Name: Azureen Shahiza binti Isa

ID: 17120067
Module: Pulmonary
Perdana University Graduate School of Medicine

Global Inititive for Asthma (GINA): What’s new in GINA 2018

1.0 Definition, description and diagnosis of asthma

Definition : asthma is a heterogenous 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. This definition was reached by
consensus, based on consideration of the characteristics that are typical of asthma and
that distinguish it from other respiratory conditions

Description: Asthma is a common, chronic respiratory disease affecting 1–18% of the

population in different countries. Asthma is characterized by variable symptoms of
wheeze, shortness of breath, chest tightness and/or cough, and by variable expiratory
airflow limitation. Both symptoms and airflow limitation characteristically vary over time
and in intensity. These variations are often triggered by factors such as exercise, allergen
or irritant exposure, change in weather, or viral respiratory infections.

Symptoms and airflow limitation may resolve spontaneously or in response to medication,

and may sometimes be absent for weeks or months at a time. On the other hand, patients
can experience episodic flare-ups (exacerbations) of asthma that may be life-threatening
and carry a significant burden to patients and the community. Asthma is usually associated
with airway hyperresponsiveness to direct or indirect stimuli, and with chronic airway
inflammation. These features usually persist, even when symptoms are absent or lung
function is normal, but may normalize with treatment.

The Global Initiative of Asthma (GINA) 15

 Patterns of respiratory symptoms that are characteristic of asthma

The following features are typical of asthma and, if present, increase the probability that the
patient has asthma:

 More than one symptom (wheeze, shortness of breath, cough, chest tightness), especially
in adults
 Symptoms often worse at night or in the early morning
 Symptoms vary over time and in intensity
 Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes
in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smells.

The following features decrease the probability that respiratory symptoms are due to asthma:

 Isolated cough with no other respiratory symptoms

 Chronic production of sputum
 Shortness of breath associated with dizziness, light-headedness or peripheral tingling
(paresthesia)
 Chest pain
 Exercise-induced dyspnea with noisy inspiration.

The Global Initiative of Asthma (GINA) 15

 Box 1-1. Diagnostic flowchart for clinical practice – initial presentation

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2.0 Assessment of Asthma

Risk Factors
 Risk factors for exacerbations (flare ups)
Having uncontrolled asthma symptoms is an important risk factor for exacerbations. GINA
Box 2-2B list other factors that, if present, increase the risk of exacerbations even if the
patient has few symptoms. These ‘independent’ risk factors are identified from analyses
that have adjusted the risk of exacerbations for symptom control.

 Additional risk factors for exacerbation in GINA 2018

In box 2-2B, higher bronchodilator reversibility has been added as an additional
independent risk factor for exacerbations in both adults and children.

 Additional risk factor for developing persistent airflow limitation

Pre-term birth, low-birth weigh and greater infant weight gain have been added to the list
of risk factors.
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Table 1
Assessments of risk factors for poor asthma outcomes

Risk factors for exacerbations include:

 Uncontrolled asthma symptoms

Additional risk factors, even if the patient has few symptoms:

High SABA use > 3 canisters/year)

 Low FEV1; higher bronchodilator reversibility

 Incorrect inhaler technique and/or poor adherence
 Smoking
 Obesity, chronic rhinosinusitis, pregnancy, bood eosinophilia
 Elevated FeNO in adults with allergic asthma taking ICS
 Ever intubated for asthma

Risk factors for fixed airflow limitation include:

 No ICS treatment, smking, occupational exposure, mucus hypersecretion, blood

eosinophilia; pre-term birth, low birth weight

Risk factors for medication side effects include:

 Frequent oral steroids, high dose / potent ICS, P450 inhibitors

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3.0 Treatment steps – changes in GINA 2018

Step 1:

It is explained that the reason ICS should be considered for patients with mild asthma
(rather pescribing SABA alone) Is to reduce the risk of serious exacerbations (Pauwels,
Lancet 2003; O’Byme AJRCCM 2001; Reddel Lancet 2017)

Step 3-4:
From the large FDA LABA safely studies: adding LABA to ICS in a combination inhaler
reduces the risk of exacerbations and improves symptoms and lung function, compared
with the same dose of ICS alone but with only a small reduction I reliever use (Stempel
NEJM 2016, Peters NEJM 2016)

Step 5 and Box 3-14: Management of severe asthma

Subcutaneous benralizumab(monoclonal anti-IL5 receptor α antibody) is another add-on
treatment for patients aged ≥12years with severe eosinophilic asthma.

4.0 Stepwise Management - Pharmacotheraphy

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5.0 Perimenstrual asthma, and asthma in pregnancy

 Perimenstrual (catamenial) asthma – new section added

Asthma worse presmenstrually in ~20% women. It is more common in older women,
higher BMI, longer duration and more severe asthma;often have dysmenorrhea. Shorter
cycles. Longer bleeding; aspirin-exacerbated respiratory disease is more common.
Add on treatment: oral contraceptives and/or LRTA may be helpful

 The recommendation against stopping ICS during pregnancy has been reinforced
ICS reduce the risk of exacerbations in pregnancy (Evidence A)
Stopping ICS increases the risk of exacerbations in pregnancy (Evidence A) (Murphy
Thorax 2006)

Exhaled nitric oxide (FeNO)

 FeNO is becoming more widely in some countries

 All sections on FeNO have been reviewed and updated
 Decisions about initial asthma treatment

GINA recommends at least two dose ICS in almost all patients with asthma, to reduce risk
of asthma exacerbations and death

SABA – the only treatment considered only if symptoms is less than twice/month. No night
walking, and no risk factors for exacerbations
In non-smoking patients, FeNO >50 ppb is associated with a good short-term response to
ICS in symptoms and lung function.
There are no studies examining the long term safety (i.e for risk of exacerbations) of with
holding ICS is initial FeNO is low

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In patients with a diagnosis or suspected diagnosis of asthma, FeNO can support the
decision to start ICS, but cannot safelt be recommended for deciding against treatment
with ICS.

 FeNO- guided treatment

I. Updated to reflect new-meta analyses that separately analyzed studies in which the
control algorithm was reasonably close to current clinical recommendations, and therefore
provided a clinically relevant comparator
II. Children/adolescents: FeNO- guided treatment was associated wit significantly fewer
exacerbations and lower exacerbations rate than treartment based on current guidelines
III. Adults: no significant difference in exacerbations with FeNO-guided reeatment compared
with treatment based on current guidelines
IV. FeNO-guided treatment is not recommended for the general asthma population at present
V. Further studies are needed to identify the populaitons most likely to benefit, an the optimal
frequency of monitoring

Follow-up after an asthma exacerbation

 Follow up all patients regularly after an exacerbation, until symptoms and lung function
return to normal
Patients are at increased risk during recovery from an exacerbation

 The opportunity
exacerbations often represent failures in chronic asthma cae, and they provide
opportunities to review the patient’s asthma management

 At follow-up visit, check:

I. The patient’s understanding of the cause of the flare-up
II. Modifiable risk factors,e.g. smoking
III. Adherence with medications, and understanding of their purposes
IV. SABA is being taken only-as needed, not regularly
V. Inhaler technique skills
VI. Written asthma action plan

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6.0 Asthma-COPD overlap

 Asthma-COPD overlap does not mean as single disease entity

It includes patients with several different forms of airways disease(phenotypes) caused by
a range of different underlying mechanisms

 Persistent airflow limitation may be found in:

I. Some children with asthma
II. Many Adults with a history of asthma

 Patients with low function in early adulthood with normal decline over time
I. patients with normal lung function in early adulthood but rapid decline over time

7.0 Treatment of patients with Asthma-COPD overlap

 Few studies where overlap patients are excluded from most Rndomized control
trial’s

The interim safely recommendation for ICS to be included in treatment for patients with
COPD and a history of asthma is supported by a well-designed case-control study

 Primary prevention of asthma

I. A systematic review of RCT’s on maternal dietary intake of fish or long chain

polyunsaturated fatty acids during pregnancy showed no consistent effects on the
risk f wheeze, asthma or atophy in the child
II. One recent study demonstrated decrased wheeze/asthma in preschool children at
high risk for asthma when mothers were given a high dose fish oil supplement in the
third trimester, but fish -oil is not wel defined, anf the optimal dosing regime has not
been established

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8.0 New GINA resources

 A practical pocket guide for assessment and management of patients with difficult to treat
and severe asthma is being developed

Planned for publication in Q2 or Q3 2018

 Resources for the asthma toolbox are being pilot-tested and will be added to the GINA
website

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