The Update GINA guideline 2006 in Adult

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The Update GINA guideline 2006 in Adult

• ??. ??. ????? ?????????? M.D., Ph.D.
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Contents

• Changing concept in asthma treatment
• Old GINA guidelines
• New GINA2006

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Changing concept in asthma treatment
short-acting b2-agonists
Inh corticosteroid
Combination
Bronchospasm
Inflammation
Airway Hyperresponsiveness
Remodelling
1980
1985
1990
1995
2000
1975
4
1995
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Six-part Asthma Management ProgramGoals of
Long-term Management

• Achieve and maintain control of symptoms
• Prevent asthma episodes or attacks
• Maintain pulmonary function as close to normal
  levels as possible
• Maintain normal activity levels, including
  exercise
• Avoid adverse effects from asthma medications
• Prevent development of irreversible airflow
  limitation
• Prevent asthma mortality

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Six-part Asthma Management ProgramControl of
Asthma

• Minimal (ideally no) chronic symptoms
• Minimal (infrequent) exacerbations
• No emergency visits
• Minimal (ideally no) need for as needed use of
  ß2-agonist
• No limitations on activities, including exercise
• PEF circadian variation of less than 20 percent
• (Near) normal PEF
• Minimal (or no) adverse effects from medicine

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Six-Part Asthma Management Program

• 1. Educate Patients
• 2. Assess and Monitor Severity
• 3. Avoid Exposure to Risk Factors
• 4. Establish Medication Plans for Chronic
  Management
• 5. Establish Plans for Managing Exacerbations
• 6. Provide Regular Follow-up Care

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Pharmacological therapy

• Controllers
• Inhaled corticosteroids
• Inhaled long-acting b2-agonists
• Oral anti-leukotrienes
• Oral theophyllines

• Relievers
• Inhaled fast-acting b2-agonists

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Classification of asthma severity GINA 1995
4
3
Severe Persistent
2
Moderate persistent
1
Mild persistent
Intermittent
lt1/wk
gt1/wk
daily
Day symptoms
daily
lt2/mo
gt2/mo
gt1/wk
frequent
Night symptoms
gt80
gt80
60-80
lt60
PEFR
lt20
20-30
gt30
gt30
PF variability
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GINA1995
High dose ICS other controller
Level 4
high dose ICS
Level 3
ICS
Level 2
B2 agonist prn
Level 1
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GINA1995
GINA 2002
High dose ICS other controller
ICSLABA other controller
Level 4
high dose ICS
ICSLABA
Level 3
ICS
Level 2
B2 agonist prn
Level 1
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Guidelines Implementation
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What is the problem?
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Classification of asthma severity GINA 1995
Severe Persistent
Moderate persistent
Mild persistent
Intermittent
lt1/wk
gt1/wk
daily
TOO COMPLICATE
Day symptoms
daily
lt2/mo
gt2/mo
gt1/wk
frequent
Night symptoms
gt80
gt80
60-80
lt60
PEFR
lt20
20-30
gt30
gt30
PF variability
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Gaining Optimal Asthma controL (GOAL) study
Bateman E. Am. J. Respir. Crit. Care
Med.2004836-844
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Common views of control?
Some?
Symptoms
A puff a day?
Salbutamol use
gt80 on most days?
PEF am
Occasional?
Night-time awakenings
Rarely?
Exacerbations
Rarely?
Emergency visits
Treatment related adverse events enforcing change
in therapy
None?
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TOTAL CONTROL definition
Some?
Symptoms
A puff a day?
Salbutamol use
gt80 on most days?
PEF am
Occasional?
Night-time awakenings
Rarely?
Exacerbations
Rarely?
Emergency visits
Treatment related adverse events enforcing change
in therapy
None?
GOAL Study
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GOAL a unique and innovative study
Stratum 3
Strata 1 2
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Patients can achieve total control regardless of
asthma severity
Seretide Phase 2
100
Seretide Phase 1
FP Phase 2
80
FP Phase 1
60
50
patients achieving total controlled asthma
44
40
40
29
28
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20
0
Steroid naïve
Low dose ICS
Moderate dose ICS
Approximately 50 patients achieved Total Control
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More patients achieved well controlled asthma
with Seretide versus FP
Seretide Phase 2
100
Seretide Phase 1
FP Phase 2
75
78
80
FP Phase 1
70
60
62
60
patients achieving well-controlled asthma
47
40
20
0
Steroid naïve
Low dose ICS
Moderate dose ICS
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The recommendations for asthma management are
laid out in five interrelated components of
therapy

• Develop Patient/Doctor Partnership
• Identify and Reduce Exposure to Risk Factors
• Assess, Treat, and Monitor Asthma
• Manage Asthma Exacerbations
• Special Considerations

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Levels of Asthma Control
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.
Lung function is not a reliable test for children
5 years and younger.
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Pharmacological therapy

• Controllers
• Inhaled corticosteroids
• Inhaled long-acting b2-agonists
• Oral anti-leukotrienes
• Oral theophyllines

• Relievers
• Inhaled fast-acting b2-agonists

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GINA1995
GINA 2002
High dose ICS other controller
ICSLABA other controller
Level 4
high dose ICS
ICSLABA
Level 3
ICS
Level 2
B2 agonist prn
Level 1
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Simplified asthma treatment
Total control
Asthma Patient
No day symptoms No night symptoms No rescue
medication No ER visit PEFR gt80
Assess Control
ICS 500ug/d Other controller

Treatment
ICS 500ug/d
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Implementation
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Thank you