2. Latest Guidelines for Asthma Management Global Initiative for Asthma By: Dr. Mahmoud Taheri

3. Strategies for Asthma Management and Prevention Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems

4. 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 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

5. Asthma Inflammation: Cells and Mediators

6. Factors that Exacerbate Asthma Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

7. Factors that Influence Asthma Development and Expression Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity Host Factors  Genetic - Atopy - Airway hyperresponsiveness  Gender  Obesity Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

8. 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

9. 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 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

10. Typical Spirometric (FEV 1 ) Tracings 1 Time (sec) 2345 FEV 1 Volume Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) Note: Each FEV 1 curve represents the highest of three repeat measurements

11. Measuring Variability of Peak Expiratory Flow

12. Measuring Airway Responsiveness

13. 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 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

14. Asthma Management and Prevention Program: Five Interrelated Components 1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma 4. Manage Asthma Exacerbations 5. Special Considerations 1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma 4. Manage Asthma Exacerbations 5. Special Considerations

15. Asthma Management and 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. 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..

16. Asthma Management and Prevention Program Part 1: Educate Patients to Develop a 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  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

17. Asthma Management and Prevention Program Component 1: Develop Patient/Doctor Partnership 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 patient’s family 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 patient’s family

18. Asthma Management and Prevention Program Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review Key factors to facilitate communication: Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review

19. Asthma Management and Prevention Program Factors Involved in Non-Adherence Medication Usage Difficulties associated with inhalers Complicated regimens Fears about, or actual side effects Cost Distance to pharmacies Medication Usage Difficulties associated with inhalers Complicated regimens Fears about, or actual side effects Cost Distance to pharmacies Non-Medication Factors Misunderstanding/lack of information Inappropriate expectations Underestimation of severity Attitudes toward ill health Cultural factors Poor communication Non-Medication Factors Misunderstanding/lack of information Inappropriate expectations Underestimation of severity Attitudes toward ill health Cultural factors Poor communication

20. Asthma Management and Prevention Program Component 2: Identify and Reduce Exposure to Risk Factors Asthma Management and Prevention Program Component 2: Identify and Reduce Exposure to Risk Factors  Measures to help reducing exposure to risk factors should be implemented wherever possible.  Asthma exacerbations are caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.  Reducing exposure to some risk factors improves the control of asthma and reduces medications needs.

21. Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma development Asthma Management and Prevention Program Component 2: Identify and Reduce Exposure to Risk Factors Asthma Management and Prevention Program Component 2: Identify and Reduce Exposure to Risk Factors

22. Asthma Management and Prevention Program Influenza Vaccination Asthma Management and Prevention Program Influenza Vaccination  Routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control

23. Asthma Management and Prevention Program 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

24. Global Strategy for Asthma Management and Prevention Clinical Control of Asthma The focus on asthma control is important because:  the attainment of control correlates with a better quality of life, and  reduction in health care use

25.  Determine the initial level of control to implement treatment (assess patient impairment)  Maintain control once treatment has been implemented (assess patient risk) Global Strategy for Asthma Management and Prevention Clinical Control of Asthma

26. Levels of Asthma Control (Assess patient impairment) Characteristic Controlled (All of the following) Partly controlled (Any present in any week) Uncontrolled Daytime symptoms Twice or less per week More than twice per week 3 or more features of partly controlled asthma present in any week Limitations of activities NoneAny Nocturnal symptoms / awakening NoneAny Need for rescue / “reliever” treatment Twice or less per week More than twice per week Lung function (PEF or FEV 1 ) Normal < 80% predicted or personal best (if known) on any day Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)

29. Assess Patient Risk 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 FEV 1, exposure to cigarette smoke, high dose medications

30. *IMPORTANT* Any exacerbation should prompt review of maintenance treatment

31. Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma  Depending on level of asthma control, the patient is assigned to one of five treatment steps  Step 2 is the initial treatment for most patients. If the patient is severely uncontrolled, we start from step 3.  Our approach includes: - Assessing Asthma Control - Treating to Achieve Control - Monitoring to Maintain Control

32. Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β 2 -agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE

34. Salbutamol (Albuterol) Availability: Aerosol 90 mcg/inh. Brand Names: Ventolin Onset: 5-15 min Peak: 1 Hour Duration: 3-6 hrs.

35. Salmeterol Availability: Aerosol 25 mcg/inh. Brand Names: Serevent Onset: 10-25 min Peak: 3-4 hrs. Duration: 12 hrs.

36. Beclomethasone Availability: Aerosol 40 mcg/inh. Aerosol 80 mcg/inh. Brand Names: Becotide, Beclazone, Qvar Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Unknown

37. Fluticasone Availability: Aerosol 44 mcg/inh. Aerosol 110 mcg/inh. Aerosol 220 mcg/inh. Brand Names: Flovent Onset: Within 24 hrs. Peak: 1-4 Weeks Duration: Days after DC.

38. Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) Drug Low Daily Dose (  g) Medium Daily Dose (  g) High Daily Dose (  g) Beclomethasone200-500 >500-1000 >1000 Budesonide200-600 600-1000>1000 Ciclesonide 80 – 160 >160-320>320-1280 Flunisolide500-1000>1000-2000 >2000 Fluticasone100-250 >250-500 >500 Mometasone furoate200-400 > 400-800>800-1200 Triamcinolone acetonide400-1000>1000-2000>2000

39. Reliever Medications  Rapid-acting inhaled β 2 -agonists  Systemic glucocorticosteroids  Anticholinergics  Theophylline  Short-acting oral β 2 -agonists

40. Component 4: Asthma Management and Prevention Program 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 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

41. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCEINCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCE INCREASE

42. Shaded green - preferred controller options TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER

43. Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE:

44. Step 1 – As-needed reliever medication  Patients with occasional daytime symptoms of short duration  A rapid-acting inhaled β 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) Treating to Achieve Asthma Control

45. Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE:

46. 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 use inhaled glucocorticosteroids. Treating to Achieve Asthma Control

47. Shaded green - preferred controller options TO STEP 4 TREATMENT, ADD EITHER TO STEP 3 TREATMENT, SELECT ONE OR MORE:

48. Step 3 – Reliever medication plus one or two controllers  For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long- acting β 2 -agonist either in a combination inhaler device or as separate components (Evidence A)  Inhaled long-acting β 2 -agonist must not be used as monotherapy Treating to Achieve Asthma Control

49. 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) Treating to Achieve Asthma Control

50. TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER Shaded green - preferred controller options

51. 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 Treating to Achieve Asthma Control

52. Step 4 – Reliever medication plus two or more controllers  Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β 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 β 2 -agonist (Evidence B) Treating to Achieve Asthma Control

53. TO STEP 3 TREATMENT, SELECT ONE OR MORE: TO STEP 4 TREATMENT, ADD EITHER Shaded green - preferred controller options

54. Treating to Achieve Asthma 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)

55. 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

56. Treating to Maintain Asthma 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)

57. Treating to Maintain Asthma Control Stepping down treatment when asthma is controlled  When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β 2 -agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β 2 -agonist (Evidence B)  If control is maintained, reduce to low- dose inhaled glucocorticosteroids and stop long-acting β 2 -agonist (Evidence D)

58. Treating to Maintain Asthma Control Stepping up treatment in response to loss of control  Rapid-onset, short-acting or long- acting inhaled β2-agonist bronchodilators provide temporary relief.  Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy

59. Treating to Maintain Asthma Control Stepping up treatment in response to loss of control  Use of a combination rapid and long-acting inhaled β 2 -agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effective 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)

60.  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 (FEV 1 or PEF)  Severe exacerbations are potentially life- threatening and treatment requires close supervision  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 (FEV 1 or PEF)  Severe exacerbations are potentially life- threatening and treatment requires close supervision Asthma Management and Prevention Program Component 4: Manage Asthma Exacerbations

61. Primary therapies for exacerbations: Repetitive administration of rapid-acting inhaled β 2 -agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function Primary therapies for exacerbations: Repetitive administration of rapid-acting inhaled β 2 -agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation Closely monitor response to treatment with serial measures of lung function Asthma Management and Prevention Program Component 4: Manage Asthma Exacerbations

62. Asthma Management and Prevention Program Asthma Management and Prevention Program 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 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