gina pocket guide 2012_wms

7/27/2019 GINA Pocket Guide 2012_wms

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POCKET GUIDE FOR

ASTHMA MANAGEMENT

AND PREVENTION

A Pocket Guide for Physicians and Nurses

Updated 2012

(for Adults and Children Older than 5 Years

BASED ON THE GLOBAL STRATEGY FOR ASTHMAMANAGEMENT AND PREVENTION

Global Initiative or Asthma


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GLOBAL INITIATIVEFOR ASTHMA

Board o Directors (2012)

Mark FitzGerald, M.D., Canada, Chair

Eric D. Bateman, M.D., South AricaLouis-Philippe Boulet, M.D., Canada

Alvaro Cruz, M.D., Brazil

Tari Haahtela, M.D., Finland

Mark Levy, M.D., United Kingdom

Paul OByrne, M.D., Canada

Ken Ohta, M.D., Japan

Pierluigi Paggario, M.D., ItalySoren Pedersen, M.D., Denmark

Manuel Soto-Quiroz, M.D., Costa Rica

Gary Wong, M.D., Hong Kong ROC

GINA Assembly (2012)

Louis-Philippe Boulet, MD, Canada, Chair

GINA Assembly members rom 45countries (names are listed on website:www.ginasthma.org)

Global Initiative or Asthma


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TABLE OF CONTENTSPREFACE 3

WHAT IS KNOWN ABOUT ASTHMA? 5DIAGNOSING ASTHMA 7

Figure 1. Is it Asthma? 7

CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL 9

Figure 2. Levels o Asthma Control 9

FOUR COMPONENTS OF ASTHMA CARE 10

Component 1. Develop Patient/Doctor Partnership 10

Figure 3. Example o Contents o an Action Plan to MaintainAsthma Control 11

Component 2. Identiy and Reduce Exposure to Risk Factors 12

Figure 4. Strategies or Avoiding Common Allergens andPollutants 12

Component 3. Assess, Treat, and Monitor Asthma 13

Figure 5. Management Approach Based on Control 15

Figure 6. Estimated Equipotent Doses o InhaledGlucocorticosteroids 16

Figure 7. Questions or Monitoring Asthma care 18

Component 4. Manage Exacerbations 19

Figure 8. Severity o Asthma Exacerbations 22

SPECIAL CONSIDERATIONS IN MANAGING ASTHMA 23

Appendix A: Glossary o Asthma Medications - Controllers 24

Appendix B: Combination Medications or Asthma 25

Appendix C: Glossary o Asthma Medications - Relievers 26


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PREFACE

Asthma is a major cause o chronic morbidity and mortality throughout theworld and there is evidence that its prevalence has increased considerablyover the past 20 years, especially in children. The Global Initiative or

Asthma was created to increase awareness o asthma among healthproessionals, public health authorities, and the general public, and toimprove prevention and management through a concerted worldwideeort. The Initiative prepares scientic reports on asthma, encourages

dissemination and implementation o the recommendations, and promotesinternational collaboration on asthma research.

The Global Initiative or Asthma oers a ramework to achieve and maintainasthma control or most patients that can be adapted to local health caresystems and resources. Educational tools, such as laminated cards, orcomputer-based learning programs can be prepared that are tailored tothese systems and resources.

The Global Initiative or Asthma program publications include:

Global Strategy for Asthma Management and Prevention(2012).Scientic inormation and recommendations or asthma programs.

Global Strategy for Asthma Management and PreventionGINA Executive Summary. Eur Respir J 2008; 31: 1-36

Pocket Guide for Asthma Management and Prevention for Adultsand Children Older Than 5 Years(2012). Summary o patient care

inormation or primary health care proessionals. Pocket Guide for Asthma Management and Prevention in Children 5

Years and Younger(2009). Summary o patient care inormation orpediatricians and other health care proessionals.

What You and Your Family Can Do About Asthma. An inormationbooklet or patients and their amilies.

Publications are available rom www.ginasthma.org.

This Pocket Guide has been developed rom the Global Strategy for AsthmaManagement and Prevention (Updated 2012). Technical discussions oasthma, evidence levels, and specic citations rom the scientic literatureare included in that source document.


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Acknowledgements:

Grateul acknowledgement is given or unrestricted educational grants

rom Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi Group, CIPLA,GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Quintiles and Takeda.The generous contributions o these companies assured that the GINACommittees could meet together and publications could be printed orwide distribution. However, the GINA Committee participants are solelyresponsible or the statements and conclusions in the publications.


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WHAT IS KNOWN

ABOUT ASTHMA?Unortunatelyasthma is one o the most common chronic diseases, withan estimated 300 million individuals aected worldwide. Its prevalence isincreasing, especially among children.

Fortunatelyasthma can be eectively treated and most patients canachieve good control o their disease. When asthma is under controlpatients can:

Avoid troublesome symptoms night and day Use little or no reliever medication Have productive, physically active lives Have (near) normal lung unction Avoid serious attacks

Asthma causes recurring episodes owheezing, breathlessness, chesttightness, and coughing, particularly at night or in the early morning.

Asthma is a chronic inlammatory disorder o the airways. Chronicallyinlamed airways are hyperresponsive; they become obstructed andairlow is limited (by bronchoconstriction, mucus plugs, and increasedinlammation) when airways are exposed to various risk actors.

Common risk actors or asthma symptoms include exposure to allergens(such as those rom house dust mites, animals with ur, cockroaches,

pollens, and molds), occupational irritants, tobacco smoke, respiratory(viral) inections, exercise, strong emotional expressions, chemicalirritants, and drugs (such as aspirin and beta blockers).

A stepwise approach to pharmacologic treatment to achieve andmaintain control o asthma should take into account the saety otreatment, potential or adverse eects, and the cost o treatmentrequired to achieve control.

Asthma attacks (or exacerbations) are episodic, but airway inlammationis chronically present.


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For many patients, controller medication must be taken daily to preventsymptoms, improve lung unction, and prevent attacks. Relievermedications may occasionally be required to treat acute symptoms such

as wheezing, chest tightness, and cough.

To reach and maintain asthma control requires the development o apartnership between the person with asthma and his or her health careteam.

Asthma is not a cause or shame. Olympic athletes, amous leaders,other celebrities, and ordinary people live successul lives with asthma.


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DIAGNOSING ASTHMA

Asthma can oten be diagnosed on the basis o a patients symptoms andmedical history(Figure 1).

Measurements o lung unction provide an assessment o the severity,repairability, and variability o airfow limitation, and help conrm thediagnosis o asthma.

Spirometryis the preerred method o measuring airfow limitation and itsreversibility to establish a diagnosis o asthma. An increase in FEV

1o 12% and 200 ml ater administration

o a bronchodilator indicates reversible airfow limitation consistentwith asthma. (However, most asthma patients will not exhibit reversibilityat each assessment, and repeated testing is advised.)

Presence o any o these signs and symptoms should increase the suspicion o asthma:

Wheezing high-pitched whistling sounds when breathing outespeciallyin children. (A normal chest examination does not exclude asthma.)

History o any o the ollowing: Cough, worse particularly at night Recurrent wheeze Recurrent diicult breathing Recurrent chest tightness

Symptoms occur or worsen at night, awakening the patient. Symptoms occur or worsen in a seasonal pattern.

The patient also has eczema, hay ever, or a amily history o asthma or atopic diseases.

Symptoms occur or worsen in the presence o: Animals with ur Aerosol chemicals Changes in temperature Domestic dust mites Drugs (aspirin, beta blockers) Exercise Pollen Respiratory (viral) inections Smoke Strong emotional expression

Symptoms respond to anti-asthma therapy Patients colds "go to the chest" or take more than 10 days to clear up

Figure 1. Is it Asthma?


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Peak expiratory ow (PEF) measurements can be an important aid in bothdiagnosis and monitoring o asthma.

PEF measurements are ideally compared to the patients own previousbest measurements using his/her own peak fow meter.

An improvement o 60 L/min (or 20% o the pre-bronchodilator PEF)ater inhalation o a bronchodilator, or diurnal variation in PEF omore than 20% (with twice-daily readings, more than 10%), suggestsa diagnosis o asthma.

Additional diagnostic tests:

For patients with symptoms consistent with asthma, but normal lungunction, measurements o airway responsiveness to methacholineand histamine, an indirect challenge test such as inhaled mannitol, or

exercise challenge may help establish a diagnosis o asthma. Skin tests with allergens or measurement o specic IgE in serum:

The presence o allergies increases the probability o a diagnosiso asthma, and can help to identiy risk actors that cause asthmasymptoms in individual patients.

Diagnostic Challenges

Cough-variant asthma. Some patients with asthma have chronic cough(requently occurring at night) as their principal, i not only, symptom.

For these patients, documentation o lung unction variability andairway hyperresponsiveness are particularly important.

Exercise-induced bronchoconstriction. Physical activity is an importantcause o asthma symptoms or most asthma patients, and or some(including many children) it is the only cause. Exercise testing with an8-minute running protocol can establish a rm diagnosis o asthma.

Children 5 Years and Younger. Not all young children who wheezehave asthma. In this age group, the diagnosis o asthma must be basedlargely on clinical judgment, and should be periodically reviewed as

the child grows (see the GINA Pocket Guide for Asthma Managementand Prevention in Children 5 Years and Youngeror urther details).

Asthma in the elderly. Diagnosis and treatment o asthma in the elderlyare complicated by several actors, including poor perception osymptoms, acceptance o dyspnea as being normal or old age, andreduced expectations o mobility and activity. Distinguishing asthmarom COPD is particularly dicult, and may require a trial o treatment.

Occupational asthma. Asthma acquired in the workplace is adiagnosis that is requently missed. The diagnosis requires a dened

history o occupational exposure to sensitizing agents; an absence oasthma symptoms beore beginning employment; and a documentedrelationship between symptoms and the workplace (improvement insymptoms away rom work and worsening o symptoms upon returningto work).


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CLASSIFICATION OF ASTHMA

BY LEVEL OF CONTROLThe goal o asthma care is to achieve and maintain control o the clinicalmaniestations o the disease or prolonged periods. When asthma iscontrolled, patients can prevent most attacks, avoid troublesome symptomsday and night, and keep physically active.

The assessment o asthma control should include control o the clinicalmaniestations and control o the expected uture risk to the patient suchas exacerbations, accelerated decline in lung unction, and side-eects o

treatment. In general, the achievement o good clinical control o asthmaleads to reduced risk o exacerbations.

Figure 2 describes the clinical characteristics o controlled, partly controlled,and uncontrolled asthma.

Examples o validated measures or assessing clinical control o asthma include: Asthma Control Test (ACT): www.asthmacontrol.com

Childhood Asthma Control test (C-Act)

Asthma Control Questionnaire (ACQ): www.qoltech.co.uk/Asthma1.htm

Asthma Therapy Assessment Questionnaire (ATAQ): www.ataqinstrument.com

Asthma Control Scoring System

Figure 2. Levels o Asthma Control

A. Assessment of current clinical control (preferably over 4 weeks)

Characteristics Controlled(All of the following) Partly Controlled(Any measure presented) Uncontrolled

Daytime symptoms None (twice or less/week) More than twice/week Three or more features of partly controlled asthma*

Limitation of activities None Any

Nocturnalsymptoms/awaking

None Any

Need for reliever/rescue inhaler

None (twice or less/week) More than twice/week

Lung function (PEF or FEV1) Normal < 80% predicted or

personal best (if known)

B. 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 asthma, low FEV

1, exposure to

cigarette smoke, high dose medications

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate By definition, an exacerbation in any week makes that an uncontrolled asthma week Without administration of bronchodilator

Lung function is not a reliable test for children 5 years and younger.


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FOUR COMPONENTS OF

ASTHMA CAREFour interrelated components o therapy are required to achieve and maintaincontrol o asthma:

Component 1. Develop patient/doctor partnershipComponent 2. Identiy and reduce exposure to risk actorsComponent 3. Assess, treat, and monitor asthmaComponent 4. Manage asthma exacerbations

Component 1: Develop Patient/Doctor Partnership

The eective management o asthma requires the development o a partnershipbetween the person with asthma and his or her health care team.

With your help, and the help o others on the health care team, patients canlearn to:

Avoid risk actors Take medications correctly Understand the dierence between "controller" and "reliever" medications Monitor their status using symptoms and, i relevant, PEF Recognize signs that asthma is worsening and take action Seek medical advice as appropriate

Education should be an integral part o all interactions between health careproessionals and patients. Using a variety o methodssuch as discussions

(with a physician, nurse, outreach worker, counselor, or educator),demonstrations, written materials, group classes, video or audio tapes,dramas, and patient support groupshelps reinorce educational messages.

Working together, you and your patient should prepare a written personalasthma action plan that is medically appropriate and practical. A sampleasthma plan is shown in Figure 3.

Additional written asthma action plans can be ound on several websites,

including:www.asthma.org.ukwww.nhlbisupport.com/asthma/index.htmlwww.asthmanz.co.nz


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Figure 3. Example of Contents of a Written Asthma to Maintain Asthma Control

Your 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? No YesActivity or exercise limited by asthma? No YesWalking at night because of asthma? No YesThe need to use your (rescue medication) more than 2 times? No YesIf 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 uncontrolledand 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 don't respond in ________________ days [specify number]___________________________________ [optional lines for additionalinstruction]

EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you 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. Use ______ mg of __________________________(oral glucocorticosteriod).3. Seek medical help: Go to _______________________________

______________Address:________________________Phone:__________________________

4. Continue to use your __________________________________[relievermedication] until your are able to get medical help.


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Component 2: Identiy and Reduce Exposure to Risk Factors

To improve control o asthma and reduce medication needs, patients shouldtake steps to avoid the risk actors that cause their asthma symptoms (Figure

4). However, many asthma patients react to multiple actors that are ubiquitousin the environment, and avoiding some o these actors completely is nearlyimpossible. Thus, medications to maintain asthma control have an importantrole because patients are oten less sensitive to these risk actors when theirasthma is under control.

Physical activity is a common cause o asthma symptoms but patients should notavoid exercise. Symptoms can be prevented by taking a rapid-acting inhaled

2-agonist beore strenuous exercise (a leukotriene modier or cromone are

alternatives).

Patients with moderate to severe asthma should be advised to receive aninuenza vaccination every year, or at least when vaccination o the generalpopulation is advised. Inactivated infuenza vaccines are sae or adults andchildren over age 3.

Avoidance measures that improve control of asthma and reduce medication needs: Tobacco smoke:Stay away from tobacco smoke. Patients and parents should not smoke. Drugs, foods, and additives: Avoid if they are known to case symptoms. Occupational sensitizers:Reduce or, preferably, avoid exposure to these agents

Reasonable avoidance measures that can be recommended but have not been shown to have clinical benefit House dust mites: Wash bed linens and blankets weekly in hot water and dry in a hot

dryer or sun. Encase pillows and mattresses in air-tight covers. Replace carpets with hardflooring, especially in sleeping rooms. (If possible, use vacuum cleaner with filters. Useacaricides or tannic acid to kill mites--but make sure the patient is not at home when thetreatment occurs.

Animals with fur: Use air filters. (Remove animals from the home, or at least from thesleeping area. Wash the pet.)

Cockroaches: Clean home thoroughly and often. Use pesticide spray--but make surethe patient is not at home when spraying occurs.

Outdoor pollens and mold: Close windows and doors and remain indoors whenpollen and mold counts are highest.

Indoor mold: Reduce dampness in the home; clean any damp areas frequently

Figure 4. Strategies for Avoiding Common Allergens and Pollutants


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Component 3: Assess, Treat and Monitor Asthma

The goal o asthma treatmentto achieve and maintain clinical control

can be reached in most patients through a continuous cycle that involves Assessing Asthma Control Treating to Achieve Control Monitoring to Maintain Control

Assessing Asthma Control

Each patient should be assessed to establish his or her current treatment

regimen, adherence to the current regimen, and level o asthma control.A simplied scheme or recognizing controlled, partly controlled, anduncontrolled asthma is provided in Figure 2.

Treating to Achieve Control

Each patient is assigned to one o ve treatment steps. Figure 5 details thetreatments at each step or adults and children age 5 and over.

At each treatment step, reliever medication should be provided or quickrelie o symptoms as needed. (However, be aware o how much relievermedication the patient is usingregular or increased use indicates thatasthma is not well controlled.)

At Steps 2 through 5, patients also require one or more regular controllermedications, which keep symptoms and attacks rom starting. Inhaledglucocorticosteroids (Figure 6) are the most eective controller medications

currently available.

For most patients newly diagnosed with asthma or not yet on medication,treatment should be started at Step 2 (or i the patient is very symptomatic,at Step 3). I asthma is not controlled on the current treatment regimen,treatment should be stepped up until control is achieved.

Patients who do not reach an acceptable level o control at Step 4 can beconsidered to have difcult-to-treat asthma. In these patients, a compromisemay need to be reached ocusing on achieving the best level o controleasiblewith as little disruption o activities and as ew daily symptoms aspossiblewhile minimizing the potential or adverse eects rom treatment.Reerral to an asthma specialist may be helpul.


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A variety o controller (Appendix AandAppendix B) and reliever (AppendixC) medications or asthma are available. The recommended treatments areguidelines only. Local resources and individual patient circumstances should

determine the specic therapy prescribed or each patient.Inhaled medications are preerred because they deliver drugs directly to theairways where they are needed, resulting in potent therapeutic eects withewer systemic side eects. Inhaled medications or asthma are availableas pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, drypowder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)devices make inhalers easier to use and reduce systemic absorption andside eects o inhaled glucocorticosteroids.

Teach patients (and parents) how to use inhaler devices. Dierent devicesneed dierent inhalation techniques.

Give demonstrations and illustrated instructions. Ask patients to show their technique at every visit. Inormation about use o various inhaler devices is ound on the

GINA Website (www.ginasthma.org).


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Figure 5. Management Approach Based on Control Adults and Children Older Than 5 Years

Controller

options***

Treatment Steps

As needed rapid-

acting 2-agonistAs needed rapid-acting 2-agonist

Low-dose ICS plus

long-acting 2-agonist

Select one

Leukotriene

modifier**

Select one

Medium-or

high-dose ICS

Medium-or high-dose

ICS plus long-acting

2-agonist

Low-dose ICS plus

leukotriene modifier

Low-dose ICS plus

sustained release

theophylline

To Step 3 treatment,

select one or more

To Step 4 treatment,

add either

Asthma education. Environmental control.

(If step-up treatment is being considered for poor symptom control, first check inhaler technique, check adherence, and confirm symptoms are due to asthma.)

Low-dose inhaled

ICS*Oral glucocorticosteroid

(lowest dose)

Anti-IgE

treatment

Leukotriene

modifier

Sustained release

theophylline

Controlled Maintain and find lowest controlling step

Partly controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

Treatment ActionLevel of ControlReduce

Reduce Increase

Increase

2Step1Step 3Step 4Step 5Step

*ICS = inhaled glucocorticosteroids**=Receptor antagonist or synthesis inhibitors***=Recommneded treatment (shaded boxes) based on group mean data. Individual patient needs, preferences, and cirumstances(including costs) should be considered.

Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists, some long-acting 2-agonists,and short-acting theophylline.

Regular dosing with short and long-acting 2-agonists is not advised unless accompanied by regular use of an inhaled glucocorticorsteriod.

For management of asthma in children 5 years and younger, refer to the Global Strategy for the Diagnosis and Managementof Asthma in Children 5 Years and Younger, available at http://www.ginasthma.org.


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Figure 6. Estimated Equipotent Daily Doses of InhaledGlucocorticosteroids for Adults and Children Older than 5 Years

Drug Low Dose (g)Medium Daily Dose

(g)High Daily Dose (g)

Beclomethasonedipropionate - CFC

200 - 500 > 500 - 1000 > 1000 - 2000

Beclomethasonedipropionate - HFA

100 - 250 > 250 - 500 > 500 - 1000

Budesonide* 200 - 400 > 400 - 800 > 800 - 1600

Ciclesonide* 80 - 160 > 160 - 320 > 320 - 1280

Flunisolide 500 - 1000 > 1000 - 2000 >2000

Fluticasone propionate 100 - 250 > 250 - 500 >500 - 1000

Mometasone furoate* 200 >400 >800

Triamcinoloneacetonide

400 - 1000 >1000 - 2000 >2000

Comparisons based on efficacy data.

Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to

consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use areassociated with increased risk of systemic side effects.

* Approved for once-daily dosing in mild patients.

Notes The most important determinant of appropriate dosing is the clinician's judgment of the patient's response

to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose

accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to theminimum dose required to maintain control, thus reducing the potential for adverse effects.

Designation of low, medium, and high doses is provided from manufacturers' recommendations where possible.Clear demonstration of dose response relationships is seldom provided or available. The principle is therefore toestablish the minimum effective controlling dose in each patient, as higher doses may not be more effective andare likely to be associated with greater potential for adverse effects.

As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefullyreviewed by the clinician for the equivalent correct dosage.


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Monitoring to Maintain Control

Ongoing monitoring is essential to maintain control and establish the loweststep and dose o treatment to minimize cost and maximize saety.

Typically, patients should be seen one to three months ater the initial visit,and every three months thereater. Ater an exacerbation, ollow-up should beoered within two weeks to one month.

At each visit, ask the questions listed in Figure 7.

Adjusting medication:

I asthma is not controlled on the current treatment regimen, step uptreatment. Generally, improvement should be seen within 1 month.But rst review the patients medication technique, compliance, andavoidance o risk actors.

I asthma is partly controlled, consider stepping up treatment, dependingon whether more eective options are available, saety and cost opossible treatment options, and the patients satisaction with the levelo control achieved.

Icontrol is maintained or at least 3 months, step down with a gradual,stepwise reduction in treatment. The goal is to decrease treatment to theleast medication necessary to maintain control.

Monitoring is still necessary even ater control is achieved, as asthma is avariable disease; treatment has to be adjusted periodically in response toloss o control as indicated by worsening symptoms or the development o anexacerbation.


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Figure 7. Questions for Monitoring Asthma Care

IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALSAsk the patient:Has your asthma awakened you at night?

Have you needed more reliever medications than usual?

Have you needed any urgent medical are?

Has your peak flow been below your personal best?

Are you participating in your usual physical activities?

Action to consider:Adjust medications and management plan as needed(step up or down).

But first, compliance should be assessed.

IS THE PATIENT USING INHALERS, SPACER, OR PEAK FLOW METERS CORRECTLY?

Ask the patient:Please show me how you take your medicine.

Action to consider:Demonstrate correct technique.Have patient demonstrate back.

IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISKFACTORS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?

Ask the patient, for example:So that we may plan therapy, please tell me howoften you actually take the medicine.

What problems have you had following themanagement plan or taking your medicine?

During the last month, have you ever stopped takingyour medicine because you were feeling better?

Action to consider:Adjust plan to be more practical.

Problem solve with the patient to overcome barriers tofollowing the plan.

DOES THE PATIENT HAVE ANY CONCERNS?

Ask the Patient:What concerns might you have about your asthma,medicines, or management plan?

Action to consider:Provide additional education to relieve concerns anddiscussion to overcome barriers.


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Component 4: Manage Exacerbations

Exacerbations o asthma (asthma attacks) are episodes o a progressive increasein shortness o breath, cough, wheezing, or chest tightness, or a combinationo these symptoms.

Do not underestimate the severity o an attack; severe asthma attacks may be liethreatening. Their treatment requires close supervision.

Patients at high risk o asthma-related death require closer attention and shouldbe encouraged to seek urgent care early in the course o their exacerbations.

These patients include those:

With a history o near-atal asthma requiring intubation and mechanicalventilation

Who have had a hospitalization or emergency visit or asthma withinthe past year

Who are currently using or have recently stopped using oralglucocorticosteroids

Who are not currently using inhaled glucocorticosteroids Who are over dependent on rapid-acting

2-agnoists, especially those

who use more than one canister o salbutamol (or equivalent) monthly With a history o psychiatric disease or psychosocial problems,including the use o sedatives

With a history o noncompliance with an asthma medication plan

Patients should immediately seek medical care i:

The attack is severe (Figure 8):- The patient is breathless at rest, is hunched orward, talks in words

rather than sentences (inant stops eeding), is agitated, drowsy, orconused, has bradycardia, or has a respiratory rate greater than 30per minute

- Wheeze is loud or absent- -Pulse is greater than 120/min (greater than160/min or inants)- PEF is less than 60 percent o predicted or personal best, even ater

initial treatment- The patient is exhausted

The response to the initial bronchodilator treatment is not prompt andsustained or at least 3 hours

There is no improvement within 2 to 6 hours ater oral glucocorticosteroidtreatment is started

There is urther deterioration


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Mild attacks, dened by a reduction in peak fow o less than 20%, nocturnalawakening, and increased us o rapid-acting

2-agonists, can usually be treated

at home i the patient is prepared and has a personal asthma managementplan that includes action steps.

Moderate attacks may require, and severe attacks usually require, care in aclinic or hospital.

Asthma attacks require prompt treatment:

Inhaled rapid-acting 2-agonists in adequate does are essential.

(Begin with 2 to 4 pus every 20 minutes or the rst hour; then mildexacerbations will require 2 to 4 pus every 3 to 4 hours, and moderateexacerbations 6 to 10 pus every 1 to 2 hours.)

Oral glucocorticosteroids (0.5 to 1 mg o prednisolone/kg or equivalentduring a 24-hour period) introduced early in the course o a moderate orsevere attack help to reverse the infammation and speed recovery.

Oxygen is given at health centers or hospitals i the patient is hyopxemic(achieve O

2saturation o 95%)

Combination 2-agonists/anticholinergic therapy is associated with

lower hospitalization rates and greater improvement in PEF and FEV1.

Methylxanthines are not recommended i used in addition to highdoses o inhaled 2-agonists. However, theophylline can be used iinhaled

2-agonists are not available. I the patient is already taking

theophylline on a daily basis, serum concentration should be measuredbeore adding short-acting theophylline.

Patients with severe asthma exacerbations unresponsive to bronchodilatorsand systemic glucocorticosteroids, 2 grams o magnesium sulphate IV hasbeen shown to reduce the need to hospitalizations.

Therapies not recommended or treating asthma attacks include:

Sedatives (strictly avoid) Mucolytic drugs (may worsen cough) Chest physical therapy/physiotherapy (may increase patient discomort) Hydration with large volumes o fuid or adults and older children (may be

necessary or younger children and inants) Antibiotics (do not treat attacks but are indicated or patients who also

have pneumonia or bacterial inection such as sinusitis) Epinephrine/adrenaline (may be indicated or acute treatment o

anaphylaxis and angioedema but is not indicated or asthma attacks)


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Monitor response to treatment:

Evaluate symptoms and, as much as possible, peak fow. In the hospital, alsoassess oxygen saturation; consider arterial blood gas measurement in patientswith suspected hypoventilation, exhaustion, severe distress, or peak fow 30-50percent predicted.

Follow up:

Ater the exacerbation is resolved, the actors that precipitated the exacerbationshould be identied and strategies or their uture avoidance implemented, andthe patients medication plan reviewed.


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Figure 8. Severity of Asthma Exacerbations*

Parameter Mild Moderate Severe Respiratoryarrest imminent

Breathless Walking

Can lie down

TalkingInfant - softer, shorter cry;difficulty feedingPreferr sitting

At restInfant stops feeding

Hunched forward

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated Drowsy or confused

Respiratory rate Increased Increased Often > 30/min

Normal rates of breathing in awake children: Age Normal rate

< 2 months 95% 91 - 95%


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SPECIAL CONSIDERATIONS

IN MANAGING ASTHMA PregnancyDuring pregnancy the severity o asthma oten changes, and patientsmay require close ollow-up and adjustment o medications. Pregnant patientswith asthma should be advised that the greater risk to their baby lies with poorlycontrolled asthma, and the saety o most modern asthma treatments should bestressed. Acute exacerbations should be treated aggressively to avoid etal hypoxia.

Obesity. Management o asthma in the obese should be the same as patients withnormal weight. Weight loss in the obese patient improves asthma control, lung

unction and reduces medication needs. Surgery. Airway hyperresponsiveness, airfow limitation, and mucus hyper-secretion

predispose patients with asthma to intraoperative and postoperative respiratorycomplications, particularly with thoracic and upper abdominal surgeries. Lungunction should be evaluated several days prior to surgery, and a brie course oglucocorticosteroids prescribed i FEV

1is less than 80% o the patients personal

best.

Rhinitis, Sinusitis, and Nasal Polyps. Rhinitis and asthma oten coexist in the samepatient, and treatment o rhinitis may improve asthma symptoms. Both acute and

chronic sinusitis can worsen asthma, and should be treated. Nasal polyps areassociated with asthma and rhinitis, oten with aspirin sensitivity and most requentlyin adult patients. They are normally quite responsive to topical glucocorticosteroids.

Occupational asthma. Pharmacologic therapy or occupational asthma is identicalto therapy or other orms o asthma, but is not a substitute or adequate avoidanceo the relevant exposure. Consultation with a specialist in asthma management oroccupational medicine is advisable.

Respiratory inections. Respiratory inections provoke wheezing and increasedasthma symptoms in many patients. Treatment o an inectious exacerbation ollowsthe same principles as treatment o other exacerbations.

Gastroesophageal reux. Gastroesophageal refux is more common in patientswith asthma compared to the general population. However, treatment with protonpump inhibitors, H

2antagonists or surgery ail to improve asthma control.

Aspirin-induced asthma. Up to 28 percent o adults with asthma, but rarelychildren, suer rom asthma exacerbations in response to aspirin and othernonsteroidal anti-infammatory drugs. The diagnosis can only be conrmed byaspirin challenge, which must be conducted in a acility with cardiopulmonary

resuscitation capabilities. Complete avoidance o the drugs that cause symptoms isthe standard management.

Anaphylaxis. Anaphylaxis is a potentially lie-threatening condition that can bothmimic and complicate severe asthma. Prompt treatment is crucial and includesoxygen, intramuscular epinephrine, injectable antihistamine, intravenoushydrocortisone, and intravenous fuid.


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Appendix A: Glossary of Asthma Medications - Controllers

Name and Also Known As Usual Doses Side Effects Comments

Glucocorticosteroids

AdrenocorticoidsCorticosteroidsGlucocorticoids

Inhaled (ICS):BeclomethasoneBudesonide CiclesonideFlunisolideFluticasone MometasoneTriamcinolone

Tablets or syrups:hydrocortisonemethylprednisoloneprednisoloneprednosone

Inhaled: Beginning dose

dependent on asthma control thentitrated down over 2-3 monthsto lowest effect dose once controlis achieved.

Tablets or syrups: For dailycontrol use lowest effective dose5-40 mg of prednisone equivalentin a.m. or qod.

For acute attacks 40-60 mg dailyin 1 or 2 divided doses for adultsor 1-2 mg/kg daily in children.

Inhaled: High daily doses may

be associated with skin thinningand bruises, and rarely adrenalsuppression. Local side effects arehoarseness and oropharyngealcandidiasis. Low to medium doseshave produced minorgrowthdelay or suppression(av. 1cm) inchildren. Attainment of predictedadult height does not appear tobe affected.

Tablets or syrups: Used longterm, may lead toosteoporosis,hypertension,diabetes, cataracts,adrenal suppression, growthsuppression,obesity, skinthinning or muscle weaknessConsider coexistingconditionsthat could be worsened byoral glucocorticosteroids,e.g. herpes virusinfections,Varicella, tuberculosis,hypertension,diabetes andosteoporosis

Inhaled: Inhaled: Potential but

small risk of side effects is wellbalanced by efficacy. Valvedholding-chambers with MDIsand mouth washing with DPIsafter inhalation decrease oralCandidiasis. Preparations notequivalent on per puff or g basis.

Tablets or syrup:Long term use: alternate day a.m.dosing produces less toxicity.Short term: 3-10 day "bursts" areeffective for gaining prompt control

Sodium cromoglycatecromolyncromones

MDI 2 mg or 5 mg 2-4inhalations 3-4 times daily.Nebulizer 20 mg 3-4 times daily.

Minimal side effects. Cough mayoccur upon inhalation.

May take 4-6 weeks to determinemaximum effects. Frequent dailydosing required.

Nedocromilcromones

MDI 2 mg/puff 2-4 inhalations2-4 times daily.

Cough may occur upon inhalation Some patients unable to toleratethe taste.

Long-acting 2-agonists

beta-adrenergissympathomimeticsLABAs

Inhaled:Formoterol (F)Salmeterol (Sm)

Sustained-release Tablets:Salbutamol (S)Terbutaline (T)Aminophyllinemethylxanthine

xanthine

Inhaled:DPI - F: 1 inhalation (12 g) bid.MDI - F: 2 puffs bid.DPI-Sm: 1 inhalation (50 g) bid.MDI -Sm: 2 puffs bid.

Tablets:S: 4 mg q 12h.T: 10 mg q 12h.

Starting does 10 mg/kg/day withusual 800 mg maximum in 1-2divided doses.

Inhaled: Inhaled: fewer, andless significant, side effects thantablets. Have been associatedwith an increased risk of severeexacerbations and asthma deathswhen added to usual therapy.

Tablets: Tablets: may causetachycardia, anxiety, skeletalmuscle tremor, headache,hypokalemia.

Nausea and vomiting are mostcommon. Serious effects occurringat higher serum concentrationsinclude seizures, tachycardia,andarrhythmias.

Inhaled: Salmeterol NOT tobe used to treat acute attacks.Should not use as mono therapy forcontroller therapy. Always use asadjunct to ICS therapy. Formoterolhas onset similar to salbutamol andhas been used as needed for acutesymptoms.

Tablets: As effective assustained-release theophylline.No data for use as adjunctivetherapy with inhaledglucocorticosteroids.

Theophylline level monitoring isoften required. Absorptionandmetabolism may be affected bymany factors,including febrile illness.


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Appendix A: Glossary of Asthma Medications - Controllers (continued)


Antileukotrienes

Leukotriene modifiersMontelukast (M)Pranlukast (P)Zafirlukast (Z)Zileuton (Zi)

Adults: M 10mg qhs

P 450 mg bidZ 20 mg bid;Zi 600 mg qid.

Children: M 5 mg qhs (6 - 14 y)M 4 mg qhs (2-5 y)Z 10 mg bid (7 - 11 y).

No specific adverse effects to date

at recommended doses. Elevationof liver enzymes with Zafirlukastand Zileuton and limited casereports of reversible hepatitus andhperbilirubinemia with Zileuton andhepatic failure with afirlukast

Antiliukotrienes are most effective for

patietns with mild persistant asthma.They provide additive benefit whenaddto ICSs though noot as effectiveas inhaled long-acting

2-agonists.

ImmunomodulatorsOmalizumabAnti-IgE

Adults: Dose administeredsubcutaneously every 2-4 weeksdependent on weight and IgEconcentration

Pain and bruising at injection site(5-20%) and very rarely anaphylaxis(0.1%)

Need to be stored underrefrigeration 2-8 C andmaximum of 150 mgadministered per injection site.

Appendix B: Combination Medications for Asthma

Formulation Inhaler DevicesDoses Available(g)1 ICS/LABA

Inhalations/day Therapeutic Use

Fluticasonepropionate/salmeterol

DPI100/501

250/50500/50

1 inhalation x 2 Maintenance

Fluticasonepropionate/salmeterol

pMDI(Suspension)

50/251

125/25250/25

2 inhalations x 2 Maintenance

Budesonide/formoterol

DPI80/4.52

160/4.5320/9.0

1-2 inhalations x 2Maintenanceand Relief

Budesonide/formoterol

pMDI(Suspension)

100/6200/6


Beclomethasone/formoterol

pMDI(Solution)

100/63 1-2 inhalations x 2 Maintenance

Mometasone/formoterol

pMDI100/5200/5


ICS = inhaled corticocosteriod; LABA = long-acting 2-agonist; pDMI = pressurized metered dose inhaler; DPI = dy powder inhaler

New formulations will be reviewed for inclusion in the table as they are approved. Such medications may be brought to the attention of the GINA Science Committee.

1Refers to metered dose. For additional information about dosages and products available in specific countries, please consult www.gsk.comto find a link to your countrywebsite or contact your local company representatives for products approved for use in your country.

2 Refers to delivered dose. For additional information about dosages and products available in specific countries, please consult www.astrazeneca.comto find a link to

your country website or contact your local company representatives for products approved for use in your country.3 Refers to metered dose. For additional information about dosages and products available in specific countries, please consult www.chiesigroup.comto find a link to yourcountry website or contact your local company representatives for products approved for use in your country.


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Appedix C: Glossary of Asthma Medications - Relievers


Short-acting2 -agonistsAdrenergics

2-stimulants

Sympathomimetics

Albuterol/salbutamolFenoterolLevalbuterolMetaproterenol

PirbuterolTerbutaline

Differences in potencyexist but all product sareessentially comparableon a per puff basis Forpre symptomatic use andpretreatment before exercise2 puffs MDI or 1 inhalationDPI. For asthma attacks 4-8puffs q2-4h, may administer

q20min x 3 with medicalsupervision or the equivalentof 5 mg salbutamolbynebulizer.

Inhaled: tachycardia,skeletal muscletremor, headache, andirritability. At very highdose hyperglycemia,hypokalemia.

Systemicadministration as

Tablets or Syrupincreases the risk ofthese side effects.

Drug of choice for acutebronchospasm. Inhaled routehas faster onset and is moreeffective than tablet or syrup.Increasing use, lack of expectedeffect, or use of > 1 canistera month indicate poor asthmacontrol; adjust long-termtherapy accordingly. Use of 2

canisters per month is associatedwith an increased risk of asevere, life-threatening asthmaattack.

AnticholinergicsIpratropium bromide (IB)Oxitropium bromide

IB-MDI 4-6 puffs q6h orq20 min in the emergencydepartment. Nebulizer500 g q20min x 3 thenq2-4hrs for adults and 250-

500 g for children.

Minimal mouthdryness or bad tastein the mouth.

May provide additive effects to

2-agonst but has slower onset

of acation. Is an alternativefor patients with intolerance to

2-agonsts.

Short-acting theophyllineAminophylline

7 mg/kg loading dose over20 min followed by 0.4mg/kg/hr continuous infusion.

Nausea, vomiting,headache. At higherserum concentrations:seizures,tachycardia,andarrhythmias.

Theophylline level monitoring isrequired. Obtain serum levels12 and 24 hours into infusion.Maintain between 10-15 g/mL.

Epinephrine/adrenalineinjection

1:1000 solution(1mg/mL) .01mg/kgup to 0.3-0.5 mg, cangive q20min x 3.

Similar, but moresignificant effectsthan selective

2-

agonist. In addition:hypertension, vomitingin children andhallucinations

In general, not recommendedfro treating asthma attacksif selective

2-agonsts are

available.


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NOTES


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NOTES


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The Global Initiative or Asthma is supported by unrestricted education grants rom:

h b h

AlmirallAstraZeneca

Boehringer Ingelheim

Chiesi Group

CIPLAGlaxoSmithKline

Merck Sharp & Dohme

Novartis

QuintilesTakeda

gina pocket guide 2012_wms

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