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ASTHMA MANAGEMENT
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AND PREVENTION
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(for Adults and Children Older than 5 Years)
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Updated 2010
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Eric D. Bateman, M.D., South Africa, Chair Louis-Philippe Boulet, MD, Canada, Chair
Louis-Philippe Boulet, M.D., Canada
Alvaro Cruz, M.D., Brazil
GINA Assembly members from 45
Mark FitzGerald, M.D., Canada Tari
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PREFACE .......................................................................................2
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WHAT IS KNOWN ABOUT ASTHMA?...........................................4
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DIAGNOSING ASTHMA ..............................................................6
Figure 1. Is it Asthma? ........................................................6
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CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............8
Figure 2. Levels of Asthma Control.........................................8
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FOUR COMPONENTS OF ASTHMA CARE .....................................9
Component 1. Develop Patient/Doctor Partnership..................9
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Figure 3. Example of Contents of an Action Plan to Maintain
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Asthma Control....................................................10
Component 2. Identify and Reduce Exposure to Risk Factors..11
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Figure 4. Strategies for Avoiding Common Allergens and
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Pollutants ............................................................11
Component 3. Assess, Treat, and Monitor Asthma.................12
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Glucocorticosteroids.............................................15
Figure 7. Questions for Monitoring Asthma Care ..................17
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PREFACE
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Asthma is a major cause of chronic morbidity and mortality throughout
the world and there is evidence that its prevalence has increased
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considerably over the past 20 years, especially in children. The Global
Initiative for Asthma was created to increase awareness of asthma
among health professionals, public health authorities, and the general
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public, and to improve prevention and management through a concerted
worldwide effort. The Initiative prepares scientific reports on asthma,
encourages dissemination and implementation of the recommendations,
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and promotes international collaboration on asthma research.
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The Global Initiative for Asthma offers a framework to achieve and
maintain asthma control for most patients that can be adapted to local
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health care systems and resources. Educational tools, such as laminated
cards, or computer-based learning programs can be prepared that are
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This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention (Updated 2010). Technical
discussions of asthma, evidence levels, and specific citations from the
scientific literature are included in that source document.
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Acknowledgements:
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Grateful acknowledgement is given for unrestricted educational grants from
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AstraZeneca, Boehringer Ingelheim, Chiesi Group, GlaxoSmithKline, MEDA
Pharma, Merck Sharp & Dohme, Mitsubishi Tanabe Pharma, Novartis,
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Nycomed, and Schering-Plough. The generous contributions of these
companies assured that the GINA Committees could meet together and
publications could be printed for wide distribution. However, the GINA
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Committee participants are solely responsible for the statements and
conclusions in the publications.
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WHAT IS KNOWN
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ABOUT ASTHMA?
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Unfortunately… asthma is one of the most common chronic diseases,
with an estimated 300 million individuals affected worldwide. Its
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prevalence is increasing, especially among children.
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achieve good control of their disease. When asthma is under control
patients can:
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Avoid troublesome symptoms night and day
Use little or no reliever medication
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Have productive, physically active lives
Have (near) normal lung function
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Avoid serious attacks
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morning.
treatment, potential for adverse effects, and the cost of treatment required
to achieve control.
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• For many patients, controller medication must be taken daily to
prevent symptoms, improve lung function, and prevent attacks.
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Reliever medications may occasionally be required to treat acute
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symptoms such as wheezing, chest tightness, and cough.
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• To reach and maintain asthma control requires the development of a
partnership between the person with asthma and his or her health
care team.
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• Asthma is not a cause for shame. Olympic athletes, famous leaders,
other celebrities, and ordinary people live successful lives with asthma.
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DIAGNOSING
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ASTHMA
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Asthma can often be diagnosed on the basis of a patient’s symptoms
and medical history (Figure 1).
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Figure 1. Is It Asthma?
Presence of any of these signs and symptoms should increase the suspicion of asthma:
I Wheezing—high-pitched whistling sounds when breathing out—especially in children.
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(A normal chest examination does not exclude asthma.)
I History of any of the following:
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• Cough, worse particularly at night
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• Recurrent wheeze
• Recurrent difficult breathing
• Recurrent chest tightness
I Symptoms occur or worsen at night, awakening the patient.
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I Symptoms occur or worsen in a seasonal pattern.
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I The patient also has eczema, hay fever, or a family history of asthma or atopic
diseases.
I Symptoms occur or worsen in the presence of:
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• Exercise
• Pollen
• Respiratory (viral) infections
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• Smoke
• Strong emotional expression
I Symptoms respond to anti-asthma therapy.
I Patient’s colds “go to the chest” or take more than 10 days to clear up.
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diagnosis of asthma.
Spirometry is the preferred method of measuring airflow limitation and
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Peak expiratory flow (PEF) measurements can be an important aid in
both diagnosis and monitoring of asthma.
• PEF measurements are ideally compared to the patient’s own previous
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best measurements using his/her own peak flow meter.
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• An improvement of 60 L/min (or ≥ 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of
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more than 20% (with twice-daily readings, more than 10%), suggests
a diagnosis of asthma.
Additional diagnostic tests:
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• For patients with symptoms consistent with asthma, but normal lung
function, measurements of airway responsiveness to methacho-
line and histamine, an indirect challenge test such as inhaled manni-
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tol, or exercise challenge may help establish a diagnosis of asthma.
• Skin tests with allergens or measurement of specific IgE in
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serum: The presence of allergies increases the probability of a
diagnosis of asthma, and can help to identify risk factors that cause
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asthma symptoms in individual patients.
Diagnostic Challenges
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Cough-variant asthma. Some patients with asthma have chronic
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The goal of asthma care is to achieve and maintain control of the clini-
cal manifestations of the disease for prolonged periods. When asthma is
controlled, patients can prevent most attacks, avoid troublesome symptoms
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day and night, and keep physically active.
The assessment of asthma control should include control of the clinical man-
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ifestations and control of the expected future risk to the patient such as
exacerbations, accelerated decline in lung function, and side-effects of
treatment. In general, the achievement of good clinical control of asthma
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leads to reduced risk of exacerbations.
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Figure 2 describes the clinical characteristics of controlled, partly con-
trolled, and uncontrolled asthma.
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Figure 2. LEVELS OF ASTHMA CONTROL
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Daytime symptoms None (twice or More than twice/week Three or more features of
less/week) partly controlled
asthma*†
Limitation of activities None Any
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B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)
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Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low
FEV1, exposure to cigarette smoke, high dose medications
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* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
† By definition, an exacerbation in any week makes that an uncontrolled asthma week
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‡ Without administration of bronchodilator, lung function is not a reliable test for children 5 years and younger
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ASTHMA CARE
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Four interrelated components of therapy are required to achieve and main-
tain control of asthma
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Component 1. Develop patient/doctor partnership
Component 2. Identify and reduce exposure to risk factors
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Component 3. Assess, treat, and monitor asthma
Component 4. Manage asthma exacerbations
partnership between the person with asthma and his or her health care team.
With your help, and the help of others on the health care team, patients
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Additional self-management plans can be found on several Websites,
including:
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www.asthma.org.uk
www.nhlbisupport.com/asthma/index.html
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www.asthmanz.co.nz
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Figure 3. Example of Contents of an Action Plan to Maintain Asthma Control
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Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
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WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control
In the past week have you had: alt
Daytime asthma symptoms more than 2 times? No Yes
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Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
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The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than______? No Yes
If you answered YES to three or more of these questions, your asthma is
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improving.
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4. Continue to use your _________ [reliever medication] until you are able to
get medical help.
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Component 2: Identify and Reduce Exposure to Risk
Factors
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To improve control of asthma and reduce medication needs, patients
should take steps to avoid the risk factors that cause their asthma symptoms
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(Figure 4). However, many asthma patients react to multiple factors that
are ubiquitous in the environment, and avoiding some of these factors
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completely is nearly impossible. Thus, medications to maintain asthma
control have an important role because patients are often less sensitive to
these risk factors when their asthma is under control.
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Physical activity is a common cause of asthma symptoms but patients
should not avoid exercise. Symptoms can be prevented by taking a
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rapid-acting inhaled 2-agonist before strenuous exercise (a leukotriene
modifier or cromone are alternatives).
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Patients with moderate to severe asthma should be advised to receive an
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influenza vaccination every year, or at least when vaccination of the
general population is advised. Inactivated influenza vaccines are safe for
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Avoidance measures that improve control of asthma and reduce medication needs:
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• Tobacco smoke: Stay away from tobacco smoke. Patients and parents should
not smoke.
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• Drugs, foods, and additives: Avoid if they are known to cause symptoms.
• Occupational sensitizers: Reduce or, preferably, avoid exposure to these agents.
Reasonable avoidance measures that can be recommended but have not been shown
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Replace carpets with hard flooring, especially in sleeping rooms. (If possible, use
vacuum cleaner with filters. Use acaricides or tannic acid to kill mites—but make
sure the patient is not at home when the treatment occurs.)
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• Animals with fur: Use air filters. (Remove animals from the home, or at least
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• Indoor mold: Reduce dampness in the home; clean any damp areas frequently.
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Component 3: Assess, Treat, and Monitor Asthma
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The goal of asthma treatment—to achieve and maintain clinical control—
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can be reached in most patients through a continuous cycle that involves
• Assessing Asthma Control
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• Treating to Achieve Control
• Monitoring to Maintain Control
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Assessing Asthma Control
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Each patient should be assessed to establish his or her current treatment
regimen, adherence to the current regimen, and level of asthma control.
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A simplified scheme for recognizing controlled, partly controlled, and
uncontrolled asthma is provided in Figure 2.
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Treating to Achieve Control
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For most patients newly diagnosed with asthma or not yet on medication,
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A variety of controller (Appendix A and Appendix B) and reliever
(Appendix C) medications for asthma are available. The recommended
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treatments are guidelines only. Local resources and individual patient
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circumstances should determine the specific therapy prescribed for each
patient.
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Inhaled medications are preferred because they deliver drugs directly to
the airways where they are needed, resulting in potent therapeutic effects
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with fewer systemic side effects. Inhaled medications for asthma are available
as pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, dry
powder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)
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devices make inhalers easier to use and reduce systemic absorption and
side effects of inhaled glucocorticosteroids.
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Teach patients (and parents) how to use inhaler devices. Different devices
need different inhalation techniques.
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• Give demonstrations and illustrated instructions.
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• Ask patients to show their technique at every visit.
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Figure 5. Management Approach Based On Control
Management Approach Based On Control
Adults and Children Older than 5 Years
For Children Older Than 5 Years, Adolescents and Adults
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Reduce
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Level of Control Treatment Action
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Partly controlled Consider stepping up to gain control
Increase
Uncontrolled Step up until controlled
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Exacerbation Treat as exacerbation
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Reduce Treatment Steps Increase
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Step 1 Step 2 Step 3 Step 4 Step 5
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Asthma education
Environmental control
As needed rapid-
As needed rapid-acting β2-agonist
acting β2-agonist
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To Step 3 treatment, To Step 4 treatment,
Select one Select one select one or more add either
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Medium-or high-dose
Low-dose inhaled Low-dose ICS plus Oral glucocorticosteroid
ICS plus long-acting
ICS* long-acting β2-agonist (lowest dose)
β2-agonist
Controller
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Figure 6. Estimated Equipotent Daily Doses of Inhaled
Glucocorticosteroids for Adults and Children Older than 5 Years †
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Drug g)†
Low Dose ( g)†
Medium Daily Dose ( g)†
High Daily Dose (
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dipropionate
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Ciclesonide* 80-160 >160-320 >320-1280
or
Fluticasone 100-250 >250-500 >500-1000
propionate
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furoate*
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Triamcinolone 400-1000 >1000-2000 >2000
acetonide
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† Comparisons based upon efficacy data.
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‡ Patients considered for high daily doses except for short periods should be referred to a
specialist for assessment to consider alternative combinations of
controllers. Maximum recommended doses are arbitrary but with prolonged use are associ-
ated with increased risk of systemic side effects.
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Notes
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• The most important determinant of appropriate dosing is the clinicianʼs judgment of the
patientʼs response to therapy. The clinician must monitor the patientʼs response in terms
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of clinical control and adjust the dose accordingly. Once control of asthma is achieved,
the dose of medication should be carefully titrated to the minimum dose required to
maintain control, thus reducing the potential for adverse effects.
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• Designation of low, medium, and high doses is provided from manufacturersʼ recommen-
dations where possible. Clear demonstration of dose-response relationships is seldom
provided or available. The principle is therefore to establish the minimum effective con-
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trolling dose in each patient, as higher doses may not be more effective and are likely to
be associated with greater potential for adverse effects.
• As CFC preparations are taken from the market, medication inserts for HFA preparations
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should be carefully reviewed by the clinician for the equivalent correct dosage.
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Monitoring to Maintain Control
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Ongoing monitoring is essential to maintain control and establish the
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lowest step and dose of treatment to minimize cost and maximize safety.
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Typically, patients should be seen one to three months after the initial
visit, and every three months thereafter. After an exacerbation, follow-up
should be offered within two weeks to one month.
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At each visit, ask the questions listed in Figure 7.
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Adjusting medication:
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• If asthma is not controlled on the current treatment regimen, step up
treatment. Generally, improvement should be seen within 1 month.
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But first review the patient’s medication technique, compliance, and
avoidance of risk factors.
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• If asthma is partly controlled, consider stepping up treatment,
depending on whether more effective options are available, safety
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Figure 7. Questions for Monitoring Asthma Care
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IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS?
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Ask the patient: Action to consider:
Has your asthma awakened you at
night?
Adjust medications and management
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plan as needed (step up or step down).
Have you needed more reliever But first, compliance should be
medications than usual? assessed.
Have you needed any urgent medical
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care?
Has your peak flow been below your
personal best?
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Are you participating in your usual
physical activities?
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IS THE PATIENT USING INHALERS, SPACER, OR
PEAK FLOW METERS CORRECTLY?
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Ask the patient: Action to consider:
Please show me how you take your
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medicine.
Demonstrate correct technique.
Have patient demonstrate back.
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the medicine.
Problem solve with the patient to over-
come barriers to following the plan.
What problems have you had follow-
ing the management plan or taking
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your medication?
During the last month, have you ever
stopped taking your medicine
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management plan?
concerns and discussion to overcome
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barriers.
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Component 4: Manage Exacerbations
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Exacerbations of asthma (asthma attacks) are episodes of a progressive
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increase in shortness of breath, cough, wheezing, or chest tightness, or a
combination of these symptoms.
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Do not underestimate the severity of an attack; severe asthma
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attacks may be life threatening. Their treatment requires close supervision.
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should be encouraged to seek urgent care early in the course of their
exacerbations. These patients include those:
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• With a history of near-fatal asthma requiring intubation and mechanical
ventilation alt
• Who have had a hospitalization or emergency visit for asthma within
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the past year
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• Who are currently using or have recently stopped using oral gluco-
corticosteroids
• Who are not currently using inhaled glucocorticosteroids
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monthly
• With a history of psychiatric disease or psychosocial problems, including
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• The response to the initial bronchodilator treatment is not
prompt and sustained for at least 3 hours
• There is no improvement within 2 to 6 hours after oral
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glucocorticosteroid treatment is started
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• There is further deterioration
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Mild attacks, defined by a reduction in peak flow of less than 20%, nocturnal
awakening, and increased use of rapid-acting 2-agonists, can usually be
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treated at home if the patient is prepared and has a personal asthma
management plan that includes action steps.
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Moderate attacks may require, and severe attacks usually require, care in
a clinic or hospital.
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Asthma attacks require prompt treatment:
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• Inhaled rapid-acting 2-agonists in adequate doses are essential.
(Begin with 2 to 4 puffs every 20 minutes for the first hour; then mild
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exacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderate
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• Antibiotics (do not treat attacks but are indicated for patients who also
have pneumonia or bacterial infection such as sinusitis)
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• Epinephrine/adrenaline (may be indicated for acute treatment of
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anaphylaxis and angioedema but is not indicated for asthma attacks)
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Monitor response to treatment:
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Evaluate symptoms and, as much as possible, peak flow. In the hospital, also
assess oxygen saturation; consider arterial blood gas measurement in
patients with suspected hypoventilation, exhaustion, severe distress, or peak
flow 30-50 percent predicted.
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Follow up:
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After the exacerbation is resolved, the factors that precipitated the
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exacerbation should be identified and strategies for their future avoidance
implemented, and the patient’s medication plan reviewed.
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Figure 8. Severity of Asthma Exacerbations*
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Parameter Mild Moderate Severe Respiratory
arrest imminent
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Breathless Walking Talking At rest
Infant - softer, shorter Infant stops
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cry; difficulty feeding feeding
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Alertness May be agitated Usually agitated Usually agitated Drowsy or confused
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Normal rates of breathing in awake children:
Age Normal rate
< 2 months < 60/min
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2-12 months < 50/min
1-5 years < 40/min
6-8 years < 30/min
Accessory muscles
and suprasternal
retractions
Usually not Usually
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thoraco-abdominal
movement
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Wheeze Moderate, often Loud Usually loud Absence of
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Possible respiratory
failure (see text)
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Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.
*Note: The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation.
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†Note: Kilopascals are also used internationally, conversion would be appropriate in this regard.
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SPECIAL CONSIDERATIONS
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IN MANAGING ASTHMA
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Pregnancy. During pregnancy the severity of asthma often changes, and
patients may require close follow-up and adjustment of medications. Pregnant
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patients with asthma should be advised that the greater risk to their baby
lies with poorly controlled asthma, and the safety of most modern asthma
treatments should be stressed. Acute exacerbations should be treated
aggressively to avoid fetal hypoxia.
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Obesity. Management of asthma in the obese should be the same as patients
with normal weight. Weight loss in the obese patient improves asthma
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control, lung function and reduces medication needs.
Surgery. Airway hyperresponsiveness, airflow limitation, and mucus hyper-
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secretion predispose patients with asthma to intraoperative and postoperative
respiratory complications, particularly with thoracic and upper abdominal
surgeries. Lung function should be evaluated several days prior to surgery,
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and a brief course of glucocorticosteroids prescribed if FEV1 is less than
80% of the patient’s personal best.
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Rhinitis, Sinusitis, and Nasal Polyps. Rhinitis and asthma often coexist
in the same patient, and treatment of rhinitis may improve asthma symptoms.
Both acute and chronic sinusitis can worsen asthma, and should be treated.
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Nasal polyps are associated with asthma and rhinitis, often with aspirin
sensitivity and most frequently in adult patients. They are normally quite
responsive to topical glucocorticosteroids.
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Appendix A: Glossary of Asthma Medications - Controllers
Name and Usual Doses Side Effects Comments
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Also Known As
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Glucocortico- Inhaled: Beginning Inhaled: High daily doses Inhaled: Potential but small
steroids dose dependent on may be associated with skin risk of side effects is well
Adrenocorticoids asthma control then thinning and bruises, and balanced by efficacy. Valved
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Corticosteroids titrated down over rarely adrenal suppression. holding-chambers with MDIs
Glucocorticoids 2-3 months to lowest Local side effects are hoarse- and mouth washing with DPIs
effective dose once ness and oropharyngeal after inhalation decrease oral
Inhaled (ICS): control is achieved. candidiasis. Low to medium Candidiasis. Preparations not
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Beclomethasone doses have produced minor equivalent on per puff or g
Budesonide growth delay or suppression basis.
Ciclesonide Tablets or syrups: (av. 1cm) in children. Attainment
Flunisolide For daily control use of predicted adult height does
Fluticasone lowest effective dose not appear to be affected. Tablet or syrup: Long
Mometasone 5-40 mg of prednisone
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term use: alternate day a.m.
Triamcinolone equivalent in a.m. or dosing produces less toxicity.
qod. Tablets or syrups: Used Short term: 3-10 day “bursts”
Tablets or syrups: long term, may lead to are effective for gaining
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hydrocortisone For acute attacks osteoporosis, hypertension, prompt control.
methylprednisolone 40-60 mg daily in diabetes, cataracts, adrenal
prednisolone 1 or 2 divided doses suppression, growth suppression,
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prednisone for adults or 1-2 mg/kg obesity, skin thinning or muscle
daily in children. weakness. Consider coexisting
conditions that could be
worsened by oral glucocortico-
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steroids, e.g. herpes virus
infections, Varicella,
tuberculosis, hypertension,
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Sodium MDI 2 mg or 5 mg Minimal side effects. Cough May take 4-6 weeks to
cromoglycate 2-4 inhalations 3-4 may occur upon inhalation. determine maximum effects.
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Nedocromil MDI 2 mg/puff 2-4 Cough may occur upon Some patients unable to
cromones inhalations 2-4 times inhalation. tolerate the taste.
daily.
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beta-adrenergis (12 g) bid. tablets. Have been associated Should not use as mono-
sympathomimetics MDI- F: 2 puffs bid. with an increased risk of therapy for controller therapy.
LABAs DPI-Sm: 1 inhalation severe exacerbations and Always use as adjunct to
(50 g) bid. asthma deaths when added ICS therapy. Formoterol has
Inhaled: MDI-Sm: 2 puffs bid. to usual therapy. onset similar to salbutamol
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Table continued...
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Appendix A: Glossary of Asthma Medications - Controllers (continued...)
Name and Usual Doses Side Effects Comments
Also Known As
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Antileukotrienes Adults: M 10mg qhs No specific adverse effects Antileukotrienes are most
Leukotriene modifiers P 450mg bid to date at recommended effective for patients with
Montelukast (M) Z 20mg bid; doses. Elevation of liver mild persistent asthma. They
enzymes with Zafirlukast provide additive benefit when
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Pranlukast (P) Zi 600mg qid.
Zafirlukast (Z) and Zileuton and limited added to ICSs though not as
Zileuton (Zi) Children: M 5 mg case reports of reversible effective as inhaled long-acting
qhs (6-14 y) hepatitis and hyperbiliru- 2-agonists.
M 4 mg qhs (2-5 y) binemia with Zileuton and
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Z 10mg bid (7-11 y). hepatic failure with afirlukast
Immunomodulators Adults: Dose Pain and bruising at injec- Need to be stored under
Omalizumab administered subcu- tion site (5-20%) and very refrigeration 2-8˚C and
Anti-IgE taneously every 2 or 4 rarely anaphylaxis (0.1%). maximum of 150 mg
or
weeks dependent administered per injection site.
on weight and IgE
concentration
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Formulation
Appendix B: Combination Medications For Asthma
ICS = inhaled corticosteroid; LABA = long acting -agonist; pMDI = pressurized metered dose inhaler; DPI = dry powder inhaler
2
New formulations will be reviewed for inclusion in the table as they are approved. Such medications may be
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1
Refers to metered dose. For additional information about dosages and products available in specific
countries, please consult www.gsk.com to find a link to your country website or contact your local company
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countries, please consult www.astrazeneca.com to find a link to your country website or contact your
local company representatives for products approved for use in your country.
3
Refers to metered dose. For additional information about dosages and products available in specific
countries, please consult www.chiesigroup.com to find a link to your country website or contact your
local company representatives for products approved for use in your country.
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Appendix C: Glossary of Asthma Medications - Relievers
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Name and Also Usual Doses Side Effects Comments
Known As
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Short-acting Differences in potency Inhaled: tachycardia, Drug of choice for acute
2-agonists exist but all products skeletal muscle tremor, bronchospasm. Inhaled route
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Adrenergics are essentially headache, and irritability. has faster onset and is more
2-stimulants comparable on a per At very high dose hyper- effective than tablet or syrup.
Sympathomimetics puff basis. For pre glycemia, hypokalemia. Increasing use, lack of expected
symptomatic use and effect, or use of > 1 canister
Albuterol/salbutamol pretreatment before Systemic administration as a month indicate poor asthma
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Fenoterol exercise 2 puffs MDI Tablets or Syrup increases control; adjust long-term
Levalbuterol or 1 inhalation DPI. the risk of these side effects. therapy accordingly. Use
Metaproterenol For asthma attacks of 2 canisters per month is
Pirbuterol 4-8 puffs q2-4h, may associated with an increased
Terbutaline administer q20min x 3 risk of a severe, life-threatening
or
with medical supervi- asthma attack.
sion or the equivalent
of 5 mg salbutamol
by nebulizer.
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Anticholinergics IB-MDI 4-6 puffs q6h or Minimal mouth dryness or May provide additive effects
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Ipratropium q20 min in the emergency bad taste in the mouth. to 2-agonist but has slower
bromide (IB) department. Nebulizer onset of action. Is an alternative
Oxitropium 500 g q20min x 3 for patients with intolerance
bromide then q2-4hrs for adults for 2-agonists.
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and 250-500 g for
children.
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Epinephrine/ 1:1000 solution Similar, but more significant In general, not recommended
adrenaline (1mg/mL) .01mg/kg effects than selective 2-agonist. for treating asthma attacks if
injection up to 0.3-0.5 mg, can In addition: hypertension, selective 2-agonists are
ial
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The Global Initiative for Asthma is supported by educational grants from:
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www.ginasthma.org/application.asp
bc30
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