What is new with the 2014
GINA update?
Gary Wong
Department of Paediatrics and School of Public Health
Chinese University of Hong Kong
Asher et al Lancet 2006;368(9537):733-43.
Guidelines from around the world
Why Asthma ICON?
Question: So many guidelines
Are there any similarities and
differences?
Are there any scientific basis for
the differences?
Writing group:
N Papadopoulos, H Arakawa,
KH Carlsen, A Custovic, J Gern, R
Lemanske, P Le Souef, M Makela
G Roberts, GW Wong, H Zar
Review group: 57 experts from around
the world
Classification of asthma: Asthma ICON
4805 patients with diagnosed asthma either with active symptoms or taking anti-asthma drugs in the past 12 months
• 3815 (79.4%) adults, i.e. >16 y
• 57.5% female
• questionnaire survey conducted 9-12/2006
Asthma in Reality in Asia-Pacific (AIRIAP) 2:Study sites
Areas for both 1 & 2
Areas for 2 only India
Sri Lanka
Thailand
Indonesia
Malaysia
Singapore
Vietnam The Philippines
Hong Kong
Taiwan
China
South Korea
Lai CK et al. Respirology 2011;16, 688–697.
Wong GW et al. Allergy April 2013
AIRIAP 2 Pediatric data
Wong GW et al. Allergy 2013;68:524-30.
2.5% 44% 53.4%
AIRIAP 2: Pediatric data (n=988)
Wong GW et al. Allergy 2013;68:524-30.
Use of urgent care
Use of medications
Rely on bronchodilators
* Between group comparisons :P<0.005
*
“Controlled asthma: Only 2.5% of the subjects
Major update in 2014
In response to feedback from end users
of the possible problems
New evidence of management of
Asthma
GINA Asthma Treatment Strategy
GINA Science Committee
Helen Reddel, Australia, Chair
12 people from around the world
Meet twice a year to review all published trials
Make recommendations of changes for the
Executives to make the final recommendations
Executive Board of Directors
12 people: assess recommendations from Science
committee, make revision and are applicable
worldwide
Members serve in a voluntary capacity
Twice-yearly meetings before ATS and ERS
conferences
Routine review of scientific literature about asthma
(treatment)
Other peer-reviewed material that has been submitted for
review
Discussion of any paper considered to impact on the GINA
report
Recommendations about therapies for which at least two good
quality clinical trials are available, and that have been approved
for asthma by a major regulator
Annual update of GINA report, generally published in
Dec/Jan
GINA Science Committee
GINA 2014
Revision of GINA documents
GINA 2014: Flow charts and tables:
Aim to help practitioners to apply in their daily
practice
Childhood Asthma: Problem with Diagnosis
Diagnosis: Primarily based on history
Lung function testing rarely done
Problems with over-diagnosis and under-
diagnosis
Diagnosis
of Asthma
Assessment: Current control vs Future risk
Current control
Symptoms
Use of bronchodilators
Sleep disturbance
Limitation of activities
Future risk
Exacerbations
Decline in lung function
© Global Initiative for Asthma
GINA assessment of asthma control
© Global Initiative for Asthma
GINA assessment of asthma control
Major problems with asthma clinical trials
Design of the trial: test the average response
of patient:
Compare mean responses in two arms
Most published asthma trials: adults or
adolescents
Do not consider individual variations of
response to each treatment
BADGER study
Lemanske et al (CARE network) NEJM 2010;362:975-85.
Comparison among the three treatments
161/165 patients showed a differential response
For most patients not well controlled
with ICS:
Addition of LABA provides significant
improvement in more than 50% of the
patients.
Some do better with increasing LABA or
the addition of LTRA
The science of picking the right drug
ICS:
A safe steroid
Combination in a single devise
Small particles getting into small airways
LABA
Long and fast acting such that your patients
can feel the bronchodilator effects early can
may be used as rescue drug
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
Achieving these goals requires a partnership between
patient and their health care providers
Ask the patient about their own goals regarding their asthma
Consider the health care system, medication availability, cultural
and personal preferences
Goals of asthma management
GINA 2014
© Global Initiative for Asthma
The control-based asthma management
cycle
© Global Initiative for Asthma
Stepwise management - pharmacotherapy
*For children 6-11 years,
theophylline is not
recommended, and preferred
Step 3 is medium dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
© Global Initiative for Asthma
Probability of asthma diagnosis or response
to asthma treatment in children ≤5 years
Typical
Atopic
Asthma
Typical
Viral
Induced
Wheeze
Oral steroid treatment for preschool wheezing attacks? Panickar et al. NEJM 2009;360: 329-338
Preemptive use of high dose futicasone for virus induced
wheeing in young children
Ducharme et al. NEJM 2009;360;339-353.
Results: High dose fluticasone 750 mcg BD
at the start of URI
The cost : growth rate of 6.56 down to 6.23 cm over one year
Preemptive use of high dose futicasone for virus induced
wheeing in young children
Ducharme et al. NEJM 2009;360;339-353.
What about the use of LTRA?
AJRCCM 2007;175:323-9.
Post-hoc analyses:
© Global Initiative for Asthma
Symptom patterns in children ≤5 years
For viral induced asthma
Regular usual dose of ICS – little
evidence for efficacy
High-dose ICS may have some benefits
but associated with significant side-
effects
May consider short course LTRA
© Global Initiative for Asthma
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 ≥3 months
No respiratory infection, patient not travelling.
Prepare for step-down Record the level of symptom control and consider risk factors
Book a follow-up visit in 1-3 months
Step down through available formulations Stepping down ICS doses by 25–50% at 3 month intervals is
feasible and safe for most patients
Step down in the appropriate seasons
General principles for stepping down
controller treatment
Preschool wheezing and childood
asthma: Conclusions
Asthma: Convince the patients that they have asthma!
DO NOT over-diagnose and emphasis on the use of LFT
Under-treatment and poor control are common
Optimize currently available treatments: ICS, LTRA, LABA, ? LAMA Selection of the “best treatment” should be individualized.
ICS is the best in reducing inflammation in most patients (improves control)
In selected patients, combine with LABA reduces future risk of exacerbations.
Drugs for asthma : Safe and highly effective in most patients and your treatment can make a big difference.
Thank you