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Update in International
Asthma Guidelines (Adult)
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Why do we need guideline?
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Asthma diagnosis
History of Asthma Guidelines
Clinical practice guidelines aresystematically developed statements
designed to help practitioners and patients
make appropriate health care decisions inspecific circumstances
First opinion based asthma guidelinepublished in Australia and New Zealand inmid 1989 (published in Medical Journal of
Australia)
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Asthma diagnosis
First Asthma Guidelines (1989)
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Asthma diagnosis
Principle of asthma guideline
1. Practical asthma guidelines should beconstructed on a strong foundation
from scientific or evidenced-based
therapies or discoveries.
2. Guideline should be widelydisseminated and implemented
throughout the health care community.
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Asthma diagnosis
Principle of asthma guideline
3. Guideline implementation shouldultimately benefit patient outcomes.
4. To ensure that guidelines remain
current and based on knowledge and
evidence, they should have amechanism for regular scheduled
update.
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Asthma diagnosisNational Asthma Guidelines
The Global Asthma Report 2011
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Asthma diagnosisInternational Asthma Guidelines
New Zealand and Australia guideline Canadian Guideline
British Guideline (NICE) Global Initiative for Asthma Guideline
(GINA)
National Asthma Education andPrevention Program Guidelines (NAEPP)
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Asthma diagnosisInternational Asthma Guidelines
the GINA guidelines focused on internationalasthma, the different financial statuses of various
countries led the GINA panel to produce a
comprehensive document that highlighted preferredtreatment categories for acute and chronic asthma
but did not focus on specific medications.
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Asthma diagnosisInternational Asthma Guidelines
GINA NICE
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Asthma diagnosisGINA Guideline
The GINA programs mission was to developrecommendations on asthma care and
management that would be based on the best
available scientific evidence so that it could becustomized or adapted to meet the needs and
resources of local health care systems.
The GINA program was a collaboration of theWorld Health Organization and the National
Heart, Lung, and Blood Institute of the United
States National Institutes of Health.
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Asthma diagnosisGINA Guideline 2011
GINA established in 1993
1st GINA guideline 1995
Revised in 2002,2006
Revised version of 2006version annually, last
update in December 2001
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Asthma diagnosisGINA Guideline 2011: Overview
Chapter 1: Definition and overviewChapter 2: Diagnosis and classificationChapter 3: Asthma medicationsChapter 4: Asthma management and prevention
Component 1: develop doctor-patientrelationship
Component 2: identification and reduceexposure to risk factors
Component 3: Assess, treat and monitor asthmaComponent 4: Manage asthma exacerbationComponent 5: Special considerations
Chapter 5: Implementation of asthma guidelines inhealth systems
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Asthma diagnosisGINA Guideline 2011: Changes
GINA science committee meet twice yearly todiscuss new evidences in asthma managementBetween July,1st,2010 and June, 30th, 2011 317
articles met the search criteria. Of the 317, 23were identified to have the impact on the GINAreport.
A) Modifying, that is, changing the text or
introducing a concept requiring a newrecommendation to the report.
B) Confirming, that is, adding to or replacing an
existing evidence
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Asthma management
Act Plan
Study Do
Same concept of asthma control
Set goal
treatmonitor
adjust
Patient with AsthmaDiagnosis
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Evaluation of Asthma Control
Characteristic Controlled
(All of the following)
Partly Controlled
(Any measurepresent in any week)
Uncontrolled
Daytime symptoms None(twice or less/wk)
More than twice/week Three or morefeatures of partlycontrolled asthmapresent in any weekLimitations of
activitiesNone Any
Nocturnal symptoms None Any
Need for reliever/rescue medication
None(twice or less/ week)
More than twice/week
Lung function (PEF orFEV1)
Normal
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REDUCE INCREASE
Asthma education Environmental controlGINA 2010
As-needed rapid-
acting 2-agonist As-needed rapid-acting 2-agonist
Controller
options
Select one Select one Add one or more Add either
Low-dose inhaled
ICS
Low-dose ICS plus
long-acting2-agonistMedium-or high-
dose ICS plus long-
acting 2-agonistOral
glucocorticosteroid
(lowest dose)
Leukotriene
modifier
Medium-or high-
dose ICS
Leukotriene
modifierAnti-IgE treatment
Low-dose ICS plus
leukotriene modifier
Sustained release
theophylline
Low-dose ICS plus
sustained release
theophylline
Treatment steps
Step 1 Step 2 Step 3 Step 4 Step 5
GINA Report 2007 (www.ginasthma.org)
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REDUCE INCREASE
Asthma education Environmental controlIf step up treatment is being considered for poor asthma control, first check
inhaler technique, check adherence and confirms symptoms are due to asthma
As-needed rapid-
acting 2-agonist As-needed rapid-acting 2-agonist
Controller
options
Select one Select one Add one or more Add either
Low-dose inhaled
ICS
Low-dose ICS plus
long-acting2-agonistMedium-or high-
dose ICS plus long-
acting 2-agonistOral
glucocorticosteroid
(lowest dose)
Leukotriene
modifier
Medium-or high-
dose ICS
Leukotriene
modifierAnti-IgE treatment
Low-dose ICS plus
leukotriene modifier
Sustained release
theophylline
Low-dose ICS plus
sustained release
theophylline
Treatment steps
Step 1 Step 2 Step 3 Step 4 Step 5
GINA Report 2007 (www.ginasthma.org)Recommended treatment (shaded boxes) based on group mean data. Individual patients needs, preferences and
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Asthma diagnosisWhat is new in GINA 2011?
Asthma education Environmental control If step up treatment is being considered for
poor asthma control, first check inhaler
technique, check adherence and confirmssymptoms are due to asthma
Recommended treatment (shaded boxes)based on group mean data. Individual patients
needs, preferences and circumstances
(including costs) should be considered
Controller option should bepersonalized
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Asthma diagnosisStep up or down treatment
If controlled > 3 months step down
If controlled for 12 months with low dose ICS may consider stop Rx
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Asthma diagnosisWhat is new in GINA 2011?
Safety of anti-IgE in asthma..anti-IgE appears to be safe as add-on therapy,including patients generally considered to be athigh risk for exacerbation
Mobile telephone-based interactive self-caresystem improve asthma control Teleheathcare follow up may be of benefit in
those with severe disease at risk for hospitaladmission Providing adherence information to clinicians
does not improve use of ICS among patients with
asthma
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Asthma diagnosisWhat is new in GINA 2011?
Consensus recommendation regardingthermoplasty in severe asthma
In adult patients whose asthma remain
uncontrolled despite application of thistherapeutic paradigm, and referral toasthma specialty center, bronchialthermoplasty is now a possible option in
some countries. Treatment has beenshown to decrease exacerbation but notsignificant effect on lung function orasthma symptoms
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Asthma diagnosisConclusion: GINA 2011
No major changes from previous report Need to find causes of uncontrolled, notjust increase step of treatment
Asthma controller can be personalizedAdopt new technology in asthma controlAccept thermoplasty as an option for
severe asthma
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Asthma diagnosisNICE Asthma Guidelines
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Asthma diagnosisNICE Asthma Guidelines
1. Introduction2. Diagnosis
3. Non-pharmacological management
4. Pharmacological management5. Inhaler devices
6. Management of acute asthma
7. Special situations8. Organization, delivery of care and audit
9. Patient education and self management
10. Development of guideline
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Asthma diagnosisMonitoring asthma update
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Asthma diagnosisAim of asthma treatment
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Asthma diagnosisMonitoring asthma update
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Asthma diagnosisMonitoring asthma update
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Asthma diagnosisPharmacological management
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Asthma diagnosisPharmacological management
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Asthma diagnosisAsthma in adolescents: new
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Asthma diagnosisConclusion: NICE 2011
No major changes from previous reportAsthma controller can start at most
appropriate step
Oral beta-2 agonist can be used as add-on controller
ACT can be used to assess control Specific sub-group such as adolescent
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Thank you for your attention!