative for Asthma

 Guidelines on asthma management

© Global Initiative for Asthma

Key factors to facilitate communication:

Medication Usage Non-Medication Factors

 Distance to pharmacies  Attitudes toward ill health

 Measures to prevent the development of asthma,

 Reduce exposure to indoor allergens

Component 3: Assess, Treat

The goal of asthma treatment, to

Clinical Control of Asthma

The focus on asthma control is

Clinical Control of Asthma

 Determine the initial level of

 Maintain control once treatment

Twice or less More than

Component 3: Assess, Treat

Component 3: Assess, Treat

 The aim is to accomplish the goals of

 Although in many countries traditional

Component 3: Assess, Treat

 Long-acting inhaled β2-agonists in combination

© Global Initiative for Asthma

Budesonide 200-600 100-200 600-1000 >200-400 >1000 >400

Budesonide-Neb 250-500 500-1000 >1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750 >1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200 >250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200 > 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800 >1000-2000 >800-1200 >2000 >1200

© Global Initiative for Asthma

 Rapid-acting inhaled β2-agonists

© Global Initiative for Asthma

maintain and find lowest

exacerbation treat as exacerbation

Shaded green - preferred controller options

Shaded green - preferred controller options

Step 1 – As-needed reliever medication

Shaded green - preferred controller options

Step 2 – Reliever medication plus a single

Shaded green - preferred controller options