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GINA 2019 presentation

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This is the presentation of Global Strategy for Asthma Management and Prevention 2019 update.

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GINA 2019 presentation

  1. 1. Global Strategy for Asthma Management and Prevention (2019 update) Dr. Md. Shafiqul Islam Dewan Phase-A Resident (Pulmonology) Medicine Unit - VIII Dhaka Medical College Hospital
  2. 2. About GINA GINA stands for Global Initiative for Asthma. Established in 1993. Work with health care professionals and public health officials around the world. To reduce asthma prevalence, morbidity, and mortality.
  3. 3. Asthma Asthma is a heterogeneous disease. Characterized by chronic airway inflammation. Causing symptoms such as wheezing, shortness of breath, chest tightness and cough. That varies in frequency and intensity together with variable expiratory airflow limitation.
  4. 4. Phenotypes of Asthma Many phenotypes have been identified. Most common phenotypes are: Allergic asthma Non-allergic asthma Adult-onset (Late onset) asthma Asthma with fixed airway limitation Asthma with obesity
  5. 5. Diagnosis of Asthma Diagnosis of asthma depends on two defining features: History of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity. Variable expiratory airflow limitation.
  6. 6. Patient with respiratory symptoms Are the symptoms typical of Asthma? Details History and Examination History and Examination Supports Asthma Diagnosis? Perform Spirometry / PEF with Reversibility test Result Support Asthma Diagnosis? Treat for Asthma Yes Yes Yes Empiric treatment with ICS and prn SABA Review response Diagnostic testing within 1-3 months Treat for Alternative Diagnosis Further History & Test for Alternative Diagnosis Clinical urgency Other diagnosis unlikely No Y e s Diagnostic flow-chart for Asthma in clinical practice
  7. 7. Assessing a patient with Asthma Assess asthma control Assess risk factor Assess for comorbidities Assess treatment issue
  8. 8. Assess asthma control Level of asthma symptom control. In the past 4 weeks, has the patient had Well controlled Partly controlled Uncontrolled Daytime symptoms more than twice/week? Yes/No None of these 1 - 2 of these 3 - 4 of these Reliever needed more than twice/week? Yes/No Any night waking due to asthma? Yes/No Any activity limitation due to asthma? Yes/No
  9. 9. Assess risk factor Risk factor for exacerbations Risk factors for developing fixed airflow limitation Risk factors for medication side-effects
  10. 10. Risk factor for exacerbations Uncontrolled asthma symptoms Comorbidities Exposures to smoking, allergen and air pollution Major socioeconomic problems Medication: Inhaled corticosteroid (ICS) not prescribed, Poor adherence, Incorrect inhaler technique, High (SABA) use.
  11. 11. Risk factors for developing fixed airflow limitation Preterm birth, LBW and greater infant weight gain. Lack of ICS treatment Exposure to tobacco smoke and noxious chemicals Low FEV1 Chronic mucus hyper-secretion Sputum or blood eosinophilia
  12. 12. Risk factors for medication side-effects Frequent oral corticosteroid use. Long term high-dose or potent ICS use. Poor inhaler technique.
  13. 13. Assess for comorbidities Rhinitis Chronic Rhinosinusitis Gastroesophageal reflux(GERD) Obesity Obstructive sleep apnea Depression and anxiety Pregnancy
  14. 14. Assess treatment issue Record the patient’s treatment and ask about side effects. Check that the patient has a written asthma action plan. Ask the patient about their attitudes and goals for their asthma.
  15. 15. Written asthma action plan The written asthma action plan should include: The patient’s usual asthma medications When and how to increase medications and start oral corticosteroid(OCS) How to access medical care if symptoms fail to respond
  16. 16. Management of Asthma Few asthma symptoms No sleep disturbance No exercise limitation Maintain normal lung function Prevent flare-ups (exacerbations) Prevent asthma deaths Avoid medication side-effects Symptom control Risk reduction
  17. 17. Management of Asthma General management Asthma medication Treatment of modifiable risk factor Treatment of comorbidity Non pharmacological therapies and strategies Follow up
  18. 18. General management Patient education regarding Asthma Inhaler skills Adherence Written asthma action plan Self-monitoring of symptoms and/or peak flow Regular medical review
  19. 19. Asthma Medication Controller medication Add-on controller medication Reliever medication
  20. 20. Controller Medication Inhaled corticosteroids (ICS) ICS and long-acting beta2 agonist (LABA) bronchodilator combinations (ICS- LABA ) Leukotriene modifiers Chromones
  21. 21. Controller Medication Inhaled corticosteroids (ICS) Beclomethasone dipropionate Budesonide Fluticasone propionate Fluticasone furoate Ciclesonide Triamcinolone
  22. 22. Low, Medium and High dose of ICS Inhaled corticosteroid Adult and Adolescent Low(mcg) Medium(mcg) High(mcg) Beclomethasone dipropionate 100-200 >200-400 >400 Budesonide (DPI) 200-400 >400-800 >800 Fluticasone propionate (DPI) 100-250 >250-500 >500 Fluticasone propionate(HFA) 100-250 >250-500 >500 Triamcinolone acetonide 400-1000 >1000- 2000 >2000
  23. 23. Controller Medication ICS and long-acting beta2 agonist bronchodilator combinations (ICS-LABA) Beclometasone-formoterol Budesonide-formoterol Fluticasone propionate-formoterol Fluticasone propionate-salmeterol Fluticasone furoate-vilanterol
  24. 24. Controller Medication Leukotriene modifiers Montelukast Pranlukast Zafirlukast Zileuton Chromones Sodium cromoglycate Nedocromil sodium
  25. 25. Add-on Controller Medication Long-acting anticholinergic Anti-IgE Anti-IL5 Anti-IL5R Anti-IL4R Systemic corticosteroids
  26. 26. Add-on Controller Medication Long-acting anticholinergic (At Step 4 or 5 with a history of exacerbations despite ICS ± LABA) Tiotropium Anti-IgE (with severe allergic asthma uncontrolled on high dose ICS-LABA) Omalizumab
  27. 27. Add-on Controller Medication  Anti-IL5 & Anti-IL5R (Severe eosinophilic asthma uncontrolled on high dose ICS-LABA) Mepolizumab & Reslizumab Benralizumab  Anti-IL4R (Severe eosinophilic asthma uncontrolled on high dose ICS-LABA, or requiring maintenance OCS)  Dupilumab
  28. 28. Add-on Controller Medication Systemic corticosteroids Prednisolone Hydrocortisone Methylprednisolone
  29. 29. Reliever Medication Short-acting inhaled beta2-agonist bronchodilators (SABA) Low-dose ICS-formoterol Short-acting anticholinergics
  30. 30. Reliever Medication Short-acting inhaled beta2-agonist bronchodilators (SABA) Salbutamol Terbutaline
  31. 31. Reliever Medication • Low-dose ICS-formoterol • Beclometasone-formoterol • Budesonide-formoterol • Short-acting anticholinergics • Ipratropium bromide • Oxitropium bromide
  32. 32. Treatment of modifiable risk factor
  33. 33. Non pharmacological therapies and strategies Cessation of smoking Physical activity Healthy diet Weight reduction Breathing exercises Avoidance of occupational exposures
  34. 34. Non pharmacological therapies and strategies Avoidance of indoor allergens and air pollution Avoidance of outdoor air pollutants / weather conditions Avoidance of medications that may make asthma worse
  35. 35. Other therapies Allergen immunotherapy Subcutaneous immunotherapy (SCIT) (Evidence D) Sublingual immunotherapy (SLIT) (Evidence B) Bronchial thermoplasty. (Evidence B)
  36. 36. Starting asthma treatment ICS-containing treatment should be initiated as soon as possible after the diagnosis of asthma is made. Consider starting at a higher step (e.g. medium/high dose ICS, or low-dose ICS-LABA) if on most days the patient has troublesome asthma symptoms; or is waking from asthma once or more a week.
  37. 37. Starting asthma treatment If the initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation, give a short course of OCS and start regular controller treatment (e.g. medium dose ICS-LABA). Consider stepping down after asthma has been well- controlled for 3 months. However, in adults and adolescents, ICS should not be completely stopped.
  38. 38. Before starting initial controller treatment Record evidence for the diagnosis of asthma, if possible. Document symptom control and risk factors. Assess lung function, when possible. Train the patient to use the inhaler correctly and check their technique. Schedule a follow-up visit.
  39. 39. After starting initial controller treatment Review response after 2–3 months, or according to clinical urgency. Review for ongoing treatment and other key management issues. Consider step down when asthma has been well- controlled for 3 months
  40. 40. Reviewing response and adjusting treatment Patients should preferably be seen 1–3 months after starting treatment Every 3–12 months after that, but in pregnancy, asthma should be reviewed every 4–6 weeks. After an exacerbation, a review visit within 1 week should be scheduled
  41. 41. Stepping up asthma treatment • Sustained step-up (for at least 2–3 months): if symptoms and/or exacerbations persist despite 2–3 months of controller treatment, assess the following common issues before considering a step-up • Incorrect inhaler technique • Poor adherence • Modifiable risk factors • Comorbid conditions
  42. 42. Stepping up asthma treatment Short-term step-up (for 1–2 weeks) by clinician or by patient with written asthma action plan, e.g. during viral infection or allergen exposure.
  43. 43. Stepping up asthma treatment • Day-to-day adjustment by patient for those who prescribed as-needed low dose ICS- formoterol for mild asthma, or low dose ICS-formoterol as maintenance and reliever therapy.
  44. 44. Stepping down asthma treatment Consider stepping down treatment once good asthma control has been achieved and maintained for 3 months, to find the lowest treatment that controls both symptoms and exacerbations, and minimizes side-effects.
  45. 45. Stepping down asthma treatment Choose an appropriate time for step-down (no respiratory infection, patient not travelling, not pregnant). Document baseline status (symptom control and lung function), provide a written asthma action plan, monitor closely and book a follow-up visit.
  46. 46. Control based asthma management cycle
  47. 47. GINA 2019 – Changes in asthma management For safety, GINA no longer recommends SABA- only treatment for Step 1 This decision was based on evidence that SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk GINA now recommends that all adults and adolescents with asthma should receive symptom- driven or regular low dose ICS-containing controller treatment, to reduce the risk of serious exacerbations This is a population-level risk reduction strategy, e.g. statins, anti-hypertensives.
  48. 48. Background to changes in 2019 Risks of mild asthma Patients with apparently mild asthma are at risk of serious adverse events 30–37% of adults with acute asthma 16% of patients with near-fatal asthma 15–20% of adults dying of asthma Exacerbation triggers are variable (viruses, pollens, pollution, poor adherence) had symptoms less than weekly in previous 3 months (Dusser, Allergy 2007)
  49. 49. Background to changes in 2019 risks of SABA-only treatment Inhaled SABA has been first-line treatment for asthma for 50 years Patient satisfaction with, and reliance on, SABA treatment is reinforced by its rapid relief of symptoms, its prominence in emergency department and hospital management of exacerbations, and low cost Patients commonly believe that “My reliever gives me control over my asthma”, so they often don’t see the need for additional treatment
  50. 50. Background to changes in 2019 risks of SABA-only treatment Regular or frequent use of SABA is associated with adverse effects β-receptor downregulation, decreased bronchoprotection, rebound hyperresponsiveness, decreased bronchodilator response (Hancox, Respir Med 2000) Increased allergic response, and increased eosinophilic airway inflammation (Aldridge, AJRCCM 2000)
  51. 51. Background to changes in 2019 risks of SABA-only treatment Higher use of SABA is associated with adverse clinical outcomes Dispensing of ≥3 canisters per year (average 1.7 puffs/day) is associated with higher risk of emergency department presentations (Stanford, AAAI 2012) Dispensing of ≥12 canisters per year is associated with higher risk of death (Suissa, AJRCCM 1994)
  52. 52. GINA 2019 - Stepwise treatment PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option
  53. 53. Step 1 Rationale for changes in GINA 2019
  54. 54. GINA 2019 – Step 1 Changes PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option Previously, no controller was recommended for Step 1, i.e. SABA-only treatment was preferred.
  55. 55. 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
  56. 56. 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
  57. 57. Step 2 Rationale for changes in GINA 2019
  58. 58. GINA 2019 - Step 2 changes PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option
  59. 59. Step 2 - there are two ‘preferred’ controller options (1) 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
  60. 60. Step 2 - there are two ‘preferred’ controller options (1) Regular low dose ICS with as-needed SABA 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.
  61. 61. Step 2 - two ‘preferred’ controller options (2) 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.
  62. 62. Step 2 - two ‘preferred’ controller options (2) As-needed low dose ICS-formoterol 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
  63. 63. 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)
  64. 64. Step 2 - other controller options Low dose ICS taken whenever SABA taken (off-label, separate or combination inhalers) 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)
  65. 65. Other changes in GINA 2019 Steps 3-5 for adults and adolescents
  66. 66. GINA 2019 - Step 3 changes PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option There is no theophylline
  67. 67. GINA 2019 - Step 4 changes PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option Step 4 treatment is medium dose ICS-LABA; high dose now in Step 5
  68. 68. GINA 2019 - Step 5 changes PREFERRED CONTROLLER to prevent exacerbations and control symptoms PREFERRED RELIEVER Other reliever option STEP 1 As-needed low dose ICS-formoterol * Low dose ICS taken whenever SABA is taken† STEP 2 Daily low dose inhaled corticosteroid (ICS), or as- needed low dose ICS-formoterol * Leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken † STEP 3 Low dose ICS-LABA Medium dose ICS, or low dose ICS+LTRA # STEP 4 Medium dose ICS-LABA High dose ICS, add-on tiotropium, or add-on LTRA # STEP 5 High dose ICS-LABA Refer for phenotypic assessment ± add-on therapy, e.g.tiotropium, anti-IgE, anti-IL5/5R, anti-IL4R Add low dose OCS, but consider side-effects As-needed low dose ICS-formoterol * As-needed low dose ICS-formoterol ‡ As-needed short-acting β2 -agonist (SABA) * Off-label; data only with budesonide-formoterol (bud-form) † Off-label; separate or combination ICS and SABA inhalers ‡ Low-dose ICS-form is the reliever for patients prescribed bud- form or BDP-form maintenance and reliever therapy # Consider adding HDM SLIT for sensitized patients with allergic rhinitis and FEV >70%predicted Asthma medication options: Adjust treatment up and down for individual patient needs Other Controller option High dose ICS-LABA Anti-IL 5R Anti-IL 4R
  69. 69. Management of asthma exacerbations
  70. 70. Management of asthma exacerbations in primary care
  71. 71. Mild or Moderate Severe or Life threatening
  72. 72. Management of asthma exacerbations in acute care facility
  73. 73. Mild or Moderate Severe
  74. 74. Uncontrolled Asthma • Poor symptoms control (frequent symptoms or reliever use, activity limited by asthma, night waking due to asthma) And / Or • Frequent exacerbation ( >2 per year) requiring oral corticosteroids or serious exacerbation ( >1 per year ) requiring hospitalization.
  75. 75. Difficult-to-treat asthma Asthma that is uncontrolled despite GINA Step 4 or 5 treatment or that requires such treatment to maintain good symptom control and reduce the risk of exacerbations. Contributory factors may include incorrect diagnosis, incorrect inhaler technique, poor adherence, comorbidities.
  76. 76. Severe asthma Severe asthma is a subset of difficult-to-treat asthma. It means asthma that is uncontrolled despite adherence with maximal optimized therapy and treatment of contributory factors, or that worsens when high dose treatment is decreased. It is sometimes called ‘severe refractory asthma’ since it is relatively refractory to high dose inhaled therapy. However, with the advent of biologic therapies, the word ‘refractory’ is no longer appropriate.
  77. 77. What proportion of adults have difficult-to-treat or severe asthma
  78. 78. Management of difficult-to-treat and severe asthma
  79. 79. Asthma with Pregnancy Asthma control often changes during pregnancy. For baby and mother, the advantages of actively treating asthma markedly outweigh any potential risks of usual controller and reliever medications. Down-titration has a low priority in pregnancy. Exacerbations should be treated aggressively.
  80. 80. Surgical Procedure in Asthma patient Whenever possible, good asthma control should be achieved preoperatively. Ensure that controller therapy is maintained throughout the perioperative period. Patients on long-term high dose ICS, or having more than 2 weeks’ OCS in the past 6 months, should receive intra-operative hydrocortisone to reduce the risk of adrenal crisis.
  81. 81. Take home message No longer recommends starting with SABA only treatment. All adults and adolescents with asthma should receive ICS-containing controller treatment, to reduce their risk of serious exacerbations and to control symptoms.
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This is the presentation of Global Strategy for Asthma Management and Prevention 2019 update.

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