Global Strategyfor Asthma Management

Global Strategy for Asthma
Management and Prevention

(2019 update)
Dr. Md. Shafiqul Islam Dewan
Phase-A Resident (Pulmonology)
Medicine Unit - VIII
Dhaka Medical College Hospital
About GINA
GINA stands for Global Initiative for Asthma.
Established in 1993.
Work with health care professionals and public

health officials around the world.
To reduce asthma prevalence, morbidity, and

mortality.
Asthma
Asthma is a heterogeneous disease.
Characterized by chronic airway inflammation.
Causing symptoms such as wheezing, shortness of

breath, chest tightness and cough.
That varies in frequency and intensity together

with variable expiratory airflow limitation.
Phenotypes of Asthma
Many phenotypes have been identified. Most

common phenotypes are:
Allergic asthma
Non-allergic asthma
Adult-onset (Late onset) asthma
Asthma with fixed airway limitation
Asthma with obesity

Diagnosis of Asthma
Diagnosis of asthma depends on two
defining features:
History of respiratory symptoms such as
wheeze, shortness of breath, chest tightness
and cough that vary over time and in intensity.
Variable expiratory airflow limitation.
Diagnostic flow-chart for Asthma in clinical practice
Patient with respiratory symptoms
Are the symptoms typical of
Asthma?
Further History &
Yes No Test for Alternative
Details History and Examination Diagnosis
History and Examination Supports
Clinical urgency Asthma Diagnosis?
Other diagnosis Yes
unlikely Y
Perform Spirometry / PEF with e
Reversibility test s
Empiric treatment Result Support Asthma Diagnosis?
with ICS and prn SABA
Yes
Review response
Diagnostic testing
within 1-3 months Treat for Alternative
Treat for Asthma
Diagnosis
Assessing a patient with Asthma
Assess asthma control

Assess risk factor
Assess for comorbidities
Assess treatment issue
Assess asthma control
Level of asthma symptom control.
In the past 4 weeks, Well Partly Uncontrolled
has the patient had controlled controlled
Daytime symptoms more Yes/No

than twice/week?
Reliever needed more Yes/No None of 1-2 3-4

than twice/week? these of these of these
Any night waking due to Yes/No
asthma?
Any activity limitation Yes/No

due to asthma?
Assess risk factor
Risk factor for exacerbations
Risk factors for developing fixed airflow

limitation
Risk factors for medication side-effects

Risk factor for exacerbations
Uncontrolled asthma symptoms
Comorbidities
Exposures to smoking, allergen and air pollution
Major socioeconomic problems
Medication: Inhaled corticosteroid (ICS) not

prescribed, Poor adherence, Incorrect inhaler
technique, High (SABA) use.
Risk factors for developing fixed airflow limitation
Preterm birth, LBW and greater infant weight gain.
Lack of ICS treatment
Exposure to tobacco smoke and noxious chemicals
Low FEV1
Chronic mucus hyper-secretion
Sputum or blood eosinophilia

Risk factors for medication side-effects
Frequent oral corticosteroid use.
Long term high-dose or potent ICS use.
Poor inhaler technique.

Assess for comorbidities
Rhinitis
Chronic Rhinosinusitis
Gastroesophageal reflux(GERD)
Obesity
Obstructive sleep apnea
Depression and anxiety
Pregnancy
Assess treatment issue
Record the patient’s treatment and ask about side

effects.
Check that the patient has a written asthma

action plan.
Ask the patient about their attitudes and goals for

their asthma.
Written asthma action plan
The written asthma action plan should

include:
The patient’s usual asthma medications
When and how to increase medications and
start oral corticosteroid(OCS)
How to access medical care if symptoms fail to
respond
Management of Asthma
Few asthma symptoms
No sleep disturbance Symptom control
No exercise limitation

Maintain normal lung function
Prevent flare-ups (exacerbations)
Risk reduction
Prevent asthma deaths
Avoid medication side-effects
Management of Asthma
General management
Asthma medication
Treatment of modifiable risk factor
Treatment of comorbidity
Non pharmacological therapies and strategies
Follow up
General management
Patient education regarding Asthma
Inhaler skills
Adherence
Written asthma action plan
Self-monitoring of symptoms and/or peak flow
Regular medical review

Asthma Medication
Controller medication
Add-on controller medication
Reliever medication
Controller Medication
Inhaled corticosteroids (ICS)
ICS and long-acting beta2 agonist (LABA)

bronchodilator combinations (ICS- LABA )
Leukotriene modifiers
Chromones
Inhaled corticosteroids (ICS)

Beclomethasone dipropionate
Budesonide
Fluticasone propionate
Fluticasone furoate
Ciclesonide
Triamcinolone
Low, Medium and High dose of ICS
Adult and Adolescent
Inhaled corticosteroid
Low(mcg) Medium(mcg) High(mcg)
Beclomethasone dipropionate 100-200 >200-400 >400
Budesonide (DPI) 200-400 >400-800 >800
Fluticasone propionate (DPI) 100-250 >250-500 >500
Fluticasone propionate(HFA) 100-250 >250-500 >500
Triamcinolone acetonide 400-1000 >1000- >2000

2000
ICS and long-acting beta2 agonist

bronchodilator combinations (ICS-LABA)
Beclometasone-formoterol
Budesonide-formoterol
Fluticasone propionate-formoterol
Fluticasone propionate-salmeterol
Fluticasone furoate-vilanterol
Leukotriene modifiers
Montelukast
Pranlukast
Zafirlukast
Zileuton
Chromones
Sodium cromoglycate
Nedocromil sodium
Add-on Controller Medication
Long-acting anticholinergic
Anti-IgE
Anti-IL5
Anti-IL5R
Anti-IL4R
Systemic corticosteroids
Long-acting anticholinergic (At Step 4 or 5 with a

history of exacerbations despite ICS ± LABA)
Tiotropium
Anti-IgE (with severe allergic asthma uncontrolled

on high dose ICS-LABA)
Omalizumab
 Anti-IL5 & Anti-IL5R (Severe eosinophilic asthma

uncontrolled on high dose ICS-LABA)
Mepolizumab & Reslizumab
Benralizumab
 Anti-IL4R (Severe eosinophilic asthma uncontrolled on

high dose ICS-LABA, or requiring maintenance OCS)
 Dupilumab
Systemic corticosteroids
Prednisolone
Hydrocortisone
Methylprednisolone
Reliever Medication
Short-acting inhaled beta2-agonist

bronchodilators (SABA)
Low-dose ICS-formoterol
Short-acting anticholinergics
Reliever Medication
Short-acting inhaled beta2-agonist

bronchodilators (SABA)
Salbutamol
Terbutaline
Reliever Medication
• Low-dose ICS-formoterol
• Beclometasone-formoterol
• Budesonide-formoterol
• Short-acting anticholinergics
• Ipratropium bromide
• Oxitropium bromide
Treatment of modifiable risk factor
Non pharmacological therapies and strategies
Cessation of smoking
Physical activity
Healthy diet
Weight reduction
Breathing exercises
Avoidance of occupational exposures

Non pharmacological therapies and strategies
Avoidance of indoor allergens and air pollution
Avoidance of outdoor air pollutants / weather

conditions
Avoidance of medications that may make asthma

worse
Other therapies
Allergen immunotherapy
Subcutaneous immunotherapy (SCIT) (Evidence D)
Sublingual immunotherapy (SLIT) (Evidence B)
Bronchial thermoplasty. (Evidence B)

Starting asthma treatment
ICS-containing treatment should be initiated as soon

as possible after the diagnosis of asthma is made.
Consider starting at a higher step (e.g. medium/high

dose ICS, or low-dose ICS-LABA) if on most days the
patient has troublesome asthma symptoms; or is
waking from asthma once or more a week.
Starting asthma treatment
If the initial asthma presentation is with severely
uncontrolled asthma, or with an acute exacerbation,
give a short course of OCS and start regular controller
treatment (e.g. medium dose ICS-LABA).
Consider stepping down after asthma has been well-

controlled for 3 months. However, in adults and
adolescents, ICS should not be completely stopped.
Before starting initial controller treatment
Record evidence for the diagnosis of asthma, if

possible.
Document symptom control and risk factors.
Assess lung function, when possible.
Train the patient to use the inhaler correctly and

check their technique.
Schedule a follow-up visit.

After starting initial controller treatment
Review response after 2–3 months, or according

to clinical urgency.
Review for ongoing treatment and other key

management issues.
Consider step down when asthma has been well-

controlled for 3 months
Reviewing response and adjusting treatment
Patients should preferably be seen 1–3 months

after starting treatment
Every 3–12 months after that, but in pregnancy,

asthma should be reviewed every 4–6 weeks.
After an exacerbation, a review visit within 1

week should be scheduled
Stepping up asthma treatment
• Sustained step-up (for at least 2–3 months): if symptoms

and/or exacerbations persist despite 2–3 months of
controller treatment, assess the following common
issues before considering a step-up
• Incorrect inhaler technique
• Poor adherence
• Modifiable risk factors
• Comorbid conditions
Short-term step-up (for 1–2 weeks) by

clinician or by patient with written asthma
action plan, e.g. during viral infection or
allergen exposure.
• Day-to-day adjustment by patient for those

who prescribed as-needed low dose ICS-
formoterol for mild asthma, or low dose
ICS-formoterol as maintenance and reliever
therapy.
Stepping down asthma treatment
Consider stepping down treatment once

good asthma control has been achieved and
maintained for 3 months, to find the lowest
treatment that controls both symptoms and
exacerbations, and minimizes side-effects.
Stepping down asthma treatment
Choose an appropriate time for step-down (no

respiratory infection, patient not travelling, not
pregnant).
Document baseline status (symptom control and

lung function), provide a written asthma action
plan, monitor closely and book a follow-up visit.
Control based asthma management cycle
GINA 2019 – Changes in asthma management
For safety, GINA no longer recommends SABA-

only treatment for Step 1
This decision was based on evidence that SABA-only
treatment increases the risk of severe exacerbations,
and that adding any ICS significantly reduces the risk
GINA now recommends that all adults and

adolescents with asthma should receive symptom-
driven or regular low dose ICS-containing
controller treatment, to reduce the risk of serious
exacerbations
This is a population-level risk reduction strategy, e.g.
statins, anti-hypertensives.
Background to changes in 2019
Risks of mild asthma
Patients with apparently mild asthma are at risk
of serious adverse events
30–37% of adults with acute asthma had symptoms less
than weekly in previous
16% of patients with near-fatal asthma 3 months (Dusser,
Allergy 2007)
15–20% of adults dying of asthma
Exacerbation triggers are variable (viruses,

pollens, pollution, poor adherence)
risks of SABA-only treatment
Inhaled SABA has been first-line treatment for
asthma for 50 years
Patient satisfaction with, and reliance on, SABA
treatment is reinforced by its rapid relief of symptoms,
its prominence in emergency department and hospital
management of exacerbations, and low cost
Patients commonly believe that “My reliever gives me

control over my asthma”, so they often don’t see the
need for additional treatment
Regular or frequent use of SABA is associated
with adverse effects
β-receptor downregulation, decreased
bronchoprotection, rebound hyperresponsiveness,
decreased bronchodilator response (Hancox, Respir Med 2000)
Increased allergic response, and increased eosinophilic

airway inflammation (Aldridge, AJRCCM 2000)
Higher use of SABA is associated with adverse
clinical outcomes
Dispensing of ≥3 canisters per year (average 1.7
puffs/day) is associated with higher risk of emergency
department presentations (Stanford, AAAI 2012)
Dispensing of ≥12 canisters per year is associated with

higher risk of death (Suissa, AJRCCM 1994)
GINA 2019 - Stepwise treatment
STEP 5
High dose
Asthma medication options: ICS-LABA
Adjust treatment up and down for
individual patient needs STEP 4 Refer for
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment
STEP 2 Low dose ± add-on

ICS-LABA therapy,
PREFERRED STEP 1 Daily low dose inhaled corticosteroid (ICS), or as- e.g.tiotropium,
CONTROLLER needed low dose ICS-formoterol *
anti-IgE,
to prevent exacerbations As-needed anti-IL5/5R,
and control symptoms low dose anti-IL4R
ICS-formoterol *
Medium dose High dose

Low dose ICS Add low dose
Other Leukotriene receptor antagonist (LTRA), or ICS, or ICS, add-on
taken whenever OCS, but
Controller option low dose ICS taken whenever SABA taken † low dose tiotropium,
SABA is taken † consider
ICS+LTRA # or add-on side-effects
LTRA #
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 bud-
† Off-label; separate or combination ICS and SABA inhalers form or BDP-form maintenance and reliever therapy
# Consider adding HDM SLIT for sensitized patients with allergic
rhinitis and FEV >70% predicted
Step 1
Rationale for changes
in GINA 2019
GINA 2019 – Step 1 Changes
Previously, no controller was STEP 5
recommended for High dose
Step 1, i.e. SABA-only
individual patient needs treatment was preferred. STEP 4 Refer for
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment

ICS-LABA therapy,
anti-IgE,
ICS-formoterol *

LTRA #

RELIEVER
reliever option
Step 1 - ‘preferred’ controller option
Step 1 is for patients with symptoms less than twice a
month, and with no exacerbation risk factors
As-needed low dose ICS-formoterol (off-label)

• Evidence
• Indirect evidence from SYGMA 1 of large reduction in severe
exacerbations vs SABA-only treatment in patients eligible for Step 2
therapy (O’Byrne, NEJMed 2018)
• Values and preferences
• High importance given to reducing exacerbations
• High importance given to avoiding conflicting messages about goals
of asthma treatment between Step 1 and Step 2
• High importance given to poor adherence with regular ICS in
patients with infrequent symptoms, which would expose them to
Step 1 - other controller option
Low dose ICS taken whenever SABA is taken (off-label)
Evidence
 Indirect evidence from studies in patients eligible for Step 2
treatment (BEST, TREXA, BASALT)
Values and preferences
 High importance given to preventing severe exacerbations
 Lower importance given to small differences in symptom control
and the inconvenience of needing to carry two inhalers
 Combination ICS-SABA inhalers are available in some countries, but
approved only for maintenance use
Daily ICS is no longer listed as a Step 1 option
 This was included in GINA 2014-18, but with high probability of
poor adherence
 Now replaced by more feasible as-needed controller options for
Step 1
Step 2
Rationale for changes
in GINA 2019
GINA 2019 - Step 2 changes
STEP 5
High dose
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment

ICS-LABA therapy,
anti-IgE,
ICS-formoterol *

LTRA #

RELIEVER
reliever option
Step 2 - there are two ‘preferred’ controller options
(1) Regular low dose ICS with as-needed SABA

• Evidence
A large body of evidence from RCTs and observational
studies that low dose ICS substantially reduces risks of
severe exacerbations, hospitalizations and death
e.g. Suissa, NEJMed 2000; Suissa, Thorax 2002; Pauwels, Lancet 2003; O’Byrne,
AJRCCM 2001
Serious exacerbations halved even in patients with

symptoms 0-1 days per week (Reddel, Lancet 2017)
Improved symptom control and reduced exercise-

induced bronchoconstriction
Step 2 - there are two ‘preferred’ controller options
(1) Regular low dose ICS with as-needed SABA

High importance was given to preventing asthma
deaths and severe exacerbations.
However, we were aware that poor adherence is
common in mild asthma in the community, and that
this would expose patients to the risks of SABA-only
treatment.
Step 2 - two ‘preferred’ controller options
(2) As-needed low dose ICS-formoterol

(off-label; all evidence with budesonide-formoterol)
Evidence
Direct evidence from two large studies of non-
inferiority for severe exacerbations vs daily low dose
ICS + as-needed SABA (O’Byrne, NEJMed 2018, Bateman, NEJMed 2018)
Direct evidence from one large study of 64% reduction

in severe exacerbations vs SABA-only treatment (O’Byrne,
NEJMed 2018)
Symptoms reduced; one study showed reduced

exercise-induced bronchoconstriction.
Step 2 - two ‘preferred’ controller options
(2) As-needed low dose ICS-formoterol

High importance was given to preventing severe
exacerbations, avoiding need for daily ICS in patients with
mild or infrequent symptoms, and safety of as-needed ICS-
formoterol in maintenance and reliever therapy, with no
new safety signals
Lower importance given to small non-cumulative differences

in symptom control (ACQ-5 difference 0.15 vs MCID 0.5) and
lung function compared with daily ICS
Makes use of normal patient behavior (seeking symptom

relief) to deliver controller
Step 2 - other controller options
Low dose ICS taken whenever SABA taken
(off-label, separate or combination inhalers)
Evidence
Two RCTs showed reduced exacerbations compared
with SABA-only treatment
 BEST, in adults, with combination ICS-SABA (Papi, NEJMed 2007)
 TREXA, in children/adolescents, with separate inhalers (Martinez,
Lancet 2011)
Three RCTs showed similar or fewer exacerbations

compared with maintenance ICS
 TREXA, BEST
 BASALT in adults, separate inhalers, vs physician-adjusted
treatment (Calhoun, JAMA 2012)
Step 2 - other controller options
Low dose ICS taken whenever SABA taken
(off-label, separate or combination inhalers)

High importance given to preventing severe exacerbations
Lower importance given to small differences in symptom
control and the inconvenience of needing to carry two
inhalers
Combination ICS-SABA inhalers are available in some
countries, but approved only for maintenance use
Another option: Leukotriene receptor antagonist

(less effective for exacerbations)
Other changes in GINA 2019
Steps 3-5
for adults and adolescents
STEP 5
High dose
Asthma medication options: There is no theophylline ICS-LABA
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment

ICS-LABA therapy,
anti-IgE,
ICS-formoterol *

LTRA #

RELIEVER
reliever option
STEP 5
Step 4 treatment is
High dose
Asthma medication options: medium dose ICS-LABA; ICS-LABA
individual patient needs
high dose now in Step 5 STEP 4 Refer for
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment

ICS-LABA therapy,
anti-IgE,
ICS-formoterol *

LTRA #

RELIEVER
reliever option
STEP 5
High dose ICS-LABA
High dose
Asthma medication options: Anti-IL 5R ICS-LABA
individual patient needs
Anti-IL 4R STEP 4 Refer for
phenotypic
Medium dose
STEP 3 ICS-LABA
assessment

ICS-LABA therapy,
anti-IgE,
ICS-formoterol *

LTRA #

RELIEVER
reliever option
Management of asthma
exacerbations
Management of asthma exacerbations in primary care
Mild or Moderate Severe or Life threatening
Management of asthma exacerbations in acute care facility
Mild or Moderate Severe
Uncontrolled Asthma
• Poor symptoms control (frequent symptoms or

reliever use, activity limited by asthma, night
waking due to asthma)
And / Or
• Frequent exacerbation ( >2 per year) requiring
oral corticosteroids or serious exacerbation ( >1
per year ) requiring hospitalization.
Difficult-to-treat asthma
Asthma that is uncontrolled despite GINA Step

4 or 5 treatment or that requires such
treatment to maintain good symptom control
and reduce the risk of exacerbations.
Contributory factors may include incorrect
diagnosis, incorrect inhaler technique, poor
adherence, comorbidities.
Severe asthma
Severe asthma is a subset of difficult-to-treat
asthma.
It means asthma that is uncontrolled despite
adherence with maximal optimized therapy and
treatment of contributory factors, or that worsens
when high dose treatment is decreased.
It is sometimes called ‘severe refractory asthma’
since it is relatively refractory to high dose inhaled
therapy.
However, with the advent of biologic therapies,
the word ‘refractory’ is no longer appropriate.
What proportion of adults have
difficult-to-treat or severe asthma
Management of
difficult-to-treat
and severe asthma
Asthma with Pregnancy
Asthma control often changes during pregnancy.
For baby and mother, the advantages of actively

treating asthma markedly outweigh any potential
risks of usual controller and reliever medications.
Down-titration has a low priority in pregnancy.
Exacerbations should be treated aggressively.

Surgical Procedure in Asthma patient
Whenever possible, good asthma control should be

achieved preoperatively.
Ensure that controller therapy is maintained
throughout the perioperative period.
Patients on long-term high dose ICS, or having more
than 2 weeks’ OCS in the past 6 months, should
receive intra-operative hydrocortisone to reduce the
risk of adrenal crisis.
Take home message
No longer recommends starting with SABA

only treatment.
All adults and adolescents with asthma

should receive ICS-containing controller
treatment, to reduce their risk of serious
exacerbations and to control symptoms.

Global Strategyfor Asthma Management

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Global Strategyfor Asthma Management

Uploaded by

Copyright:

Available Formats

Global Strategy for Asthma

Management and Prevention

GINA stands for Global Initiative for Asthma.

Work with health care professionals and public

To reduce asthma prevalence, morbidity, and

Asthma is a heterogeneous disease.

Characterized by chronic airway inflammation.

Causing symptoms such as wheezing, shortness of

That varies in frequency and intensity together

Many phenotypes have been identified. Most

Adult-onset (Late onset) asthma

Asthma with fixed airway limitation

Asthma with obesity

Assess asthma control

Daytime symptoms more Yes/No

Reliever needed more Yes/No None of 1-2 3-4

Any activity limitation Yes/No

Risk factor for exacerbations

Risk factors for developing fixed airflow

Risk factors for medication side-effects

Uncontrolled asthma symptoms

Exposures to smoking, allergen and air pollution

Major socioeconomic problems

Medication: Inhaled corticosteroid (ICS) not

Preterm birth, LBW and greater infant weight gain.

Lack of ICS treatment

Exposure to tobacco smoke and noxious chemicals

Chronic mucus hyper-secretion

Sputum or blood eosinophilia

Frequent oral corticosteroid use.

Long term high-dose or potent ICS use.

Poor inhaler technique.

Record the patient’s treatment and ask about side

Check that the patient has a written asthma

Ask the patient about their attitudes and goals for

The written asthma action plan should

No exercise limitation

Patient education regarding Asthma

Written asthma action plan

Self-monitoring of symptoms and/or peak flow

Regular medical review

Add-on controller medication

Inhaled corticosteroids (ICS)

ICS and long-acting beta2 agonist (LABA)

Inhaled corticosteroids (ICS)

Beclomethasone dipropionate 100-200 >200-400 >400

Budesonide (DPI) 200-400 >400-800 >800

Fluticasone propionate (DPI) 100-250 >250-500 >500

Fluticasone propionate(HFA) 100-250 >250-500 >500

Triamcinolone acetonide 400-1000 >1000- >2000

ICS and long-acting beta2 agonist

Long-acting anticholinergic (At Step 4 or 5 with a

Anti-IgE (with severe allergic asthma uncontrolled

 Anti-IL5 & Anti-IL5R (Severe eosinophilic asthma

Mepolizumab & Reslizumab

 Anti-IL4R (Severe eosinophilic asthma uncontrolled on

Short-acting inhaled beta2-agonist

Short-acting inhaled beta2-agonist

Avoidance of occupational exposures

Avoidance of indoor allergens and air pollution

Avoidance of outdoor air pollutants / weather

Avoidance of medications that may make asthma

Bronchial thermoplasty. (Evidence B)