G IN A: Lobal Itiative For Sthma

G lobal
INitiative for
A sthma
GINA 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
GINA Assembly
A network of individuals participating in

the dissemination and implementation of
asthma management programs at the
local, national and regional level
GINA Assembly members are invited to
meet with the GINA Executive Committee
during the ATS and ERS meetings
Saudi Arabia Bangladesh
Slovenia Germany Ireland
Australia Yugoslavia Croatia
Brazil Canada
Austria Taiwan ROC
United States
Thailand Portugal
Greece Malta
Moldova Mexico China
Syria
South Africa
United Kingdom Hong Kong
Italy New Chile
Venezuela
Zealand
Argentina Lebanon Pakistan Israel
Japan
Poland Korea GINA Assembly Netherland
Switzerland s
Russia Macedonia France Georgia
Czech
Turkey Republic Slovakia Denmark
Belgium
Romania Colombia Ukraine Singapore Spain
India
Sweden Albania Kyrgyzstan Vietnam
GINA Documents
Global Strategy for Asthma Management

and Prevention (revised 2006)
Pocket Guide: Asthma Management and
Prevention (revised 2006)
Pocket Guide: Asthma Management and

Prevention in Children (revised 2006)
Guide for asthma patients and families
All materials are available on GINA web site www.ginasthma.org
Global Strategy for Asthma
Management and Prevention
Evidence-based
Implementation oriented
Diagnosis
Management
Prevention
Outcomes can be evaluated
Management and Prevention
Evidence Category Sources of Evidence
A Randomized clinical trials

Rich body of data
B Randomized clinical trials

Limited body of data
C Non-randomized trials
Observational studies
D Panel judgment consensus

Management and Prevention (2006)
Definition and Overview

Diagnosis and
Classification
Asthma Medications
Asthma Management and

Prevention Program
Revised 2006 Implementation of Asthma
Guidelines in Health
Systems
Definition of Asthma
A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role
Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing
Widespread, variable, and often reversible
airflow limitation
Asthma Inflammation: Cells and
Mediators
Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation
Source: Peter J. Barnes,

Asthma Inflammation: Cells and
Mediators
Source: Peter J. Barnes,

MD
Burden of Asthma
Asthma is one of the most common chronic

diseases worldwide with an estimated 300
million affected individuals
Prevalence increasing in many countries,
especially in children
A major cause of school/work absence
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004

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
Factors that Exacerbate Asthma
Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Factors that Influence Asthma
Development and Expression
Host Factors Environmental Factors

Genetic Indoor allergens
Outdoor allergens
- Atopy
Occupational sensitizers
- Airway
Tobacco smoke
hyperresponsiveness
Air Pollution
Gender
Respiratory Infections
Obesity Diet
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
Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify
risk factors
Extra measures may be required to
diagnose asthma in children 5 years and
younger and the elderly
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
Measuring Variability of
Peak Expiratory Flow
Measuring Airway
Responsiveness
Intermittent
Symptoms less than once a week
Brief exacerbations
Nocturnal symptoms not more than twice a month
FEV1 or PEF 80% predicted
PEF or FEV1 variability < 20%
Mild Persistent
Symptoms more than once a week but less than once a day
Exacerbations may affect activity and sleep
Nocturnal symptoms more than twice a month
PEF or FEV1 variability < 20 30%
Moderate Persistent
Symptoms daily
Exacerbations may affect activity and sleep
Nocturnal symptoms more than once a week
Daily use of inhaled short-acting 2-agonist
FEV1 or PEF 60-80% predicted
PEF or FEV1 variability > 30%
Severe Persistent
Symptoms daily
Frequent exacerbations
Frequent nocturnal asthma symptoms
Limitation of physical activities
PEF or FEV1 variability > 30%
Levels of Asthma
Control
Controlled Partly controlled
Characteristic Uncontrolled
(All of the following) (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

Asthma Management and Prevention
Program: Five Components
1. Develop Patient/Doctor
Partnership
2. Identify and Reduce
Exposure to Risk Factors
3. Assess, Treat and Monitor
Asthma
4. Manage Asthma
Exacerbations
Revised
2006
5. Special Considerations
Asthma Management and Prevention Program
Goals of Long-term
Management
Achieve and maintain control of
symptoms
Maintain normal activity levels,
including exercise
Maintain pulmonary function as close
to normal levels as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma

medications
Prevent asthma mortality
Prevention Program
.
Asthma can be effectively controlled in
most patients by intervening to suppress
and reverse inflammation as well as
treating bronchoconstriction and related
symptoms
Early intervention to stop exposure to the
risk factors that sensitized the airway may
help improve the control of asthma and
reduce medication needs.
Prevention Program
Although there is no cure for

asthma, appropriate management
that includes a partnership
between the physician and the
patient/family most often results
in the achievement of control
Component 1: Develop
Patient/Doctor 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
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 patients
family
Key factors to facilitate communication:

Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment:
1. Each day take ___________________________
2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control
In the past week have you had:
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Waking at night because of asthma? No Yes
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 uncontrolled and
you may need to step up your treatment.
HOW TO INCREASE TREATMENT

STEP-UP your treatment as follows and assess improvement every day:
____________________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.

Call your doctor/clinic: _______________ [provide phone numbers]
If you dont respond in _________ days [specify number]
______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences,
If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not improving.
1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
3. Seek medical help: Go to _____________________; Address___________________
Phone: _______________________
4. Continue to use your _________[reliever medication] until you are able to get medical
help.
Factors Involved in Non-Adherence
Medication Usage Non-Medication Factors

Difficulties associated Misunderstanding/lack of
with inhalers information
Complicated regimens Fears about side-effects
Fears about, or actual Inappropriate expectations
side effects
Cost
Underestimation of severity
Distance to pharmacies
Attitudes toward ill health
Cultural factors
Poor communication
Component 2: Identify and Reduce
Measures to prevent the development of asthma,

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
Asthma exacerbations may be caused by a variety
of risk factors allergens, viral infections,
pollutants and drugs.
Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
Component 2: Identify and Reduce
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
Influenza Vaccination
Influenza vaccination should be

provided to patients with asthma when
vaccination of the general population is
advised
However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control
Component 3: Assess,
Treat and Monitor Asthma
The goal of asthma treatment, to
achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional
Depending on level of asthma control,
the patient is assigned to one of five
treatment steps
Treatment is adjusted in a continuous
cycle driven by changes in asthma
control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
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
The choice of treatment should be guided by:
Level of asthma control
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
The choice of treatment should be guided by:
Level of asthma control
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
Component 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled 2-agonists
Systemic glucocorticosteroids
Theophylline
Cromones
Long-acting oral 2-agonists
Anti-IgE
Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
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
Reliever Medications
Rapid-acting inhaled 2-agonists

Anticholinergics
Theophylline
Short-acting oral 2-agonists
Allergen-specific
Immunotherapy
Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is
limited
Specific immunotherapy should be considered
only after strict environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
Perform only by trained physician
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
Treating to Achieve Asthma
Control
Step 1 As-needed reliever medication
Patients with occasional daytime symptoms of
short duration
A rapid-acting inhaled 2-agonist is the
recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
Control
Step 2 Reliever medication plus a single
controller
A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence
A)
Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
Control
Step 3 Reliever medication plus one or two
controllers
For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting 2-agonist either in a combination inhaler
device or as separate components (Evidence A)
Inhaled long-acting 2-agonist must not be used
as monotherapy
For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
Control
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
Low-dose sustained-release theophylline
(Evidence B)
Control
Step 4 Reliever medication plus two or more
controllers
Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
Control
Step 4 Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid
combined with a long-acting inhaled 2-agonist
(Evidence A)
Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled 2-agonist (Evidence B)
Control
Step 5 Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other

controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
Treating to Maintain Asthma
Control
When control as been achieved,

ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored
by the health care professional and
by the patient
Control
Stepping down treatment when asthma is controlled
When controlled on medium- to high-

dose inhaled glucocorticosteroids: 50%
dose reduction at 3 month intervals
(Evidence B)
When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
Control
Stepping down treatment when asthma is controlled
When controlled on combination inhaled
glucocorticosteroids and long-acting
inhaled 2-agonist, reduce dose of inhaled
glucocorticosteroid by 50% while
continuing the long-acting 2-agonist
(Evidence B)
If control is maintained, reduce to low-
dose inhaled glucocorticosteroids and
stop long-acting 2-agonist (Evidence D)
Control
Stepping up treatment in response to loss of control
Rapid-onset, short-acting or long-
acting inhaled 2-agonist
bronchodilators provide temporary
relief.
Need for repeated dosing over more
than one/two days signals need for
possible increase in controller therapy
Control
Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting
inhaled 2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting in maintaining a high level
of asthma control and reduces exacerbations
(Evidence A)
Doubling the dose of inhaled glucocortico-
steroids is not effective, and is not
recommended (Evidence A)
Component 3: Assess, Treat and
Monitor Asthma Children 5 Years
and Younger
Childhood and adult asthma share the

same underlying mechanisms.
However, because of processes of
growth and development, effects of
asthma treatments in children differ
from those in adults.
and Younger
Many asthma medications (e.g.

glucocorticosteroids, 2- agonists,
theophylline) are metabolized faster in
children than in adults, and younger
children tend to metabolize medications
faster than older children
and Younger
Long-term treatment with inhaled
glucocorticosteroids has not been shown
to be associated with any increase in
osteoporosis or bone fracture
Studies including a total of over 3,500
children treated for periods of 1 13 years
have found no sustained adverse effect of
inhaled glucocorticosteroids on growth
and Younger
Rapid-acting inhaled 2-agonists are the
most effective reliever therapy for
children
These medications are the most
effective bronchodilators available and
are the treatment of choice for acute
asthma symptoms
Component 4: Manage Asthma
Exacerbations
Exacerbations of asthma are episodes of

progressive increase in shortness of breath,
cough, wheezing, or chest tightness
Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
Component 4: Manage Asthma
Exacerbations
Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled
2-agonist
Early introduction of systemic
glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function
Special Considerations
Special considerations are required to
manage asthma in relation to:
Pregnancy
Surgery
Rhinitis, sinusitis, and nasal polyps
Occupational asthma
Respiratory infections
Gastroesophageal reflux
Aspirin-induced asthma
Anaphylaxis and Asthma
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G lobal

A network of individuals participating in

Global Strategy for Asthma Management

Pocket Guide: Asthma Management and

A Randomized clinical trials

B Randomized clinical trials

D Panel judgment consensus

Definition and Overview

Asthma Management and

A chronic inflammatory disorder of the airways

Source: Peter J. Barnes, MD

Source: Peter J. Barnes,

Source: Peter J. Barnes,

Asthma is one of the most common chronic

Source: Masoli M et al. Allergy 2004

Host factors: predispose individuals to,

Host Factors Environmental Factors

Recurrent episodes of wheezing

Asthmatic (After Bronchodilator)

None (2 or less / More than

Lung function < 80% predicted or

Exacerbation None One or more / year 1 in any week

Avoid adverse effects from asthma

Although there is no cure for

Guidelines on asthma management

Key factors to facilitate communication:

WHEN TO INCREASE TREATMENT

HOW TO INCREASE TREATMENT

WHEN TO CALL THE DOCTOR/CLINIC.

EMERGENCY/SEVERE LOSS OF CONTROL

Medication Usage Non-Medication Factors

Measures to prevent the development of asthma,

Reduce exposure to indoor allergens

Influenza vaccination should be

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

Budesonide-Neb 250- >500- >1000

Rapid-acting inhaled 2-agonists

maintain and find lowest

exacerbation treat as exacerbation

Addition of oral glucocorticosteroids to other

When control as been achieved,

When controlled on medium- to high-

Childhood and adult asthma share the

Many asthma medications (e.g.

Exacerbations of asthma are episodes of

Primary therapies for exacerbations:

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