Treating asthma to control

symptoms and minimize risk

GINA Global Strategy for Asthma

Management and Prevention 2014

Global Initiative for Asthma

 APA YANG DIKETAHUI
TENTANG ASMA

Asma adalah salah satu penyakit kronis yang

tersering,ada 300 juta orang penderita di
seluruh dunia,prevalensinya cenderung
meningkat terutama anak anak
Asma secara efektif dapat diobati dan
sebagian besar dapat mencapai TOTAL
CONTROL.
 Clinical Control of Asthma

No (or minimal)* daytime symptoms

No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue
medication
Normal lung function
No exacerbations
_________
 Levels of Asthma Control
Controlled Partly controlled
Characteristic (Any present in any week)
Uncontrolled
(All of the following)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than any week
reliever treatment week) twice / week

Lung function < 80% predicted or

(PEF or FEV1) Normal personal best (if
known) on any day

Exacerbation None One or more / year 1 in any week

Pasien yang mencapai kontrol
Hanya 5% pasien Partly dan Uncontrolled
Controlled
yang mencapai
kontrol asma

Rabe et al. Eur Respir J, 2000

 Hanya 5 % pasien yang mencapai kontrol
asma. Hal ini dikarenakan:
Ekspektasi yang rendah tentang kontrol
asma baik dari dokter maupun pasien.
Komunikasi dokter / pasien yang kurang
tentang tingkatan asma kontrol
GOAL
GOAL Study:
Study: Dengan Seretide 70% pasien asma
yang
yang tidak terkontrol dapat mencapai dan
mempertahankan
mempertahankan kontrol
kontrol asma

Tidak Terkontrol Membaik

100%

Terkontrol Baik
% pasien

Terkontrol Penuh
100 100
% %
71%
41%

pre-study post-
study
Bateman et al, Amer J Respir Crit Care Med 2004; 170: 836-844
 4 Komponen Penatalaksanaan Asma

1. Membangun Hubungan pasien

-dokter
2. Mengidentifikasi dan mengurangi
paparan terhadap faktor resiko
3. Menilai,penyesuaian pengobatan
dan mereview respon pengobatan,
(Assess Adjust Treatment and
Review Response)
4. Pengelolaan Eksaserbasi Asma
ASSESS
NILAI STATUS KONTROL ASMA
PERLU ALAT SEDERHANA UNTUK MENILAI
KONTROL ASMA

ASTHMA CONTROL TEST

(ACT)
 ACTTM (Asthma Control Test):
Direkomendasikan oleh GINA & DAI (Dewan
Asma Indonesia)
Tervalidasi dengan pemeriksaan paru lainnya;
spirometri, peak flow meter.
Mudah (5 pertanyaan) & tanpa biaya
(www.asthmacontroltest.com).

www.asthmacontroltest.com, GINA 20
Asthma Control TestTM
CONTROLLED
PARTLY CONTROLLED
UNCONTROLLED
 Levels of Asthma Control

Characteristic
25
Controlled
(All of the following) 20-24
Partly controlled
(Any present in any week) <20
Uncontrolled

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than any week
reliever treatment week) twice / week

Lung function < 80% predicted or

(PEF or FEV1) Normal personal best (if
known) on any day

Exacerbation None One or more / year 1 in any week

 The control-based asthma management cycle

NEW!

GINA 2014, Box 3-2 Global Initiative for Asthma

 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
 Component
Component 4:
4: Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program

Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers

Long-acting inhaled -agonists

2
Systemic glucocorticosteroids

Theophylline

Cromones

Long-acting oral -agonists

2
Anti-IgE
 Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age

Drug
Drug Low
Low Daily
Daily Dose
Dose (g)
(g) Medium
Medium Daily
Daily Dose
Dose (g)
(g) High
High Daily
Daily Dose
Dose (g)
(g)
>> 55 yy Age
Age << 55 yy >> 55 yy Age
Age << 55 yy >> 55 yy Age
Age << 55 yy
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100- 600-1000 >200-400 >1000 >400

200

Budesonide-Neb 250- >500- >1000

Inhalation Suspension 500 1000
Ciclesonide 80 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500- >1000-2000 >750-1250 >2000 >1250
750
Fluticasone 100-250 100- >250-500 >200-500 >500 >500
200
Mometasone furoate 200-400 100- > 400-800 >200-400 >800-1200 >400
200
Triamcinolone acetonide 400-1000 400- >1000-2000 >800-1200 >2000 >1200
800
 Component
Component 4:
4: Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program

Reliever Medications

Rapid-acting inhaled 2-agonists

Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists
 Stepwise approach to control asthma symptoms
and reduce risk

NEW!

GINA 2014, Box 3-5 Global Initiative for Asthma

 Stepwise management - pharmacotherapy

*For children 6-11 years,

theophylline is not
recommended, and
preferred Step 3 is medium
dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance
and reliever therapy

GINA 2014, Box 3-5 (upper part) Global Initiative for Asthma
 Step 1 as-needed inhaled short-acting
beta2-agonist (SABA)

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 1 Global Initiative for Asthma

 Step 2 low-dose controller + as-needed
inhaled SABA

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 2 Global Initiative for Asthma

 Step 3 one or two controllers + as-needed
inhaled reliever

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 3 Global Initiative for Asthma

 Step 4 two or more controllers + as-needed
inhaled reliever

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 4 Global Initiative for Asthma

 Step 5 higher level care and/or add-on
treatment

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 5 Global Initiative for Asthma

 3. Review Response

Check
Check Status
Status
Kontrol/
Kontrol/ nilai
nilai ACT
ACT

Membaik / memburuk?

Membaik Memburuk
Pertahankan Naikkan
Naikkan dosis
dosis dan
dan
dosis : cek
cek respon:
respon:
3 bulan
3 bulan

GINA 2008
 REVIEW RESPONSE

Stepping down treatment when asthma is controlled

Bila kontrol asma tercapai pada Inhalasi

kortikosteroid dosis medium sampai
tinggi: pengurangan dosis 50% pada
interval 3 bulan.(Evidence B)
Bila kontrol asma tercapai pada inhalasi
kortikosteroid dosis rendah : ubah ke
dosis sehari (Evidence A)
 REVIEW RESPONSE

Stepping down treatment when asthma is controlled

Bila kontrol asma tercapai pada
kombinasi inhalasi kortikosteroid inhalasi
2-agonist kerja panjang , kurangi dosis
inhalasi KS 50% 2-agonist kerja panjang
tetap diberikan (Evidence B)
Bila kontrol asma tetap terjaga, kurangi
dosis inhalasi KS ke dosis rendah dan
stop 2-agonist kerja panjang(Evidence D)
STUDI KASUS
 KASUS I
Anak 5 tahun
Batuk setiap malam selama >1bulan,kadang
ada suara mengi
Riwayat atopi dalam keluarga
Bacaan X Foto torak proses spesifik
 NILAI STATUS KONTROL ASMA
Characteristic Controlled Partly controlled Uncontrolled
(Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than any week
reliever treatment week) twice / week

Lung function < 80% predicted or

(PEF or FEV1) Normal personal best (if
known) on any day

Exacerbation None One or more / year 1 in any week

 Step 3 one or two controllers + as-needed
inhaled reliever

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 3 Global Initiative for Asthma

1 bulan kemudian
Batuk dan sesak hilang
Asthma Control TestTM

5 25

5
 3. REVIEW RESPONSE

Check
Check Status
Status
Kontrol/
Kontrol/ nilai
nilai ACT
ACT

Membaik / memburuk?

Membaik Memburuk
Pertahankan Naikkan
Naikkan dosis
dosis dan
dan
dosis : cek
cek respon:
respon:
3 bulan
3 bulan

GINA 2008
 KASUS 2
Wanita 35 tahun
Riwayat asma sejak umur 18 tahun
Dalam 1 bulan ini hampir seminggu
sekali menggunakan pelega
Setiap malam selalu terbangun
karena batuk atau sesak
Dalam 1tahun ini 2 kali ke UGD
karena asma
 NILAI STATUS KONTROL ASMA
Characteristic Controlled Partly controlled Uncontrolled
(Any present in any week)

None (2 or less / More than

Daytime symptoms
week) twice / week
Limitations of 3 or more
None Any
activities features of
Nocturnal partly
symptoms / None Any controlled
awakening asthma
present in
Need for rescue / None (2 or less / More than any week
reliever treatment week) twice / week

Lung function < 80% predicted or

(PEF or FEV1) Normal personal best (if
known) on any day

Exacerbation None One or more / year 1 in any week

 Step 2 low-dose controller + as-needed
inhaled SABA

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 2 Global Initiative for Asthma

1 bulan kemudian
Keluhan tetap sama,hampir
seminggu sekali menggunakan
obat semprot pelega
Asthma Control TestTM

2 10

1
 Step 3 one or two controllers + as-needed
inhaled reliever

*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium
dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy

GINA 2014, Box 3-5, Step 3 Global Initiative for Asthma

TERIMA KASIH