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Global Initiative for AsthmaGLOBAL INITIATIVE FOR ASTHMA (GINA)
TEACHING SLIDE SETJanuary 2013
This slide set is restricted for academic and educational
purposes only. Use of the slide set, or of individual slides, for
commercial or promotional purposes requires approval from GINA.
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G IN Alobal itiative for sthma Global Initiative for Asthma
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GINA Program ObjectivesIncrease appreciation of asthma as a
global public health problemPresent key recommendations for
diagnosis and management of asthmaProvide strategies to adapt
recommendations to varying health needs, services, and
resourcesIdentify areas for future investigation of particular
significance to the global community
Global Initiative for Asthma
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Executive CommitteeChair: Mark FitzGerald, MD
Dissemination CommitteeChair: L.B. Boulet, MDGINA
StructureScience CommitteeChair: Helen Reddel, MD Global Initiative
for Asthma
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GINA Board of DirectorsM. FitzGerald, Chair, CanadaE. Bateman,
S. Africa P. Paggario, ItalyL.P. Boulet, Canada S. Pedersen,
Denmark A. Cruz, Brazil H. Reddel, Australia M. Haahtela, Finland
M. Soto-Quiroz, Costa Rica M. Levy, U.K. G. Wong, Hong Kong ROCP.
OByrne, Canada Global Initiative for Asthma
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GINA Science CommitteeH. Reddel, Chair, AustraliaN. Barnes, UK
M. FitzGerald, CanadaP. Barnes, UK R. Lemanske, US A. Becker,
Canada P. OByrne, CanadaE. Bel, NetherlandsE. Pizzichini, BrazilJ.
DeJongste, NetherlandsS. Pedersen, DenmarkJ. Drazen, USH. Reddel,
Australia
Global Initiative for Asthma
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Executive CommitteeChair: Mark FitzGerald, MD
Dissemination CommitteeChair: L.P. Boulet, MDGINA
StructureScience CommitteeChair: H. Reddel, MDGINA ASSEMBLY Global
Initiative for Asthma
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GINA AssemblyA network of individuals participating in the
dissemination and implementation of asthma management programs at
the local, national and regional levelGINA Assembly members are
invited to meet with the GINA Executive Committee during the ATS
and ERS meetings Global Initiative for Asthma
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United StatesUnited
KingdomArgentinaAustraliaBrazilAustriaCanadaChileBelgiumChinaDenmarkColombiaCroatiaGermanyGreeceIrelandItalySyriaHong
Kong
ROCJapanIndiaKoreaKyrgyzstanMoldovaMacedoniaMaltaNetherlandsNew
ZealandPolandPortugalGeorgiaRomaniaRussiaSingaporeSlovakiaSloveniaSaudi
ArabiaSouth
AfricaSpainSwedenThailandSwitzerlandUkraineTaiwanVenezuelaVietnamYugoslaviaAlbaniaBangladeshFranceMexicoTurkeyCzech
RepublicLebanonPakistanGINA
AssemblyIsraelPhilippinesCambodiaMongoliaEgypt
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GINA DocumentsGlobal Strategy for Asthma Management and
Prevention (updated 2012)Pocket Guide: Asthma Management and
Prevention (updated 2012)Global Strategy for Asthma Management and
Prevention for Children 5 Years and Younger (2009)Pocket Guide:
Asthma Management and Prevention in Children 5 Years and younger
(2009)Guide for asthma patients and familiesAll materials are
available on GINA web site www.ginasthma.org Global Initiative for
Asthma
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Global Strategy for Asthma Management and Prevention
Evidence-based Implementation oriented Diagnosis Management
Prevention Outcomes can be evaluated Global Initiative for
Asthma
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Global Strategy for Asthma Management and PreventionEvidence
Category Sources of Evidence
A Randomized clinical trials Rich body of data B Randomized
clinical trials Limited body of data C Non-randomized trials
Observational studies D Panel judgment consensus
Global Initiative for Asthma
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Global Strategy for Asthma Management and Prevention
(2012)Definition and OverviewDiagnosis and ClassificationAsthma
MedicationsAsthma Management and Prevention ProgramImplementation
of Asthma Guidelines in Health SystemsUpdated 2012 Global
Initiative for Asthma
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Definition of AsthmaA chronic inflammatory disorder of the
airwaysMany cells and cellular elements play a roleChronic
inflammation is associated with airway hyperresponsiveness that
leads to recurrent episodes of wheezing, breathlessness, chest
tightness, and coughingWidespread, variable, and often reversible
airflow limitation Global Initiative for Asthma
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Source: Peter J. Barnes, MDAsthma Inflammation: Cells and
Mediators
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Mechanisms: Asthma Inflammation
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Source: Peter J. Barnes, MDAsthma Inflammation: Cells and
Mediators
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Burden of AsthmaAsthma is one of the most common chronic
diseases worldwide with an estimated 300 million affected
individualsPrevalence increasing in many countries, especially in
childrenA major cause of school/work absence Global Initiative for
Asthma
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Burden of AsthmaHealth care expenditures very highDeveloped
economies might expect to spend 1-2 percent of total health care
expenditures on asthma. Developing economies likely to face
increased demandPoorly controlled asthma is expensive; investment
in prevention medication likely to yield cost savings in emergency
care Global Initiative for Asthma
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Asthma Prevalence and MortalitySource: Masoli M et al. Allergy
2004
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Countries should enter their own data on burden of asthma.
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Risk Factors for AsthmaHost factors: predispose individuals to,
or protect them from, developing asthmaEnvironmental factors:
influence susceptibility to development of asthma in predisposed
individuals, precipitate asthma exacerbations, and/or cause
symptoms to persist
Global Initiative for Asthma
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Factors that Exacerbate AsthmaAllergensRespiratory
infectionsExercise and hyperventilationWeather changesSulfur
dioxideFood, additives, drugs Global Initiative for Asthma
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Factors that Influence Asthma Development and ExpressionHost
FactorsGenetic - Atopy - Airway hyperresponsiveness
GenderObesityEnvironmental Factors Indoor allergens Outdoor
allergens Occupational sensitizers Tobacco smoke Air Pollution
Respiratory Infections Diet Global Initiative for Asthma
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Is it Asthma?Recurrent episodes of wheezingTroublesome cough at
nightCough or wheeze after exerciseCough, wheeze or chest tightness
after exposure to airborne allergens or pollutantsColds go to the
chest or take more than 10 days to clear Global Initiative for
Asthma
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Asthma DiagnosisHistory and patterns of symptomsMeasurements of
lung function - Spirometry - Peak expiratory flowMeasurement of
airway responsiveness Measurements of allergic status to identify
risk factorsExtra measures may be required to diagnose asthma in
children 5 years and younger and the elderly Global Initiative for
Asthma
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Typical Spirometric (FEV1) Tracings1Time
(sec)2345FEV1VolumeNormal SubjectAsthmatic (After
Bronchodilator)Asthmatic (Before Bronchodilator)Note: Each FEV1
curve represents the highest of three repeat measurements Global
Initiative for Asthma
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Measuring Variability of Peak Expiratory Flow
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Measuring Airway Responsiveness Global Initiative for Asthma
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1. Develop Patient/Doctor Partnership2. Identify and Reduce
Exposure to Risk Factors3. Assess, Treat and Monitor Asthma4.
Manage Asthma Exacerbations5. Special ConsiderationsAsthma
Management and PreventionProgram: Five Components Global Initiative
for Asthma
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Asthma Management and Prevention ProgramGoals of Long-term
ManagementAchieve and maintain control of symptomsMaintain normal
activity levels, including exerciseMaintain pulmonary function as
close to normal levels as possiblePrevent asthma exacerbationsAvoid
adverse effects from asthma medicationsPrevent asthma mortality
Global Initiative for Asthma
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Asthma Management and Prevention Program: Five Interrelated
Components1. Develop Patient/Doctor Partnership2. Identify and
Reduce Exposure to Risk Factors3. Assess, Treat and Monitor
Asthma4. Manage Asthma Exacerbations5. Special Considerations
Global Initiative for Asthma
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Asthma Management and Prevention ProgramAsthma can be
effectively controlled in most patients by intervening to suppress
and reverse inflammation as well as treating bronchoconstriction
and related symptomsEarly intervention to stop exposure to the risk
factors that sensitized the airway may help improve the control of
asthma and reduce medication needs.. Global Initiative for
Asthma
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Asthma Management and Prevention ProgramAlthough 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
Global Initiative for Asthma
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Asthma Management and Prevention ProgramPart 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 teamsClear communication between health care professionals
and asthma patients is key to enhancing compliance Global
Initiative for Asthma
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Asthma Management and Prevention ProgramComponent 1: Develop
Patient/Doctor Partnership Educate continuallyInclude the
familyProvide information about asthmaProvide training on
self-management skillsEmphasize a partnership among health care
providers, the patient, and the patients family Global Initiative
for Asthma
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Asthma Management and Prevention ProgramComponent 1: Develop
Patient/Doctor PartnershipKey factors to facilitate communication:
Friendly demeanor Interactive dialogue Encouragement and praise
Provide appropriate information Feedback and review
Global Initiative for Asthma
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Global Initiative for Asthma
Example Of Contents Of An Action Plan To Maintain Asthma
ControlYour Regular Treatment: 1. Each day take
___________________________ 2. Before exercise, take
_____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn
the past week have you had: Daytime asthma symptoms more than 2
times ? NoYes Activity or exercise limited by asthma? NoYes Waking
at night because of asthma? NoYes The need to use your [rescue
medication] more than 2 times? No Yes If you are monitoring peak
flow, peak flow less than________? NoYesIf you answered YES to
three or more of these questions, your asthma is uncontrolled and
you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and
assess improvement every
day:____________________________________________ [Write in next
treatment step here] Maintain this treatment for _____________ days
[specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic:
_______________ [provide phone numbers]If you dont respond in
_________ days [specify number]______________________________
[optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of
breath, and can only speak in short sentences,If you are having a
severe attack of asthma and are frightened,If you need your
reliever medication more than every 4 hours and are not
improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2.
Take ____mg of ____________ [oral glucocorticosteroid]3. Seek
medical help: Go to _____________________;
Address___________________ Phone: _______________________4.
Continue to use your _________[reliever medication] until you are
able to get medical help.
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Asthma Management and Prevention ProgramFactors Involved in
Non-AdherenceMedication UsageDifficulties associated with
inhalersComplicated regimensFears about, or actual side
effectsCostDistance to pharmaciesNon-Medication
FactorsMisunderstanding/lack of informationFears about side-effects
Inappropriate expectationsUnderestimation of severityAttitudes
toward ill healthCultural factorsPoor communication Global
Initiative for Asthma
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Asthma Management and Prevention ProgramComponent 2: Identify
and Reduce Exposure to Risk FactorsMeasures 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. Global Initiative for
Asthma
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Reduce exposure to indoor allergensAvoid tobacco smokeAvoid
vehicle emissionIdentify irritants in the workplaceExplore role of
infections on asthma development, especially in children and young
infantsAsthma Management and Prevention ProgramComponent 2:
Identify and Reduce Exposure to Risk Factors Global Initiative for
Asthma
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Asthma Management and Prevention ProgramInfluenza
VaccinationInfluenza vaccination should be provided to patients
with asthma when vaccination of the general population is
advisedHowever, routine influenza vaccination of children and
adults with asthma does not appear to protect them from asthma
exacerbations or improve asthma control Global Initiative for
Asthma
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Asthma Management and Prevention ProgramComponent 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 Initiative for Asthma
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Global Strategy for Asthma Management and PreventionClinical
Control of AsthmaThe focus on asthma control isimportant
because:the attainment of control correlates with a better quality
of life, and reduction in health care use Global Initiative for
Asthma
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Determine the initial level of control to implement treatment
(assess patient impairment)
Maintain control once treatment has been implemented (assess
patient risk)Global Strategy for Asthma Management and
PreventionClinical Control of Asthma Global Initiative for
Asthma
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Levels of Asthma Control(Assess patient impairment)
Assessment of Future Risk (risk of exacerbations, instability,
rapid decline in lung function, side effects) Global Initiative for
Asthma
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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 asthmaLow FEV1, exposure to cigarette smoke, high dose
medications Global Initiative for Asthma
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Assessment of Future Risk Risk of exacerbations, instability,
rapid decline in lung function, side effects
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
asthmaLow FEV1, exposure to cigarette smoke, high dose
medicationsAny exacerbation should prompt review of maintenance
treatment Global Initiative for Asthma
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Asthma Management and Prevention Program Component 3: Assess,
Treat and Monitor AsthmaDepending on level of asthma control, the
patient is assigned to one of five treatment stepsTreatment 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 Global
Initiative for Asthma
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A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least
possible medicationAlthough in many countries traditional methods
of healing are used, their efficacy has not yet been established
and their use can therefore not be recommendedAsthma Management and
Prevention Program Component 3: Assess, Treat and Monitor Asthma
Global Initiative for Asthma
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The choice of treatment should be guided by: Level of asthma
controlCurrent treatmentPharmacological properties and availability
of the various forms of asthma treatmentEconomic
considerationsCultural preferences and differing health caresystems
need to be considered
Asthma Management and Prevention Program Component 3: Assess,
Treat and Monitor Asthma Global Initiative for Asthma
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Controller Medications Inhaled glucocorticosteroids Leukotriene
modifiersLong-acting inhaled 2-agonists in combination with inhaled
glucocorticosteroids Systemic glucocorticosteroids Theophylline
Cromones Anti-IgE Global Initiative for Asthma
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Estimate Comparative Daily Dosages for Inhaled
Glucocorticosteroids by AgeDrug 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 Global Initiative for Asthma
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000
>400
Budesonide200-600 100-200 600-1000 >200-400 >1000 >400
Budesonide-Neb Inhalation Suspension 250-500 500-1000 >1000
Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280
>320Flunisolide500-1000 500-750 >1000-2000 >750-1250
>2000 >1250 Fluticasone100-250 100-200 >250-500
>200-500 >500 >500 Mometasone furoate200-400 100-200 >
400-800 >200-400>800-1200 >400Triamcinolone
acetonide400-1000 400-800 >1000-2000 >800-1200 >2000
>1200
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Reliever Medications Rapid-acting inhaled 2-agonists Systemic
glucocorticosteroids Anticholinergics Theophylline Short-acting
oral 2-agonists
Global Initiative for Asthma
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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 rhinitisThe role of specific immunotherapy in
asthma is limitedSpecific immunotherapy should be considered only
after strict environmental avoidance and pharmacologic
intervention, including inhaled glucocorticosteroids, have failed
to control asthmaPerform only by trained physician Global
Initiative for Asthma
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Global Initiative for Asthma
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Shaded green - preferred controller options Global Initiative
for Asthma
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Shaded green - preferred controller optionsTO STEP 4 TREATMENT,
ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global
Initiative for Asthma
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Step 1 As-needed reliever medicationPatients with occasional
daytime symptoms of short durationA rapid-acting inhaled 2-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)Treating to Achieve Asthma
Control Global Initiative for Asthma
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Shaded green - preferred controller optionsTO STEP 4 TREATMENT,
ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global
Initiative for Asthma
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Step 2 Reliever medication plus a single controllerA 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 glucocorticosteroidsTreating to Achieve Asthma Control
Global Initiative for Asthma
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Shaded green - preferred controller optionsTO STEP 4 TREATMENT,
ADD EITHERTO STEP 3 TREATMENT, SELECT ONE OR MORE: Global
Initiative for Asthma
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Step 3 Reliever medication plus one or two controllersFor adults
and adolescents, combine a low-dose inhaled glucocorticosteroid
with an inhaled long-acting 2-agonist either in a combination
inhaler device or as separate components (Evidence A) Inhaled
long-acting 2-agonist must not be used as monotherapy For children,
increase to a medium-dose inhaled glucocorticosteroid (Evidence
A)Treating to Achieve Asthma Control Global Initiative for
Asthma
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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)Treating to Achieve Asthma Control Global Initiative for
Asthma
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Shaded green - preferred controller options Global Initiative
for Asthma
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Step 4 Reliever medication plus two or more controllersSelection
of treatment at Step 4 depends on prior selections at Steps 2 and
3Where possible, patients not controlled on Step 3 treatments
should be referred to a health professional with expertise in the
management of asthmaTreating to Achieve Asthma Control Global
Initiative for Asthma
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Step 4 Reliever medication plus two or more controllersMedium-
or high-dose inhaled glucocorticosteroid combined with a
long-acting inhaled 2-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 2-agonist (Evidence B)Treating to Achieve
Asthma Control Global Initiative for Asthma
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Shaded green - preferred controller options Global Initiative
for Asthma
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Treating to Achieve Asthma ControlStep 5 Reliever medication
plus additional controller optionsAddition 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) Global
Initiative for Asthma
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Treating to Maintain Asthma ControlWhen 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 Global
Initiative for Asthma
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Treating to Maintain Asthma ControlStepping down treatment when
asthma is controlledWhen 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)
Global Initiative for Asthma
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Treating to Maintain Asthma ControlStepping down treatment when
asthma is controlledWhen controlled on combination inhaled
glucocorticosteroids and long-acting inhaled 2-agonist, reduce dose
of inhaled glucocorticosteroid by 50% while continuing the
long-acting 2-agonist (Evidence B)If control is maintained, reduce
to low-dose inhaled glucocorticosteroids and stop long-acting
2-agonist (Evidence D) Global Initiative for Asthma
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Treating to Maintain Asthma ControlStepping up treatment in
response to loss of controlRapid-onset, short-acting or long-acting
inhaled 2-agonist bronchodilators provide temporary relief.Need for
repeated dosing over more than one/two days signals need for
possible increase in controller therapy Global Initiative for
Asthma
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Treating to Maintain Asthma ControlStepping up treatment in
response to loss of controlUse of a combination rapid and
long-acting inhaled 2-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) Global Initiative for Asthma
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Exacerbations of asthma are episodes of progressive increase in
shortness of breath, cough, wheezing, or chest
tightnessExacerbations 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 supervisionAsthma
Management and Prevention ProgramComponent 4: Manage Asthma
Exacerbations Global Initiative for Asthma
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Asthma Management and Prevention ProgramComponent 4: Manage
Asthma ExacerbationsTreatment of exacerbations depends on:The
patientExperience of the health care professionalTherapies that are
the most effective for the particular patientAvailability of
medicationsEmergency facilities Global Initiative for Asthma
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Primary therapies for exacerbations:Repetitive administration of
rapid-acting inhaled 2-agonistEarly introduction of systemic
glucocorticosteroidsOxygen supplementationClosely monitor response
to treatment with serialmeasures of lung function
Asthma Management and Prevention ProgramComponent 4: Manage
Asthma Exacerbations Global Initiative for Asthma
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Asthma Management and Prevention ProgramSpecial
ConsiderationsSpecial considerations are required tomanage asthma
in relation to:PregnancySurgeryRhinitis, sinusitis, and nasal
polypsOccupational asthmaRespiratory infectionsGastroesophageal
refluxAspirin-induced asthmaAnaphylaxis and Asthma Global
Initiative for Asthma
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Global Strategy for the Diagnosis and Management of Asthma in
Children 5 Years and Younger2009
www.ginasthma.org Global Initiative for Asthma
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Asthma can be effectively controlled in most patients by
intervening to suppress and reverse inflammation as well as
treating bronchoconstriction and related symptomsAlthough 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 controlAsthma Management and
Prevention Program: Summary Global Initiative for Asthma
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A stepwise approach to pharmacologic therapy is recommended. The
aim is to accomplish the goals of therapy with the least possible
medication
The availability of varying forms of treatment, cultural
preferences, and differing health care systems need to be
considered
Asthma Management and Prevention Program: Summary Global
Initiative for Asthma
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http://www.ginasthma.org Global Initiative for Asthma
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