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    GINA Assessment of Asthma Control

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    GINA Assessment of Asthma Control

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    GINA Assessment of Asthma Control

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    GINA assessment of asthma control

    From the Global Strategy for Asthma Management and Prevention 2016,
    © Global Initiative for Asthma (GINA) all rights reserved. Available from
    http://www.ginasthma.org
    Preferred choice of pharmacotherapy: 6-11 years, adolescents,
    adult
    GINA 2016

    Disease severity
    Severe
    asthma
    Moderate
    asthma Step 5
    Mild asthma Step 4 Refer for
    add-on
    PREFERRED Step 3 Medium- treatment
    CONTROLLER Step 1 Step 2
    dose e.g.
    CHOICE Low-dose ICS/LABA tio*, oma,
    Low-dose ICS ICS/LABA mepo

    Med/high-dose Add tio*


    Other Consider ICS; low-dose High-dose Add low-
    controller low-dose LTRA
    ICS+LTRA ICS+LTRA dose OCS
    options ICS Low-dose theoph (or + theoph) (or + theoph)
    As-needed SABA or low dose
    RELIEVER As-needed SABA
    ICS/formoterol

    *Tiotropium by mist inhaler is an add-on treatment for patients with a history of exacerbations.
    GINA, Global Initiative for Asthma; ICS, inhaled corticosteroid; LABA, long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; mepo,
    mepolizumab; OCS, oral corticosteroid; oma, omalizumab; SABA, short-acting beta2-agonist; theoph, theophylline; tio, tiotropium.

    Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. Available from: https://www.ginasthma.org. 2
    © 2016 Global Initiative for Asthma, all rights reserved. Use is by express license from the owner
    Asthma control: fixed vs variable
     Managing the challenge of residual asthma
    symptoms in adults using ICS/LABA has been
    managed in two ways:1
    – Increase maintenance dose of fixed-dose
    combination
    – Use combination as single maintenance and
    reliever therapy (SMART)2
     SMART suggested to offer convenience and better
    improvements in outcomes with lower ICS dosing3
     Does evidence support the use of this strategy?

    1. Bousquet J, et al. Respir Med 2007. 2. Chapman KR, et al. Thorax 2010.
    3. Humbert M, et al. Allergy 2008.
    Reliever used in SMART study 1

    Asthma control by SMART study


    (formoterol/budesonide as reliever and controller)

    Rabe Scicchi O’Bryne Rabe Vogelme Kuna Bousquet Weighted


    et a 2 tano et et al 4 et al 5 ier et al 6 et al 7 et al8 Averages
    al 3
    N 354 947 925 1107 1067 1052 1151
    (SMART arm)
    Length of study 6 12 12 12 12 6 6 bulan N/A
    bulan bulan bulan bulan bulan bulan
    Usage of
    reliever 1.04 0.9 1.01 1.02 0.59† 1.02 0.95 0.92
    inhalation /day

    Usage formoterol/budesonide as reliever & controller


    showing that patient add almost one puff every day
    1.K. Czarnecka and K. Chapman. ‘The clinical impact of single inhaler therapy in asthma’ Clin Exp Allergy 2012. 2. Rabe KF et al. Budesonide/Formoterol in a Single Inhaler for Maintenance and
    Relief in Mild-to-Moderate Asthma. A Randomised, Double-Blind Trial. CHEST 2006; 129: 246 - 256.3. Scicchitano R. et al. Efficacy and safety of budesonide/formoterol single inhaler therapy
    versus a higher dose of budesonide in moderate to severe asthma. Curr Med Res Opin 2004; 20: 1403-18.4. O’Byrne PM et al. Budesonide/formoterol combination therapy as both maintenance
    and reliever medication in asthma.5. Rabe KF et al. Effect of budesonide in combination with formoterol for reliver therapy in asthma exacerbations: a randomised controlled, double-blind study.
    Lancet 2006; 368: 744 - 753.6. Vogelmeier C et al. Budesonide/formoterol maintenance And reliever therapy: an effective asthma treatment option?Eur Respir J 2005; 26: 819-28.
    7. Kuna et al. Effect of budesonide/formoterol maintenance and reliever therapy on asthma exacerbations. Int J Clin Pract 2007; 61:725-36.8. Bousquet et al. Budesonide/formoterol for
    maintenance and relief in uncontrolled asthma vs. high-dose salmeterol/fluticasone. Respir Med 2007; 101: 2437-46.
    TOTAL CONTROL WELL-CONTROL
    (GOAL )1 (GINA) 2
    Night awakening Use of reliever ≤2x per
    No Daily symptoms
    due to asthma almost every week

    Exacerbation No day
    Activity limitation
    No
    due to asthma
    Reliever What it is
    No
    usage mean? ≤2x per
    Reliever usage
    week
    Emergency visit No

    morning PEF  Night awakening


    No
    normal Asthma control due to asthma
    80%
    Drug related
    cannot be
    No achieved using
    adverse event
    Form/Bud as
    reliever &
    controller
    1. Bateman ED et al. Am J Respir Crit Care Med 2004; 170(8):836–844.
    2. Global Strategy for Asthma Management and Prevention, GINA 2016 page 29. Downloaded from www.ginasthma.org
    How many patients can
    achieved asthma control
    defined by GINA ?
    Achieving GINA guideline-defined control
    by fixed dose Salm/FP (GOAL study)
    100

    80 78%* 75%**
    70%

    60% 62%**
    60

    47%

    40
    CONTROLLED
    % of patients

    20

    Well Well Well Well Well Well


    Controlled Controlled Controlled Controlled Controlled Controlled
    0
    Moderate dose ICS (S3)
    Steroid naïve (S1) Low dose ICS (S2)

    *p=0.003 Fp
    **p<0.001 Bateman et al ARJCCM 2004
    Sal/Fp
    Level of patients’ asthma control that
    treated by SMART concept
    Studies analyzed:
    17.1%
    44.2%

    37.8%

    n = 5,246

    Controlled Partly Controlled


    Uncontrolled

    Only 17% of asthma patients can be controlled by Form/Bud SMART !

    Czarnecka & Chapman. Clinical & Experimental Allergy, 1–8, 2012


    REGULAR DOSING VS. VARIABLE DOSING:
    BIOPSY INFLAMMATORY CELLS

    120 +
    100
    80
    60
    % 40
    change 20 **
    from
    0
    baseline +
    -20 Total Cells Mast Cells** CD4+ Eosinophils
    -40
    -60
    Regular Dosing Variable Dosing

    n = 127
    + p < 0.001
    ** p = 0.0012

    Pavord et al J Allergy Clin Immunol 2009;123:1083-1089


    Asthma control: fixed vs variable:
    Conclusion
     Based on Chapman review, the reliever used in
    SMART study show that the patient use
    additional almost one puff per day1

     GINA defined asthma control achieved by:


    – 71% fixed dose Salm/FP2
    – 17% adjustable dose For/Bud1

    1. Chapman KR et al. Thorax 2010


    2. Bateman et al ARJCCM 2004
    Thank you

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