Asthma Management

based on GINA 2015

Prof. Dr. Tamsil Syafiuddin, SpP(K)

Department of Pulmonology and Respiratory Medicine,

Faculty of Medicine,
Universitas Islam Sumatera Utara / Universitas Sumatera Utara,
Medan-2016
Standar Kompetensi Dokter Indonesia

Konsil Kedokteran Indonesia

Indonesian Medical Council
Jakarta 2012
 Daftar Penyakit
Sistem Respirasi
(Tingkat Kompetensi)

Lampiran 3 SKDI 2012

 TINGKAT KEMAPUAN/KOMPETENSI DU:
Kemampuan 1 : Mengenali dan Menjelaskan
Kemampuan 2: Mendiagnosis dan Merujuk
Kemampuan 3: Mendiagnosis, Penatalaksanaan
awal dan Merujuk
3A: Bukan gawat darurat
3B: Gawat darurat
Kemampuan 4: Mendiagnosis,Tatalaksana
mandiri dan Tuntas
4A: Kompetensi saat lulus dokter
4B: Kompetensi internsip dan PKB

Lampiran 3 SKDI 2012

 DAFTAR KOMPETENSI SISTEM RESPIRASI

1.Asma 4A
2.Bronkitis akut 4A
3.Pneumonia,Bronkopneumonia 4A
4.Tuberkulosis tanpa komplikasi 4A
5.Influenza 4A
6.Pertusis 4A

Lampiran 3 SKDI 2012

 DAFTAR KOMPETENSI SISTEM RESPIRASI
7.ARDS 3B
8.SARS 3B
9.Flu burung 3B
10.Asma akut berat 3B
11.Bronkiolitis akut 3B
12.Efusi pleura masif 3B
13.Pneumonia aspirasi 3B
14.PPOK Eksaserbasi akut 3B
15.Edema paru 3B
16.Haematotoraks 3B
Lampiran 3 SKDI 2012
 G lobal
IN itiative for
A sthma
Global Initiative for Asthma 2015
 Definition of asthma
Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
It is defined by the history of respiratory
symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time
and in intensity, together with variable
expiratory airflow limitation.
Heterogenous disease, phenotypes
NEW!

GINA 2015
 Inflammation
() (+) Asthma
Normal

Bronchial hyperreactivity ( - ) Bronchial hyperreactivity ( + )

Bronchoconstriction ( - ) Bronchoconstriction ( + )

Symptoms (-) Symptoms (+)

The pathogenesis of asthma
 AIRWAY REMODELLING IN
ASTHMA
Eosinophil

Desquamations of epithelium

MBP, ECP
Epithelium

Thickening of basement membrane

Increase in airway smooth muscle

 Inflammation

Controller
Bronchial hyperreactivity

Bronchoconstriction
Reliever
Symptoms
Medicines and Pathogenesis of asthma
 Asthma Therapy Evolution
ICS treatment Adding
introduced LAA to ICS therapy
Large use of 1972 Kips et al, AJRCCM 2000
Pauwels et al, NEJM 1997
short-acting
Greening et al, Lancet 1992
2-agonists
1975 Single
inhaler therapy

1980
Fear of ICS+LABA
short-acting
2-agonists

1985
2000
1990 1995

Bronchospasm Inflammation Remodelling

GINA 2015
 Symptoms
Remodelling
Treatment

Based on Inflammation
 The pharmacological treatment of asthma
categories:

-Controller medications,

-Reliever medications,

-Add-on therapies, these may be considered when

patients have persistent symptoms and/or exacerbations
despite optimized treatment with high dose controller
medications.

Note: Non pharmacological treatment ok

GINA 2015
 Non pharmacological treatment to achieving
these goals requires a partnership between patient and
their health care providers
Ask the patient about their own goals regarding their
asthma
Good communication strategies are essential, Adherence
Incorrect/poor technique inhaler
Smooking
Co-morbid, Rhinitis
Consider the health care system, medication availability,
cultural and personal preferences and health literacy

GINA 2015
 Inflammation
() (+) Asthma
Normal

Bronchial hyperreactivity ( - ) Bronchial hyperreactivity ( + )

Bronchoconstriction ( - ) Bronchoconstriction ( + )

Symptoms (-) Symptoms (+)

The pathogenesis of asthma
 Combination therapy
( ICS + LABA )

1.Symbicort
Budesonide + Formoterol
( Rapid onset of action and Long acting of duration)

2.Seretide
Fluticasone + Salmoterol
( Non rapid onset of action and Long acting of duration)

(BPJS Kesehatan)
 A basis for synergy
ICS and LABA
Effects of ICS on Effects of LABA on
the glucocorticoid
the 2 receptor system
receptor system

Corticosteroids increase LABASs prime

2-receptor synthesis glucocorticoid receptor
for steroid dependent
activation

Overall biological / therapeutic

consequences
Zain-Hamid R Faculty of Medicine,
Universitas Sumatera Utara, Indonesia.
 Formoterol: intermediate lipophilicity explains its rapid
and long duration of action
Aqueous biophase

Cell membrane
with b2-receptor

Salbutamol Formoterol Salmeterol

Hydrophilic Intermediate Lipophilic
Short duration Long duration Long duration
Fast onset Fast onset Slow onset

Anderson et al 1993
 SABA and Rapid onset of LABA in
treating acute severe asthma/exacerbation
Symbicort
FEV1 (% change from baseline) (Rapid onset of LABA)

Salbutamol
45
(SABA)
40
35
30
25
20
15
10
5
0
0 30 60 90 120 150 180
Time since last administration of study drug (minutes)
Balanag et al, Pulmonary Pharmacology&Therapeutics 2005
The Beginning of
Treatment
 Exacerbation x

The beginning of treatment ?

Stable condition

 Increasing combination therapy earlier
to prevent exacerbations
FACET exacerbation profiles
% change from
day 14
100
Reliever 2-agonist
Morning PEF
80 Window of
Night-time symptoms
opportunity to
60 prevent
exacerbations?
40

20

15 10 5 0 5 10 15
Days before and after an exacerbation
Tattersfield AE, et al. Am J Respir Crit Care Med 1999;160:594599.
 Guidelines on Asthma Management:
Past and Current Trends

Mild Moderate Severe Old classification

Intermittent persistent persistent persistent

Exacerbation
Total control Partially control Uncontrol New classification

Inhalation SABA or Rapid onset of action LABA

GINA 1998 ICS LABA and ICS

(adapted)

GINA 2008-2015 ICS+LABA Stable condition

 Inflammation can also be present
during symptom-free periods
Rate of response of different measures of asthma
control over 18 months of ICS treatment
% Reduction

AHR is a marker of inflammation

AHR

Night Rescue medication use

symptoms Impaired am PEF
Impaired FEV1

Start of 2 4 6 18
treatment Months

Adapted from Woolcock A. Clin Exp Allergy Rev 2001; 1: 6264.

 Treatment targets in common chronic diseases
Clear therapeutic targets exist for many
chronic diseases
Philosophy of treat to target
Hypertension BP 140/90 mmHg or less
Diabetes HbA1c 7% or less
Dyslipidaemia LDL-cholesterol <100 mg/dl

Asthma treatment is designed to meet specific

targets and achieve:
ASTHMA CONTROL
 Goals of asthma management
The long-term goals of asthma management are
1. Symptom control: to achieve good control of
symptoms and maintain normal activity levels
QoL
2. Risk reduction: to minimize future risk of exa
cerbations, fixed airflow limitation and medica
tion side-effects,

GINA 2015
GINA 2015
 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
Daytime asthma symptoms more
than twice a week? Yes No
Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
Reliever needed for symptoms* these these these
more than twice a week? Yes No
Any activity limitation due to asthma? Yes No

*Excludes reliever taken before exercise, because many people take this routinely

This classification is the same as the GINA 2010-12 assessment

of current control, except that lung function now appears only
in the assessment of risk factors

GINA 2015, Box 2-2A Global Initiative for Asthma

 Dr.Mesty Ariotejo Amanda Putri Witdarmono
(Children in Harmony) (We The Teacher)

RSIA IBNU SINA Jakarta Koningin Emma Kliniek

(Kasir Loss Hospital) (Tinggal Kenangan,
Sitou Timou Tumou Tou dipupus oleh keserakahan)
(Sam Ratulangi 1890-1949)
Reference :
Global Initiative for Asthma (GINA)
Global Strategy for Asthma Management and
Prevention (updated 2015)