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ASTHMA – GINA, 2017

Zulfatul Ain binti Zulkefli


What is Asthma ?

Asthma is a heterogeneous disease, usually characterized by


chronic airway inflammation.

History of
Shortness of respiratory
Wheeze
breath symptoms

Variable
Chest tightness
expiratory
and cough
airflow limitation

GINA 2017
Airway INDUCERS
Hyperresponsiveness Allergens, Chemical
Sensitisers, Air
Genetic
Pollutants,Virus
Infections

INFLAMMATION

TRIGGERS Airflow limitation


Alergen, Exercise,
Cold Air, So2
Particulates
SYMPTOMS
Cough, wheeze,
dyspnea
Diagnosis of asthma

Document evidence for the


The diagnosis of asthma diagnosis in the patient’s
should be based on: notes, preferably before
starting controller treatment
• A history of characteristic • It is often more difficult to
symptom patterns confirm the diagnosis after
• Evidence of variable airflow treatment has been started
limitation, from
bronchodilator reversibility
testing or other tests
Asthma is usually characterized by
- Airway inflammation
- Airway hyperresponsiveness

but these are not necessary or sufficient to make the diagnosis of asthma~

GINA 2017
Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES


ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (4/4) © Global Initiative for Asthma


Diagnosis of asthma – symptoms
• More than one type of symptom (wheeze, shortness
of breath, cough, chest tightness)

Increased • Symptoms often worse at night or in the early


morning
• Symptoms vary over time and in intensity

probability • Symptoms are triggered by viral infections, exercise,


allergen exposure, changes in weather, laughter,
irritants such as car exhaust fumes, smoke, or strong
smells

• Isolated cough with no other respiratory


symptoms

Decreased • Chronic production of sputum


• Shortness of breath associated with dizziness,

probability
light-headedness or peripheral tingling
• Chest pain
• Exercise-induced dyspnea with noisy inspiration
(stridor)

GINA 2017
Diagnosis of asthma – variable airflow
limitation

• Document that FEV1/FVC is reduced (at least once, when FEV1 is


low)
• FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
Confirm presence of >0.90 in children
airflow limitation

• The greater the variation, or the more times variation is seen, the greater
probability that the diagnosis is asthma
• Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and
>200mL; children: increase >12% predicted)
Confirm variation in • Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily
lung function is greater amplitude x 100/daily mean, averaged)
than in healthy • Significant increase in FEV1 or PEF after 4 weeks of controller treatment
individuals

GINA 2017, Box 1-2


Typical spirometric tracings
Volume Flow
Normal

FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)

Asthma
(before BD)

1 2 3 4 5 6 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements

GINA 2017 © Global Initiative for Asthma


Diagnosis of asthma – physical examination

Wheezing may
be absent
during severe
asthma
exacerbations
(‘silent chest’)

Wheezing is
also found in
other
conditions,
for example:
•Respiratory infections
•COPD
•Upper airway dysfunction Physical examination in
•Endobronchial obstruction people with asthma
•Inhaled foreign body
•Often normal
•The most frequent finding is
wheezing on auscultation,
especially on forced
expiration

GINA 2017
Assessment of asthma
Asthma control -
Treatment issues Comorbidities
two domains
• Assess symptom • Check inhaler • Think of
control over the technique and rhinosinusitis,
last 4 weeks adherence GERD, obesity,
• Assess risk factors • Ask about side- obstructive sleep
for poor effects apnea, depression,
outcomes, • Does the patient anxiety
including low lung have a written • These may
function asthma action contribute to
plan? symptoms and
• What are the poor quality of life
patient’s attitudes
and goals for their
asthma?

GINA 2017, Box 2-1


GINA assessment of symptom control

A. Symptom control Level of asthma symptom control


Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No

*Excludes reliever taken before exercise, because many people take this routinely

GINA 2017, Box 2-2A © Global Initiative for Asthma


GINA assessment of asthma control

A. Symptom control Level of asthma symptom control


Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week? Yes No
• Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
• Reliever needed for symptoms* these these these
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes


• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
GINA 2017 Box 2-2B (1/4) © Global Initiative for Asthma
Assessment of risk factors for poor asthma
outcomes
Risk factors for
Independent* risk
exacerbations
factors for exacerbations
include: include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
UPDATED
• Smoking 2017

• Obesity, pregnancy,
Elevated FeNO in adults
bloodwith
eosinophilia
allergic asthma
• Obesity, pregnancy, blood eosinophilia

* Independent of the level of symptom control

GINA 2017, Box 2-2B (2/4) © Global Initiative for Asthma


Assessment of risk factors for poor asthma
outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Elevated FeNO in adults with allergic asthma
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia

GINA 2017, Box 2-2B (3/4) © Global Initiative for Asthma


Assessment of risk factors for poor asthma
outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Elevated FeNO in adults with allergic asthma
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
GINA 2017, Box 2-2B (4/4) © Global Initiative for Asthma
Assessing asthma severity
 How?
 Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
 When?
 Assess asthma severity after patient has been on controller
treatment for several months
 Severity is not static – it may change over months or years, or as
different treatments become available
 Categories of asthma severity
 Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or
low dose ICS)
 Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)
 Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ±
add-on), or remains uncontrolled despite this treatment

GINA 2017
How to distinguish between
uncontrolled and severe asthma
Watch patient using their Compare inhaler technique with a device-
specific checklist, and correct errors;
inhaler. Discuss adherence
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,


Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 2–3 weeks.

Remove potential Check for risk factors or inducers such as


smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.


Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

If asthma still uncontrolled after 3–6 months


Refer to a specialist or on Step 4 treatment, refer for expert advice.
severe asthma clinic Refer earlier if asthma symptoms severe,
or doubts about diagnosis.

GINA 2017, Box 2-4 (5/5) © Global Initiative for Asthma


Goals of asthma management
 The long-term goals of asthma management are
1. Symptom control: to achieve good control of symptoms
and maintain normal activity levels
2. Risk reduction: to minimize future risk of exacerbations,
fixed airflow limitation and medication side-effects

GINA 2017
Treating to control symptoms and
minimize risk
 Establish a patient-doctor partnership
 Manage asthma in a continuous cycle:
 Assess
 Adjust treatment (pharmacological and
non-pharmacological)
 Review the response
 Teach and reinforce essential skills
 Inhaler skills
 Adherence
 Guided self-management education
 Written asthma action plan
 Self-monitoring
 Regular medical review

GINA 2017
The control-based asthma
management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

GINA 2017, Box 3-2


Choosing between controller options –
population-level decisions
Choosing between treatment options at a population level
e.g. national formularies, health maintenance organisations, national guidelines

The ‘preferred treatment’ at each step is based on:


 Efficacy
based on group mean data for symptoms, exacerbations and lung
 Effectiveness function (from RCTs, pragmatic studies and observational data)
 Safety
 Availability and cost at the population level

GINA 2017, Box 3-3 (1/2) © Global Initiative for Asthma


Choosing between controller options –
individual patient decisions
Decisions for individual patients
Use shared decision-making with the patient/parent/carer to discuss the following:
1. Preferred treatment for symptom control and for risk
reduction
2. Patient characteristics (phenotype)
• Does the patient have any known predictors of risk or response?
(e.g. smoker, history of exacerbations, blood eosinophilia)
3. Patient preference
• What are the patient’s goals and concerns for their asthma?
4. Practical issues
• Inhaler technique - can the patient use the device correctly after
training?
• Adherence: how often is the patient likely to take the medication?
• Cost: can the patient afford the medication?

GINA 2017, Box 3-3 (2/2) © Global Initiative for Asthma


Initial controller treatment for adults,
adolescents and children 6–11 years
Start Indications for If initial asthma
Consider
controller regular low- presentation is
starting at a
treatment dose ICS - any with an
higher step if:
early of: exacerbation:
Asthma
symptoms more
than twice a Troublesome
month asthma symptoms Give a short
For best on most days course of oral
outcomes, initiate
steroids and start
controller
Waking due to regular controller
treatment as
asthma more than treatment (e.g.
early as possible
once a month high dose ICS or
after making the Waking from medium dose
diagnosis of asthma once or ICS/LABA, then
asthma more a week,
Any asthma step down)
symptoms plus especially if any
any risk factors risk factors for
for exacerbations exacerbations

GINA 2017, Box 3-4 (1/2)


Initial controller treatment

Before starting initial controller treatment


After starting initial controller treatment
Record evidence for diagnosis of asthma, if
possible
Review response after 2-3 months, or
Record symptom control and risk factors,
according to clinical urgency
including lung function
Adjust treatment (including non-
Consider factors affecting choice of pharmacological treatments)
treatment for this patient
Consider stepping down when asthma has
Ensure that the patient can use the inhaler
been well-controlled for 3 months
correctly
Schedule an appointment for a follow-up
visit

GINA 2017, Box 3-4 (2/2)


Stepwise approach to control
asthma symptoms and reduce risk
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
UPDATED
Symptoms
2017
Exacerbations
Asthma medications
Side-effects
Non-pharmacological strategies
Patient satisfaction
Treat modifiable risk factors
Lung function

STEP 5

STEP 4
STEP 3 Refer for add-
PREFERRED STEP 1 STEP 2
CONTROLLER on treatment
e.g.
CHOICE Med/high tiotropium,*
anti-IgE,
ICS/LABA
Low dose anti-IL5*

Low dose ICS ICS/LABA**

Other Med/high dose ICS Add tiotropium* Add low dose


Consider low Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS OCS
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

• Provide guided self-management education (self-monitoring + written action plan + regular review)
REMEMBER
• Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
TO...
• Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of
sensitizers where appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler
technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite
ICS treatment, provided FEV1 is >70% predicted
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.

GINA 2017, Box 3-5 (1/8) © Global Initiative for Asthma


Stepwise management -
pharmacotherapy UPDATED
2017

Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors

STEP 5

STEP 4

STEP 3 Refer for *Not for children <12 years


PREFERRED STEP 1 STEP 2 add-on **For children 6-11 years, the
CONTROLLER treatment preferred Step 3 treatment is
CHOICE e.g.
Med/high tiotropium,* medium dose ICS
ICS/LABA anti-IgE,
#For patients prescribed
Low dose anti-IL5*
Low dose ICS BDP/formoterol or BUD/
ICS/LABA**
formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose OCS  Tiotropium by mist inhaler is
+ LTRA
options (or + theoph*)
(or + theoph*)
an add-on treatment for
patients ≥12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER
low dose ICS/formoterol#

GINA 2017, Box 3-5 (2/8) (upper part)


Stepwise management – additional components
UPDATED
2017

• Provide guided self-management education


REMEMBER
• Treat modifiable risk factors and comorbidities
TO...
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who
have exacerbations despite ICS treatment, provided FEV 1 is 70% predicted
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.

SLIT: sublingual immunotherapy

GINA 2017, Box 3-5 (3/8) (lower part) © Global Initiative for Asthma
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)

STEP 5

STEP 4

STEP 3 Refer for


PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Low dose ICS ICS/LABA**

Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

*Not for children <12 years


**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
GINA 2017, Box 3-5, Step 1 (4/8)
Step 1 – as-needed reliever inhaler
Preferred option: as-needed inhaled short-
acting beta2-agonist (SABA)
• SABAs are highly effective for relief of asthma symptoms
• However …. there is insufficient evidence about the
safety of treating asthma with SABA alone
• This option should be reserved for patients with
infrequent symptoms (less than twice a month) of short
duration, and with no risk factors for exacerbations

Other options

• Consider adding regular low dose inhaled corticosteroid


(ICS) for patients at risk of exacerbations

GINA 2017
Step 2 – low-dose controller + as-
needed
inhaled SABA

STEP 5

STEP 4

STEP 3 Refer for


PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Low dose ICS ICS/LABA**

Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

*Not for children <12 years


**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
GINA 2017, Box 3-5, Step 2 (5/8)
Step 2 – Low dose controller + as-needed
SABA
Preferred option: regular low dose ICS with as-needed inhaled
SABA
• Low dose ICS reduces symptoms and reduces risk of exacerbations and asthma-
related hospitalization and death

Other options

• 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
• 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
• Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with
no interval symptoms
• Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends

GINA 2017
Step 3 – one or two controllers + as-
needed inhaled reliever

STEP 5

STEP 4

STEP 3 Refer for


PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Low dose ICS ICS/LABA**

Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

*Not for children <12 years


**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
GINA 2017, Box 3-5, Step 3 (6/8) © Global Initiative for Asthma
Step 3 – one or two controllers + as-
needed inhaled reliever
Before considering step-up

• Check inhaler technique and adherence, confirm diagnosis

Adults/adolescents: preferred options are either combination low dose ICS/LABA


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

• Adding LABA reduces symptoms and exacerbations and increases FEV1, while allowing lower dose of ICS
• 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

Children 6-11 years: preferred option is medium dose ICS with


as-needed SABA

Other options

UPDATED
• Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less effective than ICS/LABA)
2017
• Adults: consider adding SLIT (see Non-pharmacological interventions)
• Children 6-11 years – add LABA (similar effect as increasing ICS)

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2017
Step 4 – two or more controllers +
as-needed inhaled reliever

STEP 5

STEP 4

STEP 3 Refer for


PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Low dose ICS ICS/LABA**

Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

*Not for children <12 years


**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
GINA 2017, Box 3-5, Step 4 (7/8) © Global Initiative for Asthma
Step 4 – two or more controllers + as-
needed inhaled reliever
Before considering step-up

• Check inhaler technique and adherence

Adults or adolescents: preferred option is combination low dose


ICS/formoterol as maintenance and reliever regimen*, OR
combination medium dose ICS/LABA with as-needed SABA

Children 6–11 years: preferred option is to refer for expert advice

UPDATED
2017

Other options (adults or adolescents)

• Tiotropium by mist inhaler may be used as add-on therapy for patients aged ≥12 years with a
history of exacerbations
• Adults: consider adding SLIT (see Non-pharmacological therapy)
• Trial of high dose combination ICS/LABA, but little extra benefit and increased risk of side-effects
• Increase dosing frequency (for budesonide-containing inhalers)
• Add-on LTRA or low dose theophylline
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2017
Step 5 – higher level care and/or UPDATED
2017

add-on treatment

STEP 5

STEP 4

STEP 3 Refer for


PREFERRED STEP 1 STEP 2 add-on
CONTROLLER treatment
CHOICE e.g.
Med/high tiotropium,*
anti-IgE,
ICS/LABA anti-IL5*
Low dose
Low dose ICS ICS/LABA**

Other Consider low Med/high dose ICS Add tiotropium* Add low
Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS dose OCS
Low dose theophylline*
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

*Not for children <12 years


**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
 Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations

GINA 2017, Box 3-5, Step 5 (8/8)


Step 5 – higher level care and/or add-on
treatment
Preferred option is referral for specialist investigation
and consideration of add-on treatment
• If symptoms uncontrolled or exacerbations persist despite Step 4
treatment, check inhaler technique and adherence before referring
• Add-on tiotropium for patients ≥12 years with history of exacerbations
• Add-on anti-IgE (omalizumab) for patients with severe allergic asthma
• Add-on anti-IL5 (mepolizumab (SC) or reslizumab (IV)) for severe
eosinophilic asthma (≥12 yrs)
UPDATED
2017
Other add-on treatment options at Step 5 include:

• Sputum-guided treatment: this is available in specialized centers; reduces


exacerbations and/or corticosteroid dose
• Add-on low dose oral corticosteroids (≤7.5mg/day prednisone
equivalent): this may benefit some patients, but has significant systemic
side-effects. Assess and monitor for osteoporosis
• See ERS/ATS Severe Asthma Guidelines (Chung et al, ERJ 2014) for more
detail

GINA 2017
Low, medium and high dose inhaled corticosteroids
Adults and adolescents (≥12 years)
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000


Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone furoate (DPI) 100 n.a. 200
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
 This is not a table of equivalence, but of estimated clinical comparability
 Most of the clinical benefit from ICS is seen at low doses
 High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects

GINA 2017, Box 3-6 (1/2)


Low, medium and high dose inhaled corticosteroids
Children 6–11 years
Inhaled corticosteroid Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 100–200 >200–400 >400
Beclometasone dipropionate (HFA) 50–100 >100–200 >200
Budesonide (DPI) 100–200 >200–400 >400
Budesonide (nebules) 250–500 >500–1000 >1000
Ciclesonide (HFA) 80 >80–160 >160
Fluticasone furoate (DPI) n.a. n.a. n.a.
Fluticasone propionate (DPI) 100–200 >200–400 >400
Fluticasone propionate (HFA) 100–200 >200–500 >500
Mometasone furoate 110 ≥220–<440 ≥440
Triamcinolone acetonide 400–800 >800–1200 >1200
 This is not a table of equivalence, but of estimated clinical comparability
 Most of the clinical benefit from ICS is seen at low doses
 High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with
increased risk of systemic side-effects
GINA 2017, Box 3-6 (2/2)
Reviewing response and adjusting treatment
How often should asthma be reviewed?
1-3 months after treatment started, then
During pregnancy, every 4-6 weeks After an exacerbation, within 1 week
every 3-12 months

Stepping up asthma treatment


Sustained step-up, for at least 2-3 months Short-term step-up, for 1-2 weeks, e.g. with Day-to-day adjustment
if asthma poorly controlled viral infection or allergen •For patients prescribed low-dose
•Important: first check for common causes •May be initiated by patient with written ICS/formoterol maintenance and reliever
(symptoms not due to asthma, incorrect asthma action plan regimen*
inhaler technique, poor adherence)

Stepping down asthma treatment


Consider step-down after good control maintained for 3 Find each patient’s minimum effective dose, that controls both
months symptoms and exacerbations

GINA 2017
General principles for stepping down
controller treatment
Aim
To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects

When to consider stepping down


When symptoms have been well controlled and lung function stable for
No respiratory infection, patient not travelling, not pregnant
≥3 months

Prepare for step-down


Record the level of symptom control and Make sure the patient has a written asthma
Book a follow-up visit in 1-3 months
consider risk factors action plan

Step down through available formulations


Stepping down ICS doses by 25–50% at 3 month intervals is feasible and
See GINA 2017 report Box 3-7 for specific step-down options
safe for most patients (Hagan et al, Allergy 2014)

Stopping ICS is not recommended in adults with asthma because of risk of exacerbations
(Rank et al, JACI 2013)
GINA 2017, Box 3-7
Non-pharmacological interventions
 Avoidance of tobacco smoke exposure
 Physical activity
 Occupational asthma
 Avoid medications that may worsen asthma
 Remediation of dampness or mold in homes

GINA 2017, Box 3-9


It can be controlled but not cured

TERIMA KASIH