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G IN A

G IN A. lobal itiative for sthma. 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

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G IN A

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  1. GINA lobal itiative for sthma

  2. 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

  3. GINA Structure Executive CommitteeChair: Tim Clark, MD Dissemination Committee Chair: Martyn Partridge, MD Science Committee Chair: Paul O’Byrne, MD GINA reports prepared during workshops conducted in cooperation with the U.S. National Heart, Lung, and Blood Institute, NIH and the World Health Organization.

  4. GINA Sponsors AstraZeneca Merck, Sharp & Dohme Aventis Mitsubishi Pharma Bayer Nikken Chemicals Boehringer Ingelheim Novartis Byk Gulden Schering-Plough Chiesi Sepracor GlaxoSmithKline Viatris Yamanouchi

  5. Executive Committee T. Clark, UK, ChairK. Ohta, Japan J. Bousquet, France M. Partridge, UK W. Busse, USA S. Pedersen, Denmark S. Holgate, UK R. Singh, India C. Lenfant, USA A. Sheffer, USA P. O’Byrne, Canada W. Tan, Singapore

  6. Science Committee P. O’Byrne, Canada, Chair P. Barnes, UK P. Gibson, Australia E. Bateman, S. Africa S. Holgate, UK J. Bousquet, France J. Kips, Belgium W. Busse, USA K. Ohta, Japan J. Drazen, USA S. Pedersen, Denmark M. FitzGerald, Canada E. von Mutius, Germany

  7. Science Committee: Objectives • Develop methods to track and evaluate new scientific research on asthma • Develop a process to evaluate impact of new scientific findings on GINA documents

  8. Science Committee:Objectives (continued) • Identify a network of individuals to serve as ongoing reviewers • With the Dissemination Committee, develop methods to disseminate new scientific findings that impact on GINA documents

  9. Dissemination Committee M. Partridge, UK, chair R. Neville, UK G. Anabwani, Botswana A. Sheffer, USA R. Beasley, N. Zealand J. Sinnadurai, Malaysia H. Campos, Brazil R. Singh, India Y. Chen, China W. Tan, Singapore F. Gallefoss, Norway R. Tomlins, Australia M. Haida, Japan O. van Schyack, Netherlands J. Khan, Pakistan H. Zar, S. Africa

  10. Dissemination Committee: Objectives • Enhance dissemination of GINA reports • Ensure that all concerned with care of patients with asthma are knowledgeable about recommendations • Evaluate methods to alter health professional behaviour • Recommend methods to assess and monitor outcomes

  11. GINA Documents • Workshop Report: Global Strategy for Asthma Management and Prevention (updated 2002) • Pocket guide for health care providers • Pocket guide for management of pediatric asthma (available mid-2002) • Guide for asthma patients and their families All materials are available on GINA web site www.ginasthma.com

  12. GINA Workshop Report • Developed during workshops conducted in cooperation with the National Heart, Lung, and Blood Institute, NIH and the World Health Organization • Evidence-based • Implementation oriented Diagnosis Management Prevention • Outcomes can be evaluated

  13. GINA Workshop Report 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

  14. GINA Workshop Report • Topics: • Definition • Burden of Asthma • Risk Factors • Mechanisms • Diagnosis and Classification • Education and Delivery of Care • Six Part Asthma Management Plan • Research Recommendations

  15. Definition of Asthma • A chronic inflammatory disorder of the airways • Many cells and cellular elements play a role • Chronic inflammation leads to an increase in airway hyperresponsiveness with recurrent episodes of wheezing, coughing, and shortness of breath • Widespread, variable, and often reversible airflow limitation

  16. Definition of Asthma • Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role • Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning • These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment

  17. Mechanisms Underlying the Definition of Asthma Risk Factors (for development of asthma) INFLAMMATION Airway Hyperresponsiveness Airflow Obstruction Symptoms Risk Factors (for exacerbations)

  18. Burden of Asthma • Asthma is one of the most common chronic diseases worldwide • Prevalence increasing in many countries, especially in children • A major cause of school/work absence • An overall increase in severity of asthma increases the pool of patients at risk for death

  19. Burden of Asthma • Health care expenditures very high • Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand • Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care

  20. Worldwide Variation in Prevalence of Asthma Symptoms International Study of Asthma and Allergies in Children (ISAAC) Lancet 1998;351:1225

  21. Increasing Prevalence of Asthma in Children/Adolescents { 1966 Finland (Haahtela et al) 1989 { 1979 Sweden (Aberg et al) 1991 { 1982 Japan (Nakagomi et al) 1992 { 1982 Scotland (Rona et al) 1992 { 1989 UK (Omran et al) 1994 { 1982 USA (NHIS) 1992 { 1975 New Zealand (Shaw et al) 1989 { 1982 Australia (Peat et al) 1992 0 5 10 15 20 25 30 35 Prevalence (%)

  22. Countries should enter their own data on burden of asthma. The following three slides are US data on prevalence, hospitalization rates and mortality.

  23. Trends in Prevalence of AsthmaBy Age, U.S., 1985-1996 Rate/1,000 Persons 80 Age (years) 70 <18 18-44 45-64 65+ Total (All Ages) 60 50 40 30 20 95 96 85 86 87 88 89 90 91 92 93 94 Year

  24. Hospitalization Rates for Asthmaby Age, U.S., 1974 - 1997 Rate/100,000 Persons 40 <15 15-44 45-64 65+ 35 30 25 20 15 10 5 0 74 76 78 80 82 84 86 88 90 92 94 96 Year

  25. Death Rates for AsthmaBy Race, Sex, U.S., 1980-1998 Rate/100,000 Persons 5 Black Female 4 Black Male 3 White Female 2 White Male 1 0 1980 1985 1990 1995 2000 Year

  26. 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

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

  28. Risk Factors that Lead to Asthma Development Host Factors • Genetic predisposition • Atopy • Airway hyper- responsiveness • Gender • Race/Ethnicity • Environmental Factors • Indoor allergens • Outdoor allergens • Occupational sensitizers • Tobacco smoke • Air Pollution • Respiratory Infections • Parasitic infections • Socioeconomic factors • Family size • Diet and drugs • Obesity

  29. 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

  30. Asthma Diagnosis • History and patterns of symptoms • Physical examination • Measurements of lung function • Measurements of allergic status to identify risk factors

  31. Classification of Severity CLASSIFY SEVERITY Clinical Features Before Treatment Nocturnal Symptoms FEV1 or PEF Symptoms Continuous Limited physical activity STEP 4 Severe Persistent  60% predicted Variability > 30% Frequent 60 - 80% predicted Variability > 30% STEP 3 Moderate Persistent Daily Attacks affect activity > 1 time week STEP 2 Mild Persistent  80% predicted Variability 20 - 30% > 2 times a month > 1 time a week but < 1 time a day < 1 time a week Asymptomatic and normal PEF between attacks  80% predicted Variability < 20% STEP 1 Intermittent  2 times a month The presence of one feature of severity is sufficient to place patient in that category.

  32. Six-Part Asthma Management Program 1.Educate Patients 2. Assess and Monitor Severity 3. Avoid Exposure to Risk Factors 4. Establish Medication Plans for Chronic Management: Adults and Children 5. Establish Plans for Managing Exacerbations 6. Provide Regular Follow-up Care

  33. Six-Part Asthma Management Program 1. Educate patients to develop a partnership in asthma management 2. Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible 3. Avoid exposure to risk factors 4. Establish medication plans for chronic management in children and adults 5. Establish individual plans for managing exacerbations 6. Provide regular follow-up care

  34. Six-part Asthma Management Program Goals of Long-term Management • Achieve and maintain control of symptoms • Prevent asthma episodes or attacks • Maintain pulmonary function as close to normal levels as possible • Maintain normal activity levels, including exercise • Avoid adverse effects from asthma medications • Prevent development of irreversible airflow limitation • Prevent asthma mortality

  35. Six-part Asthma Management Program Control of Asthma • Minimal (ideally no) chronic symptoms • Minimal (infrequent) exacerbations • No emergency visits • Minimal (ideally no) need for “as needed” use of β2-agonist • No limitations on activities, including exercise • PEF circadian variation of less than 20 percent • (Near) normal PEF • Minimal (or no) adverse effects from medicine

  36. . Six-Part Asthma Management Program • The most effective management is to prevent airway inflammation by eliminating the causal factors • Asthma can be effectively controlled in most patients, although it can not be cured • The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment

  37. Six-Part Asthma Management Program • Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms

  38. Six-part Asthma Management ProgramPart 1: Educate Patients to Develop a Partnership • Patient education involves a partnership between the patient and health care professional(s) with frequent revision and reinforcement • Aim is guided self-management – giving patients the ability to control their asthma • Interventions, including use of written action plans, have been shown to reduce morbidity in both children and adults

  39. Six-part Asthma Management ProgramPart 1: Educate Patients to Develop a Partnership • Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams • Clear communication between health care professionals and asthma patients is key to enhancing compliance

  40. Six-part Asthma Management ProgramPart 1: Educate Patients to Develop a Partnership • Educate continually • Include the family • Provide information about asthma • Provide training on self-management skills • Emphasize a partnership among health care providers, the patient, and the patient’s family

  41. Six-part Asthma Management ProgramFactors Associated with Non-Compliance in Asthma Care • Patient/Physician • Misunderstanding/lack of information • Underestimation of severity • Attitudes toward ill health • Cultural factors • Poor communication Medication Usage • Difficulties associated with inhalers • Complicated regimens • Fears about, or actual side effects • Cost

  42. Six-part Asthma Management Program Part 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function • Symptom reports • Use of reliever medication • Nighttime symptoms • Activity limitations • Spirometry for initial assessment. Peak Expiratory Flow for follow-up: • Assess severity • Assess response to therapy • PEF monitoring at home • Important for those with poor perception of symptoms • Daily measurement recorded in a diary • Assesses the severity and predicts worsening • Guides the use of a zone system for asthma self-management • Arterial blood gas for severe exacerbations

  43. Typical Spirometric (FEV1) Tracings Volume FEV1 Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) 1 2 3 4 5 Time (sec) Note: Each FEV1 curve represents the highest of three repeat measurements

  44. A Simple Index of PEF Variation

  45. Six-part Asthma Management ProgramPart 3: Avoid Exposure to Risk Factors • Methods to prevent onset of asthma are not yet available but this remains an important goal • Measures to reduce exposure to causes of asthma exacerbations (e.g. allergens, pollutants, foods and medications) should be implemented whenever possible

  46. Six-part Asthma Management ProgramPart 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children • At present, inhaled glucocorticosteroids are the most effective controller medications and are recommended for persistent asthma at any step of severity • Long-term treatment with inhaled glucocorticosteroids markedly reduces the frequency and severity of exacerbations

  47. Six-part Asthma Management ProgramPart 3: Avoid 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

  48. Six-part Asthma Management Program Part 4: Establish Medication Plans for Long-Term Asthma Management • A stepwise approach to pharmacological therapy is recommended • The aim is to accomplish the goals of therapy with the least possible medication • Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

  49. Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy • The choice of treatment should be guided by: • Severity of the patient’s asthma • Patient’s current treatment • Pharmacological properties and availability of the various forms of asthma treatment • Economic considerations Cultural preferences and differing health care systems need to be considered.

  50. Part 4: Long-term Asthma Management Pharmacologic Therapy Controller Medications: • Inhaled glucocorticosteroids • Systemic glucocorticosteroids • Cromones • Methylxanthines • Long-acting inhaled β2-agonists • Long-acting oral β2-agonists • Leukotriene modifiers

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