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20. Điều trị Hen 2019

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20. Điều trị Hen 2019

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  1. ĐIỀU TRỊ HEN Bs TS LêThượngVũ GiảngViên BM NộiĐạiHọc Y Dược TP HCM PhóTrưởngKhoaHôHấp BV ChợRẫy TổngthưkýHộiHôhấpTpHồChí Minh

  2. Điềutrị Hen Nhắclại Tầmquantrọng Hen Địnhnghĩa Cơchếbệnhsinh Chẩnđoánvàđánhgiá Điềutrịkiểmsoát Hen Điềutrị Hen cấp

  3. Prevalence of asthma in children aged 13-14 years © Global Initiative for Asthma GINA 2016 Appendix Box A1-1; figure provided by R Beasley

  4. Tầnsuất hen và hen nặngtrẻ 13-14 tuổi ở Việt Nam theo ISAAC pha 3 • Hen: sao đỏ > 20% • Hen nặng: saođỏ > 7,5% Lai, C.K. Thorax, 2009. 64(6): p. 476-83

  5. Hen vẫn chưa đạt kiểm soát tốt Zainudin, B.M., et al., Asthma control in adults in Asia-Pacific. Respirology, 2005. 10(5): p. 579-86

  6. ĐỊNH NGHĨA Hen làmộtbệnhkhôngđồngnhất, thườngđặctrưngbởiviêmmạnđườngthở. Hen đượcxácnhậnbởicáctriệuchứnghôhấpnhưkhòkhè, khóthở, nặngngựcvà ho thayđổivềcườngđộ/ theothờigiankèmvớitắcnghẽnđườngdòngkhíthởra.

  7. Cơ chế bệnh sinh HEN

  8. Sự tạo thành cơn hen Yếu tố khởi phát cơn hen HEN: VIÊM BÌNH THƯỜNG CO THẮT HẸP: TẮC NGHẼN CƠN HEN CẤP TÍNH

  9. CƠ CHẾ VIÊM VÀ VỊ TRÍ TÁC ĐỘNG CỦA CÁC NHÓM THUỐC ĐIỀU TRỊ HEN Màng Phospholipid tế bào Phospholipase A2 Corticosteroids Arachidonic Acid Cyclooxygenase 5-LO FLAP PGE2 PGD2 PGF2 PGI2 Prostaglandins LTA4 LTC4 Synthase LTA4 Hydrolase Thromboxane Synthase LTC4 LTB4 Thromboxanes LTD4 LTE4 5-LO=5 lipoxygenase; FLAP=5-lipoxygenase-activating protein; PG=prostaglandin; LT=leukotriene Adapted from Holgate ST et al J Allergy Clin Immunol 1996;98:1–13; Hay DWP et al Trends Pharmacol Sci 1995;16:304–309; Chung KF Eur Respir J 1995;8:1203–1213; Spector SL Ann Allergy 1995;75:463–474.

  10. Yếu tố khởi phát hen • Dịứngnguyên • Chất ô nhiễmkhôngkhí • Nhiễmtrùnghôhấp • Gắngsứcvàtăngthôngkhí • Thayđổithờitiết • Sulfur dioxide (SO 2) • Thứcăn, giavịvàchấtbảoquản, thuốc

  11. Triệu chứng cơ năng/thực thể Tiền căn bản thân và / hoặc gia đình có bệnh dị ứng ví dụ hen, viêm mũi dị ứng, viêm kết mạc dị ứng, viêm da tiếp xúc, dị ứng thức ăn Triệu chứng cơ năng gợi ý hen là: Nhiều hơn một triệu chứng sau: ho khan, khó thở, khò khè, nặng ngực Triệu chứng thay đổi về thời gian và cường độ Ban đêm về sáng, theo mùa Tăng khi có yếu tố khởi phát: nhiễm siêu vi, gắng sức, tiếp xúc dị ứng nguyên, thay đổi thời tiết, cười, chất kích thích khói thải, khói thuốc lá, mùi mạnh… Triệu chứng cơ năng không gợi ý hen là: chỉ có một trong bốn triệu chứng ho khạc đàm chứ không phải ho khan khó thở kèm chóng mặt, choáng váng, dị cảm chân tay đau ngực thở rít thì hít vào Khám Khò khè thay đổi Tăng với FVC Lâmsàng Hôhấpký = Hen

  12. Chẩnđoán hen qua khámlâmsàng • Khám lâm sàng ở những người bị bệnh hen suyễn • Thường bình thường • Thường gặpnhất là thở khò khè khinghe, đặc biệtkhithởragắngsức • Thở khò khè do nguyênnhânkhác, ví dụ: • Nhiễm trùng hô hấp • COPD • Rối loạn chức năng đường hô hấp trên • Tắc nghẽnnộikhíquản • Dịvật • Khòkhèmấtkhicơn hen nặng “lồngngựcimlìm” GINA 2016

  13. Chẩn đoán Hen: chức năng phổi Tắcnghẽn: FEV1/FVC giảm (ítnhất 1 lần <LLN hoặc 70%) Thayđổi: Tăngđángkểkhidùngthuốcdãnphếquản (FEV1 >12% và >200mL; trẻem: >12%) Thayđổiđángkểngày-đêm >10% (trẻem 13%) Tăngđángkểkhidùngthuốckiểmsoát 4 tuần Lưu ý: Càngthayđổinhiềucàngnghĩ hen (>400ml và 15%) Lậplạixnkhibncótriệuchứnghoặcsaukhingưngthuốcdãnphếquản Flow Lâmsàng Hôhấpký = Hen Normal Asthma (after BD) Asthma (before BD) Volume GINA 2014

  14. Patient with respiratory symptoms Are the symptoms typical of asthma? NO YES Detailed history/examination for asthma History/examinationsupports asthma diagnosis? Further history and tests for alternative diagnoses Alternative diagnosis confirmed? NO Clinical urgency, and other diagnoses unlikely YES Perform spirometry/PEF with reversibility test Results support asthma diagnosis? Repeat on another occasion or arrange other tests Confirms asthma diagnosis? NO NO YES NO Empiric treatment with ICS and prn SABA Review response Diagnostic testing within 1-3 months YES YES Consider trial of treatment for most likely diagnosis, or refer for further investigations Treat for alternative diagnosis Treat for ASTHMA GINA 2017, Box 1-1 (4/4) © Global Initiative for Asthma

  15. Đánhgiá Hentriệuchứnghiệntại/nguycơtươnglai Mứcđộkiểmsoát hen hiệntại (trong 4 tuần) qua bốntiêuchí: Triệuchứng ban ngày > 2 lần /tuần. Triệuchứng ban đêm > 0 lần / tuần. Sửdụngthuốcgiảmtriệuchứng > 2 lần/ tuần. Giớihạnhoạtđộng do hen > 0 lần/ tuần. Phânloại: Hen kiểmsoátkhikhông vi phạmtiêuchínào Hen kiểmsoátmộtphầnnếu vi phạm 1 – 2 tiêuchí Hen khôngkiểmsoátnếu vi phạm 3 – 4 tiêuchí. Nguycơkếtcụcxấu Nguycơcơn hen cấp (1) tiềncănnhập ICU hay đặtnộikhíquảnvìcơn hen cấp; (2) có ≥ 1 cơn hen nặngtrong 12 tháng qua (3) hen khôngkiểmsoát; (4) Lạmdụngthuốcgiãnphếquản SABA (> 1 hộp 200 nhát/ tháng); (5) khôngđượcdùng ICS do khôngđượcchỉđịnhhoặcđượcchỉđịnhnhưngbệnhnhântuânthủđiềutrịkém, sửdụngbìnhxịt, hútsaikỹthuật; (5) FEV1 cơbảnthấp, đặcbiệt < 60% dựđoán; (6) cóvấnđềthầnkinhtâmlýhoặckinhtếxãhội; (7) tiếptụctiếpxúcthuốclá, dịứngnguyên; (8) cóbệnhđồngmắc: béophì, viêmmũidịứng, dịứngthứcăn; (8) tăngtếbàoáitoantrongmáu hay đàm; (9) thaikỳ. Nguycơtắcnghẽnluồngkhícốđịnh: (1) khôngdùng ICS; (2) tiếptụchútthuốcláhoặctiếpxúchóachất, môitrường ô nhiễm; (3) tăngtiếtđàm; (4) tăngEomáu. Nguycơtácdụngphụthuốc: (1) dùng OSC thườngxuyên; (2) dùng ICS mạnh, kéodài (3) dùngkèmthuốcứcchế men P450.

  16. Đánh giá điều trị/bệnh đồng mắc và độ nặng Đánh giá điều trị Kiểm tra kỹ thuật hít và sự tuân thủ điều trị Tác dụng phụ điều trị Bn đã có kế hoạch hành động viết? Thái độ và mục tiêu bn đối với hen Bệnh đồng mắc Viêm mũi xoang Béo phì Ngưng thở khi ngủ GERD Lo lắng, trầm cảm Hen nhẹ: kiểmsoáttốtvớitrịliệu hen bậc 1 và/hoặc 2 (corticoid hítliềuthấpvà SABA) Hen trungbình: kiểmsoátvớibậc 3 (corticoid hítliềuthấpvà LABA) Hen nặng: chỉđạtkiểmsoátnếudùngbậc 4/5 hoặckhôngđạtkiểmsoátdùbậc 4/5 (corticoid/LABA liềucaocóthểkèmcácthuốcthêmvào)

  17. Tiếpcận Hen khôngkiểmsoáttriệuchứnghiệntạinhiều, nguycơtươnglaicao

  18. Chẩnđoán Hen • Xácđịnh: Có hen? • Phânbiệt: Đợtcấp COPD? Cơn hen tim? • Nguyênnhân: vôcăn, ABPA, Churg Strauss…? • Độnặng: • Triệuchứnghiệntại: hen kiểmsoát? • Nguycơtươnglai: đợtcấp? tắcnghẽncốđịnh? tácdụngphụthuốc? • Theo mứcđiềutrịđểđạtkiểmsoát? • Thểlâmsàng: bệnhđồngmắc?

  19. Điềutrị Hen Nhắclại Điềutrịkiểmsoát Hen Điềutrị Hen cấp

  20. Mục tiêu điều trị HEN Kiểmsoáttriệuchứngvàduytrìhoạtđộngtíchcựcbìnhthường Giảmnguycơ: nguycơđợtcấp, tắcnghẽncốđịnhvàtácdụngphụthuốc Mụctiêu BS- BN

  21. Thầythuốc: mộtphươngtiệnđiềutrị Thiếtlậpquanhệtốtthầythuốc-bệnhnhân Điềutrị hen theochutrìnhkín: đánhgiá, hiệuchỉnhđiềutrị, xemlạiđápứng Dạyvànhấnmạnhcáckỹnăngthiếtyếu Kỹnăngsửdụngbìnhhít Tuânthủ Giáodụctựquảnlý hen cóđịnhhướng Kếhoạchhànhđộng hen viết Tựtheodõi Xemlạithuốc hen

  22. GINA 2018 – main treatment figure Step 1 treatment is for patients with symptoms <twice/month and no risk factors for exacerbations Previously, no controller was recommended for Step 1, i.e. SABA-only treatment was ‘preferred’ GINA 2018, Box 3-5 (2/8) (upper part)

  23. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST ‘Controller’ treatment means the treatment taken to prevent exacerbations Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Other controlleroptions Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  24. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects Other controlleroptions PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  25. Step 2 – there are two ‘preferred’ controller options Regular low dose ICS with as-needed SABA • Evidence • A large body of evidence from RCTs and observational studies that low dose ICS substantially reduces risks of severe exacerbations, hospitalizations and death e.g. Suissa, NEJMed 2000; Suissa, Thorax 2002; Pauwels, Lancet 2003; O’Byrne, AJRCCM 2001 • Serious exacerbations halved even in patients with symptoms 0-1 days per week (Reddel, Lancet 2017) • Improved symptom control and reduced exercise-induced bronchoconstriction • Values and preferences • High importance was given to preventing asthma deaths and severe exacerbations • However, we were aware that poor adherence is common in mild asthma in the community, and that this would expose patients to the risks of SABA-only treatment

  26. Step 2 – two ‘preferred’ controller options As-needed low dose ICS-formoterol(off-label; all evidence with budesonide-formoterol) • Evidence • Direct evidence from two large studies of non-inferiority for severe exacerbations vs daily low dose ICS + as-needed SABA (O’Byrne, NEJMed 2018, Bateman, NEJMed 2018) • Direct evidence from one large study of 64% reduction in severe exacerbations vs SABA-only treatment(O’Byrne, NEJMed 2018) • Symptoms reduced; one study showed reduced exercise-induced bronchoconstriction • Values and preferences • High importance was given to preventing severe exacerbations, avoiding need for daily ICS in patients with mild or infrequent symptoms, and safety of as-needed ICS-formoterol in maintenance and reliever therapy, with no new safety signals • Lower importance given to small non-cumulative differences in symptom control (ACQ-5 difference 0.15 vs MCID 0.5) and lung function compared with daily ICS • Makes use of normal patient behavior (seeking symptom relief) to deliver controller

  27. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects Other controlleroptions PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  28. Step 2 - other controller options Low dose ICS taken whenever SABA taken(off-label, separate or combination inhalers) • Evidence • Two RCTs showed reduced exacerbations compared with SABA-only treatment • BEST, in adults, with combination ICS-SABA (Papi, NEJMed 2007) • TREXA, in children/adolescents, with separate inhalers (Martinez, Lancet 2011) • Three RCTs showed similar or fewer exacerbations compared with maintenance ICS • TREXA, BEST • BASALT in adults, separate inhalers, vs physician-adjusted treatment (Calhoun, JAMA 2012) • Values and preferences • High importance given to preventing severe exacerbations • Lower importance given to small differences in symptom control and the inconvenience of needing to carry two inhalers • Combination ICS-SABA inhalers are available in some countries, but approved only for maintenance use • Another option: leukotriene receptor antagonist (less effective for exacerbations)

  29. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects Other controlleroptions PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  30. Step 1 – ‘preferred’ controller option • Step 1 is for patients with symptoms less than twice a month, and with no exacerbation risk factors As-needed low dose ICS-formoterol (off-label) • Evidence • Indirect evidence from SYGMA 1 of large reduction in severe exacerbations vs SABA-only treatment in patients eligible for Step 2 therapy (O’Byrne, NEJMed 2018) • Values and preferences • High importance given to reducing exacerbations • High importance given to avoiding conflicting messages about goals of asthma treatment between Step 1 and Step 2 • High importance given to poor adherence with regular ICS in patients with infrequent symptoms, which would expose them to risks of SABA-only treatment

  31. Step 1 - other controller option Low dose ICS taken whenever SABA is taken (off-label) • Evidence • Indirect evidence from studies in patients eligible for Step 2 treatment (BEST, TREXA, BASALT) • Values and preferences • High importance given to preventing severe exacerbations • Lower importance given to small differences in symptom control and the inconvenience of needing to carry two inhalers • Combination ICS-SABA inhalers are available in some countries, but approved only for maintenance use Daily ICS is no longer listed as a Step 1 option • This was included in GINA 2014-18, but with high probability of poor adherence • Now replaced by more feasible as-needed controller options for Step 1

  32. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse Step 4 treatment is medium dose ICS-LABA; high dose now in Step 5 Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects Other controlleroptions PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  33. Box3-5A Adults & adolescents 12+years Confirmation of diagnosis if necessary Symptom control &modifiable risk factors (including lungfunction) Comorbidities Inhaler technique &adherence Patientgoals ASSESS REVIEW RESPONSE Personalized asthmamanagement: Assess, Adjust, Reviewresponse See severe asthma Pocket Guide for details about Step 5 Symptoms Exacerbations Side-effects Lungfunction Patientsatisfaction ADJUST Treatment of modifiablerisk factors &comorbidities Non-pharmacological strategies Education & skills training Asthmamedications STEP5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Asthma medicationoptions: Adjust treatment up and down for individual patientneeds STEP4 Mediumdose ICS-LABA STEP3 Low dose ICS-LABA STEP2 Daily low dose inhaled corticosteroid (ICS), or as-needed low dose ICS-formoterol* PREFERRED CONTROLLER to prevent exacerbations and controlsymptoms STEP1 As-needed lowdose ICS-formoterol* Low dose ICS takenwhenever SABA is taken† Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken† Medium dose ICS, or lowdose ICS+LTRA # High dose ICS, add-on tiotropium,or add-onLTRA # Add lowdose OCS, but consider side-effects Other controlleroptions PREFERRED RELIEVER As-needed low dose ICS-formoterol* As-needed low dose ICS-formoterol‡ Other relieveroption As-needed short-acting β2 -agonist(SABA) * Off-label; data only with budesonide-formoterol(bud-form) † Off-label; separate or combination ICS and SABAinhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud-form or BDP-form maintenance and relievertherapy # Consider adding HDM SLIT for sensitized patientswithallergic rhinitis and FEV>70%predicted 1 © Global Initiative for Asthma, www.ginasthma.org

  34. Children 6-11 years • Step 4 • Medium dose ICS-LABA, but refer for expert advice • Step 3 • Low dose ICS-LABA and medium dose ICS are ‘preferred’ controller treatments • No safety signal with ICS-LABA in children 4-11 years (Stempel, NEJMed 2017) • Step 2 • Preferred controller is daily low dose ICS • Other controller options include as-needed low dose ICS taken whenever SABA is taken, but only one study in children (Martinez, Lancet 2011) • Studies of as-needed ICS-formoterol are needed; maintenance and reliever therapy with low dose budesonide-formoterol in children 4-11 years reduced exacerbations by 70-79% compared with ICS and ICS-LABA (Bisgaard, Chest 2006) • Step 1 • Low dose ICS whenever SABA taken (indirect evidence), or daily low dose ICS

  35. © Global Initiative for Asthma, www.ginasthma.org

  36. © Global Initiative for Asthma, www.ginasthma.org

  37. © Global Initiative for Asthma, www.ginasthma.org

  38. © Global Initiative for Asthma, www.ginasthma.org

  39. © Global Initiative for Asthma, www.ginasthma.org

  40. © Global Initiative for Asthma, www.ginasthma.org

  41. © Global Initiative for Asthma, www.ginasthma.org

  42. © Global Initiative for Asthma, www.ginasthma.org

  43. © Global Initiative for Asthma, www.ginasthma.org

  44. © Global Initiative for Asthma, www.ginasthma.org

  45. © Global Initiative for Asthma, www.ginasthma.org

  46. © Global Initiative for Asthma, www.ginasthma.org

  47. © Global Initiative for Asthma, www.ginasthma.org

  48. © Global Initiative for Asthma, www.ginasthma.org

  49. © Global Initiative for Asthma, www.ginasthma.org

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