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Fallacy of Asthma Guideline: Discrepancy between Science and Practice

Fallacy of Asthma Guideline: Discrepancy between Science and Practice. Gary Wong Department of Paediatrics and School of Public Health Chinese University of Hong Kong. Guidelines from around the world. GINA Asthma Treatment Strategy. GINA Science Committee

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Fallacy of Asthma Guideline: Discrepancy between Science and Practice

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  1. Fallacy of Asthma Guideline: Discrepancy between Science and Practice Gary Wong Department of Paediatrics and School of Public Health Chinese University of Hong Kong

  2. Guidelines from around the world

  3. GINA Asthma Treatment Strategy • GINA Science Committee • 10 respirologists and 3 paediatricians • Meet twice a year to review all published trials • Make recommendations of changes for the Executives to make the final recommendations • Executive Board • 8 respirologists, 3 paediatricians, • 1 General practitioner

  4. Revision of GINA documents • Minor revision every 12 months • Major revision every 4-6 yrs 2013 : Major revision PubMed: RCT, asthma, child :4224 Real-life or pragmatic trials, asthma, child: 33

  5. Asher et al Lancet 2006;368(9537):733-43.

  6. Asthma in Reality in Asia-Pacific (AIRIAP) 2:Study sites • 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 South Korea China Areas for both 1 & 2 India Taiwan Areas for 2 only Hong Kong Vietnam The Philippines Thailand Malaysia Sri Lanka Singapore Lai CK et al. Respirology 2011;16, 688–697. Wong GW et al. Allergy 2012 (In Press). Indonesia

  7. AIRIAP 2: Pediatric data (n=988) * Use of urgent care Use of medications * Between group comparisons :P<0.005 Wong GW wt al. Allergy (In press)

  8. Emerging classification of asthma • Proposed by expert panel from EAACI/AAAAI • Lotvall et al. Asthma endotypes: A new approach to classification of disease entities within the asthma syndrome. JACI 2011;127:355-60. • Asthma endotypes: defined by their phenotypes and putative pathophysiology

  9. Pediatric Asthma ICON Allergy 2012; DOI: 10.1111/j.1398-9995.2012.02865.x(epub June 15, 2012)

  10. The many “faces” of pediatric asthma

  11. 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

  12. 40 Adult Study 35 CAMP ACRN 30 25 Patients, % 20 15 10 5 0 < -20 -20 to -10 -10 to 0 0 to 10 10 to 20 20 to 30 30 to 40 >40 % Change in FEV1 From Baseline Variability of Response to ICS:3 large studies in Children and Adults With Asthma Tantisira KG, et al. Hum Molec Genetics. 2004;13:1353–1359.

  13. BADGER study. Lemanske et al (CARE network) NEJM 2010;362:975-85. 161/165 patients showed a differential response

  14. Top 3 priorities for REG • Identification/Establishment of database for real-life studies in paediatric asthma • Establishment of evaluation tools for pragmatic studies similar to those for evaluating RCT • Influence (political/personal/professional) of guideline bodies to include pragmatic studies and discuss limitations of RCT in real world settings

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