G IN A

1. Revised 2006 GINA lobal itiative for sthma Juan Sancha-Cadiz 24 Mayo 2007

2. Novedades GINA 2006 • En la definición,clínica y patogenia • Diagnóstico: clínico, funcional, alergológico y diagº diferencial • Clasificación : De etiología y gravedad ....al CONTROL • Tratamiento: Nuevo escalonamiento.Aumento de protagonismo de los antileucotrienos • Manejo y prevención: (5 componentes: medico/paciente-factores de riesgo-valoración/tto/monitorización del asma-manejo de exacerbaciones-consideraciones especiales)

3. Definición • Importancia de la variabilidad clínica • La obstrucción y los síntomas son variables, pero la inflamación siempre existe. • Por primera vez se habla del ASMA DIFICIL DE TRATAR: “Aquel que afecta a pacientes relativamente insensibles a los Glucocorticoides y por lo tanto difíciles de que logren el mismo nivel de control con estos fármacos, que otros pacientes”

4. Clasificación : De etiología y gravedad ....al CONTROL • CONTROL DEL ASMA: • Ausencia de síntomas durante el día (=/< 2 v/s) • No limitación de actividades incluido ejercicio • Ausencia de síntomas y despertares nocturnos. • No uso de medicación de rescate (=/< 2 v/s) • Función pulmonar normal o cerca de la normalidad • Ausencia de exacerbaciones

5. 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

6. Global Strategy for Asthma Management and Prevention • Evidence-based • Implementation oriented Diagnosis Management Prevention • Outcomes can be evaluated

7. Global Strategy for Asthma Management and Prevention Evidence Category Sources of Evidence ARandomized clinical trials Rich body of data BRandomized clinical trials Limited body of data CNon-randomized trials Observational studies DPanel judgment consensus

8. 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

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

10. 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

11. 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

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

13. Factors that Influence Asthma Development and Expression Host Factors • Genetic - Atopy - Airway hyperresponsiveness • Gender • Obesity • Environmental Factors • Indoor allergens • Outdoor allergens • Occupational sensitizers • Tobacco smoke • Air Pollution • Respiratory Infections • Diet

14. 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

15. 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

16. Clinical Control of Asthma • No (or minimal)* daytime symptoms • No limitations of activity • No nocturnal symptoms • No (or minimal) need for rescue medication • Normal lung function • No exacerbations _________ * Minimal = twice or less per week

17. Revised 2006 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 5. Special Considerations

18. Asthma Management and Prevention Program 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.

19. Asthma Management and Prevention Program 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

20. Asthma Management and Prevention ProgramComponent 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

21. Asthma Management and Prevention ProgramComponent 3: Assess, Treat 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

22. Levels of Asthma Control

23. Component 4: Asthma Management and Prevention Program Controller Medications • Inhaled glucocorticosteroids • Leukotriene modifiers • Long-acting inhaled β2-agonists • Systemic glucocorticosteroids • Theophylline • Cromones • Long-acting oral β2-agonists • Anti-IgE • Systemic glucocorticosteroids

24. Component 4: Asthma Management and Prevention Program Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids • Anticholinergics • Theophylline • Short-acting oral β2-agonists

25. Component 4: Asthma Management and PreventionProgramAllergen-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

26. LEVEL OF CONTROL TREATMENT OF ACTION REDUCE maintain and find lowest controlling step controlled consider stepping up to gain control partly controlled uncontrolled step up until controlled INCREASE exacerbation treat as exacerbation REDUCE INCREASE TREATMENT STEPS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

29. Treating to Achieve Asthma Control • Step 1 – As-needed reliever medication • Patients with occasional daytime symptoms of short duration • A rapid-acting inhaled β2-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)

31. Treating to Achieve Asthma Control • 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

32. Nivel central

33. A ver si vas acabando Juanito

34. Treating to Achieve Asthma Control • Step 3 – Reliever medication plus one or two controllers • For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A) • Inhaled long-acting β2-agonist must not be used as monotherapy • For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)

35. Treating to Achieve Asthma Control • 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)

37. Treating to Achieve Asthma Control • 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

38. Treating to Achieve Asthma Control • Step 4 – Reliever medication plus two or more controllers • Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-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 β2-agonist (Evidence B)

40. 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

41. Treating to Maintain Asthma Control 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)

42. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled • When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B) • If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)

43. Treating to Maintain Asthma Control Stepping up treatment in response to loss of control • Use of a combination rapid and long-acting inhaled β2-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)

44. Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger • Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture • Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth

45. Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger • Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children • These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms

46. Asthma Management and Prevention ProgramComponent 4: Manage Asthma 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

47. Asthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations Primary therapies for exacerbations: • Repetitive administration of rapid-acting inhaled β2-agonist • Early introduction of systemic glucocorticosteroids • Oxygen supplementation Closely monitor response to treatment with serial measures of lung function

48. Hasta la próxima amigos sancha08@telefonica.net