1.GINA Slideset 2013

GLOBAL INITIATIVE FOR ASTHMA (GINA)
TEACHING SLIDE SET

January 2013
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GINA.
Global Initiative for Asthma

G lobal
INitiative for
A sthma
GINA Program Objectives
Increase appreciation of asthma as a global public

health problem
Present key recommendations for diagnosis and

management of asthma
Provide strategies to adapt recommendations to

varying health needs, services, and resources
Identify areas for future investigation of particular

significance to the global community
GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD
Dissemination Science
Committee Committee
Chair: L.B. Boulet, MD Chair: Helen Reddel, MD

GINA Board of Directors
M. FitzGerald, Chair, Canada

E. Bateman, S. Africa P. Paggario, Italy
L.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 ROC
P. OByrne, Canada
GINA Science Committee
H. Reddel, Chair, Australia

N. Barnes, UK M. FitzGerald, Canada
P. Barnes, UK R. Lemanske, US
A. Becker, Canada P. OByrne, Canada
E. Bel, Netherlands E. Pizzichini, Brazil
J. DeJongste, Netherlands S. Pedersen, Denmark
J. Drazen, US H. Reddel, Australia
GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD
Dissemination Science
Committee Committee
Chair: L.P. Boulet, MD Chair: H. Reddel, MD
GINA ASSEMBLY
GINA Assembly
A network of individuals participating in

the dissemination and implementation of
asthma management programs at the
local, national and regional level
GINA Assembly members are invited to
meet with the GINA Executive Committee
during the ATS and ERS meetings
Saudi Arabia Bangladesh
Slovenia Germany Ireland
Australia Yugoslavia Croatia
Brazil Canada
United States Austria Taiwan
Thailand Portugal
Philippines
Mexico Greece Malta
Moldova China
Syria Egypt South Africa
United Kingdom Hong Kong ROC Chile
Italy New Zealand Venezuela Cambodia
Argentina Israel
Lebanon Pakistan
Mongolia Japan
Poland Korea GINA Assembly Netherlands
Switzerland Russia Macedonia Georgia
France
Turkey Czech Belgium
Denmark
Republic Slovakia
Romania Colombia Ukraine Singapore Spain
India
Sweden Albania Kyrgyzstan Vietnam
GINA Documents
Global 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 families
All materials are available on GINA web site www.ginasthma.org
Global Strategy for Asthma
Management and Prevention
Evidence-based
Implementation oriented
Diagnosis
Management
Prevention
Outcomes can be evaluated
Management and Prevention
Evidence 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

Management and Prevention (2012)
Definition and Overview

Diagnosis and Classification
Asthma Medications
Asthma Management and

Prevention Program
Implementation of Asthma
Updated 2012 Guidelines in Health
Systems
Definition of Asthma
A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role
Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing
Widespread, variable, and often reversible
airflow limitation

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

Mechanisms: Asthma Inflammation

Asthma Inflammation: Cells and Mediators

Burden of Asthma
Asthma is one of the most common chronic

diseases worldwide with an estimated 300
million affected individuals
Prevalence increasing in many countries,
especially in children
A major cause of school/work absence

Burden of Asthma
Health care expenditures very high

Developed economies might expect to
spend 1-2 percent of total health care
expenditures on asthma. Developing
economies likely to face increased demand
Poorly controlled asthma is expensive;
investment in prevention medication likely
to yield cost savings in emergency care
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004

Countries should enter their
own data on burden of
asthma.
Risk Factors for Asthma
Host factors: predispose individuals to, or

protect them from, developing asthma
Environmental factors: influence

susceptibility to development of asthma in
predisposed individuals, precipitate asthma
exacerbations, and/or cause symptoms to
persist

Factors that Exacerbate Asthma
Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

Factors that Influence Asthma
Development and Expression
Host Factors Environmental Factors

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

Is it Asthma?
Recurrent episodes of wheezing

Troublesome cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness
after exposure to airborne allergens
or pollutants
Colds go to the chest or take more
than 10 days to clear
Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk
factors
Extra measures may be required to diagnose
asthma in children 5 years and younger and the
elderly
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)
1 2 3 4 5
Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak
Expiratory Flow
Measuring Airway Responsiveness

Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce Exposure
to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma Exacerbations
Updated 2012
5. Special Considerations
Asthma Management and Prevention Program
Goals of Long-term Management
Achieve and maintain control of symptoms

Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to
normal levels as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma

medications
Prevent asthma mortality
Asthma Management and Prevention
Program: Five Interrelated Components
1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to
Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Prevention Program
.
Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
Early intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
Prevention Program
Although there is no cure for asthma,

appropriate management that includes
a partnership between the physician
and the patient/family most often
results in the achievement of control

Part 1: Educate Patients to
Develop a Partnership
Guidelines on asthma management

should be available but adapted and
adopted for local use by local asthma
planning teams
Clear communication between health
care professionals and asthma patients
is key to enhancing compliance

Component 1: Develop
Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health
care providers, the patient, and the
patients family
Component 1: Develop
Patient/Doctor Partnership
Key factors to facilitate communication:

Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than________? No Yes
If 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 TREATMENT

STEP-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 CONTROL

If 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.

Factors Involved in Non-Adherence
Medication Usage Non-Medication Factors

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

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

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
Asthma exacerbations may be caused by a variety
of risk factors allergens, viral infections,
pollutants and drugs.
Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
Component 2: Identify and Reduce
Exposure to Risk Factors
Reduce exposure to indoor allergens

Avoid tobacco smoke
Avoid vehicle emission
Identify irritants in the workplace
Explore role of infections on asthma
development, especially in children and
young infants
Influenza Vaccination
Influenza vaccination should be
provided to patients with asthma when
vaccination of the general population is
advised
However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control
Component 3: Assess, Treat

and Monitor Asthma
The goal of asthma treatment, to

achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional
Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
The focus on asthma control is

important because:
the attainment of control correlates
with a better quality of life, and
reduction in health care use
Global Strategy for Asthma Management and Prevention
Clinical Control of Asthma
Determine the initial level of

control to implement treatment
(assess patient impairment)
Maintain control once treatment

has been implemented
(assess patient risk)
Levels of Asthma Control
(Assess patient impairment)
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (Any present in any week)
Twice or less More than

Daytime symptoms
per week twice per week
Limitations of 3 or more
None Any
activities features of
partly
Nocturnal symptoms controlled
None Any
/ awakening asthma
present in
Need for rescue / Twice or less More than any week
reliever treatment per week twice per week
< 80% predicted or
Lung function
Normal personal best (if
(PEF or FEV1)
known) on any day
Assessment of Future Risk (risk of exacerbations, instability, rapid
decline in lung function, side effects)
Assess Patient Risk
Features that are associated with increased
risk of adverse events in the future include:
Poor clinical control
Frequent exacerbations in past year
Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke,
high dose medications
Assessment of Future Risk
Risk of exacerbations, instability, rapid decline
Any
in lungexacerbation
function, side effects
should prompt review
Features that are associated with increased
of maintenance
risk of adverse events in the future include:
Poor clinical
treatment
control
Frequent exacerbations in past year
Ever admission to critical care for asthma
Low FEV1, exposure to cigarette smoke,
high dose medications

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

and Monitor Asthma
A stepwise approach to pharmacological
therapy is recommended
The aim is to accomplish the goals of

therapy with the least possible medication
Although in many countries traditional

methods of healing are used, their efficacy
has not yet been established and their use
can therefore not be recommended

and Monitor Asthma
The choice of treatment should be guided by:
Level of asthma control
Current treatment
Pharmacological properties and availability
of the various forms of asthma treatment
Economic considerations
Cultural preferences and differing health care
systems need to be considered
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled 2-agonists in combination

with inhaled glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones
Anti-IgE

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

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

Reliever Medications
Rapid-acting inhaled 2-agonists

Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists

Component 4: Asthma Management and Prevention Program
Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is
limited
Specific immunotherapy should be considered
only after strict environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
Perform only by trained physician
REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION
maintain and find lowest

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


Treating to Achieve Asthma Control
Step 1 As-needed reliever medication

Patients with occasional daytime symptoms of
short duration
A rapid-acting inhaled 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)

Step 2 Reliever medication plus a single

controller
A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence A)
Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids

Step 3 Reliever medication plus one or two

controllers
For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting 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)
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled

glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
Low-dose sustained-release theophylline
(Evidence B)

Step 4 Reliever medication plus two or more

controllers
Selection of treatment at Step 4 depends

on prior selections at Steps 2 and 3
Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Step 4 Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid

combined with a long-acting inhaled 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)

Step 5 Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other

controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
When control as been achieved,

ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored
by the health care professional and
by the patient
Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose

inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence
B)
When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
Stepping down treatment when asthma is controlled

When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled 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)
Stepping up treatment in response to loss of control

Rapid-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
Stepping up treatment in response to loss of control

Use 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)
Component 4: Manage Asthma
Exacerbations
Exacerbations of asthma are episodes of

progressive increase in shortness of breath,
cough, wheezing, or chest tightness
Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
Exacerbations
Treatment of exacerbations depends on:

The patient
Experience of the health care professional
Therapies that are the most effective for
the particular patient
Availability of medications
Emergency facilities
Exacerbations
Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled
2-agonist
Early introduction of systemic
glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

Special Considerations
Special considerations are required to
manage asthma in relation to:
Pregnancy
Surgery
Rhinitis, sinusitis, and nasal polyps
Occupational asthma
Respiratory infections
Gastroesophageal reflux
Aspirin-induced asthma
Anaphylaxis and Asthma
Global Strategy
for the Diagnosis
and Management
of Asthma in
Children 5 Years
and Younger
2009
www.ginasthma.org
Prevention Program: Summary
Asthma can be effectively controlled in most

patients by intervening to suppress and reverse
inflammation as well as treating
bronchoconstriction and related symptoms
Although there is no cure for asthma,
appropriate management that includes a
partnership between the physician and the
patient/family most often results in the
achievement of control
Prevention Program: Summary
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
http://www.ginasthma.org

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GLOBAL INITIATIVE FOR ASTHMA (GINA)

TEACHING SLIDE SET

Global Initiative for Asthma

Increase appreciation of asthma as a global public

Present key recommendations for diagnosis and

Provide strategies to adapt recommendations to

Identify areas for future investigation of particular

Global Initiative for Asthma

M. FitzGerald, Chair, Canada

H. Reddel, Chair, Australia

A network of individuals participating in

Global Strategy for Asthma Management and

A Randomized clinical trials

B Randomized clinical trials

D Panel judgment consensus

Definition and Overview

Asthma Management and

A chronic inflammatory disorder of the airways

Global Initiative for Asthma

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

Source: Peter J. Barnes, MD

Asthma is one of the most common chronic

Global Initiative for Asthma

Health care expenditures very high

Source: Masoli M et al. Allergy 2004

Host factors: predispose individuals to, or

Environmental factors: influence

Global Initiative for Asthma

Global Initiative for Asthma

Host Factors Environmental Factors

Global Initiative for Asthma

Recurrent episodes of wheezing

Asthmatic (After Bronchodilator)

Global Initiative for Asthma

Goals of Long-term Management

Achieve and maintain control of symptoms

Avoid adverse effects from asthma

1. Develop Patient/Doctor Partnership

Although there is no cure for asthma,

Global Initiative for Asthma

Guidelines on asthma management

Global Initiative for Asthma

Key factors to facilitate communication:

WHEN TO INCREASE TREATMENT

HOW TO INCREASE TREATMENT

WHEN TO CALL THE DOCTOR/CLINIC.

EMERGENCY/SEVERE LOSS OF CONTROL

Global Initiative for Asthma

Medication Usage Non-Medication Factors

Distance to pharmacies Attitudes toward ill health

Measures to prevent the development of asthma,

Reduce exposure to indoor allergens

Component 3: Assess, Treat

The goal of asthma treatment, to

Clinical Control of Asthma

The focus on asthma control is

Clinical Control of Asthma

Determine the initial level of

Maintain control once treatment

Twice or less More than

Component 3: Assess, Treat

Component 3: Assess, Treat