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GINA GUIDELINES LONGTERM MANAGEMENT OF ASTHMA.pdf
- 1. Longterm management ofAsthma
- 2. Introduction ● Asthma diagnosisis mainly clinical ● Probability based diagnosis is the recommended method for diagnosis in children less than 5 years. ● For older children we have objective diagnostic tools,Spirometry and PEFR that can be used for diagnosis ofAsthma.
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- 4. Key Messages forpharmacotherapy of Asthma (Dos): ● Inhaled corticosteroids (ICS) are the mainstay to be used daily. ● Short acting Beta2 Agonists (SABAs) are for SOS use as relievers particularly in under fives. ● Dose of ICS depends upon their age and severity of the diseases.
- 5. ● For childrenmore than 6 years we may add a Long Acting Beta2 Agonist(LABA) ● Children more than 12 years need to be treated with adult dosages ● pMDI + Spacer with or without mask is the preferred inhalation device for all children.
- 6. Key Messages forpharmacotherapy of Asthma (Don’ts) ● Montelukast has a limited role: only as add on to ICS. ● There is a serious warning against Montelukast due to risk of neuropsychiatric side effects on long term use. ● Use of nebulizers is to be restricted to only a severe acute exacerbation with desaturation. ● Nebulizers at home should be strictly discouraged.
- 7. ● GINA 2022recommendation for children under 5 yrs, 6-11 years, adolescents and adults:- ● Every step of treatment, should receive an Inhaled Corticosteroid either regularly or whenever a reliever is used . ● Reliever may be SABA or Formoterol + ICS
- 8. ICS Dosages asper GINA 2022 -
- 9. ● Monteleukast (LTRA)- ● 2-5yrs age- 4mg/day, 6-14 yrs age – 5mg/day, >14yrs age 10mg/daily ● Ipratrpium bromide- nebulisation 250micrograms diluted in 2ml of normal saline, given over 10 minutes F/b 250micrograms every 2-4 hours.
- 10. Formoterol dosage For inhalationdosage form (powder): ● For preventing an asthma attack: ● Adults and children 5 years of age and older - 12 micrograms (mcg) (1 capsule) by oral inhalation every 12 hours. ● Usual Pediatric Dose for Asthma - Maintenance ● Formoterol 12 mcg inhalation capsule: (Less than 5 years: Not approved) ● 5 years or older: 12 mcg (1 inhalation) orally every 12 hours using the aerolizer inhaler ● Maximum dose: 24 mcg daily
- 11. ● Inhalation powder:(Less than 6 years: Not approved) ● 6 to 16 years: ● 6 mcg or 12 mcg inhaled orally every 12 hours Maximum dose: 12 mcg twice a day (total of 24 mcg daily) ● 16 years or older: ● 6 mcg or 12 mcg inhaled orally every 12 hours Maximum dose: 24 mcg twice a day (total of 48 mcg daily)
- 12. RELIEVER: As-needed short-actingbeta2- agonist STEP 1 Take ICS whenever SABA taken STEP 2 Low dose maintenance ICS STEP 3 Low dose maintenanc e ICS-LABA STEP 4 Medium/high dose maintenance ICS-LABA STEP 5 Add-on LAMA Refer for assessment of phenotype. Consider high dose maintenance ICS- LABA, ± anti-IgE, anti-IL5/5R, anti- IL4R, anti-TSLP RELIEVER: As-needed low-dose ICS- formoterol STEPS 1 – 2 As-needed low dose ICS- formoterol STEP 3 Low dose maintenance ICS- formoterol STEP 4 Medium dose maintenance ICS- formoterol STEP 5 Add-on LAMA Refer for assessment of phenotype. Consider high dose maintenance ICS- formoterol, ± anti-IgE, anti- IL5/5R, anti-IL4R, anti-TSLP Treatment of modifiable risk factors and comorbidities Non-pharmacological strategies Asthma medications (adjust down/up/between tracks) Education & skills training Adults & adolescents 12+ years Personalized asthma management Assess, Adjust, Review for individual patient needs Symptoms Exacerbatio ns Side- effects Lung function Patient satisfaction Confirmation of diagnosis if necessary Symptom control & modifiable risk factors (see Box 2-2B) Comorbidities Inhaler technique & adherence Patient preferences and goals CONTROLLER and PREFERRED RELIEVER (Track 1). Using ICS- formoterol as reliever reduces the risk of exacerbations compared with using a SABA reliever CONTROLLER and ALTERNATIVE RELIEVER (Track 2). Before considering a regimen with SABA reliever, check if the patient is likely to be adherent with daily controller See GIN severe asthma guide
- 13. Step 1 –symptomsless than twice a month Step 2 – symptoms twice a month or more but less than 4-5 days a week Step 3 - Symptoms most days or waking with asthma once a week or more. Step 4 - daily symptoms or waking with asthma once a week or more and low lung function
- 14. Add-on anti-IL5 or, aslast resort, consider add-on low dose OCS, but consider side-effects PREFERRED CONTROLLER to prevent exacerbations and control symptoms Other controller options (limited indications, or less evidence for efficacy or safety) RELIEVER STEP 1 Low dose ICS taken whenever SABA taken Consider daily low dose ICS Children 6-11 years Personalized asthma management: Assess, Adjust, Review Asthma medication options: Adjust treatment up and down for individual child’s needs STEP 2 Daily low dose inhaled corticosteroid (ICS) Daily leukotriene receptor antagonist (LTRA), or low dose ICS taken whenever SABA taken STEP 3 Low dose ICS- LABA, OR medium dose ICS, OR very low dose* ICS-formoterol maintenance and reliever (MART) STEP 4 Medium dose ICS-LABA, OR low dose† ICS-formoterol maintenance and reliever therapy (MART). Refer for expert advice STEP 5 Refer for phenotypic assessment ± higher dose ICS-LABA or add-on therapy, e.g. anti-IgE, anti-IL4R Add tiotropium or add LTRA Low dose ICS + LTRA As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4) Symptoms Exacerbations Side-effects Lung function Child and parent satisfaction Confirmation of diagnosis if necessary Symptom control & modifiable risk factors (see Box 2-2B) Comorbidities Inhaler technique & adherence Child and parent preferences and goals Treatment of modifiable risk factors & comorbidities Non-pharmacological strategies Asthma medications (adjust down or up) Education & skills training
- 15. PREFERRED CONTROLLER CHOICE Other controller options (limitedindications, or less evidence for efficacy or safety) RELIEVER CONSIDER THIS STEP FOR CHILDREN WITH: STEP 1 Children 5 years and younger Personalized asthma management: Assess, Adjust, Review response Asthma medication options: Adjust treatment up and down for individual child’s needs Infrequent viral wheezing and no or few interval symptoms Asthma diagnosis, and asthma not well-controlled on low dose ICS Asthma not well-controlled on double ICS Before stepping up, check for alternative diagnosis As-needed short-acting beta2-agonist Symptom pattern not consistent with asthma but wheezing episodes requiring SABA occur frequently, e.g. ≥3 per year. Give diagnostic trial for 3 months. Consider specialist referral. Symptom pattern consistent with asthma, and asthma STEP 2 Daily low dose inhaled corticosteroid (ICS) STEP 3 Double ‘low dose’ ICS Low dose ICS + LTRA Consider specialist referral STEP 4 Continue controller & refer for specialist assessment Add LTRA, or increase ICS frequency, or add intermittent ICS Daily leukotriene receptor antagonist (LTRA), or intermittent short course of ICS at onset of respiratory illness Symptoms Exacerbations Side-effects Parent satisfaction Exclude alternative diagnoses Symptom control & modifiable risk factors Comorbidities Inhaler technique & adherence Parent preferences and goals Treat modifiable risk factors and comorbidities Non-pharmacological strategies Asthma medications Education & skills training Consider intermittent short course ICS at onset of viral illness
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- 17. Simple questions toask to assess level of asthma control ● Asthma symptom control : ● In the past 4 weeks patient had - ● 1. day time asthma symptoms > twice a week? ● 2. Any night wakenings ? ● 3. Releiver(SABA) use for symptoms > twice a week ? ● 4. Any activity limitation due to asthma ? ● Level of symptom control – well controlled (0), ● Partly controlled(1-2), Uncontrolled ( 3-4).
- 18. When to considerstep down of treatment? ● 1. Assess symptom control over past 4 weeks ● 2. Assess future risk for poor asthma outcomes ● Risk factors for asthma exacerbations in next few months: ● Uncontrolled symptoms ● Severe exacerbation in past year ● Start of child’s usual flare-up season Exposure to trigger (or likelihood of trigger like Festivals, Exam etc.), ● Poor adherence ● If well controlled for 3 months and no immediate risk for poor asthma outcomes: Step down treatment
- 19. Stepping down treatment: •While using ICS alone (med to high doses): • 50% reduction at 3 months interval • Control achieved at low dose ICS, switch to OD. While using ICS+LABA: • Reduce ICS by 50% while continuing LABA. • Control maintained at low dose ICS+LABA, switch to OD
- 20. Aims of treatment ●To relieve airflow obstruction and hypoxemia as quickly as possible, & ● To plan the prevention of future relapses. ● Prevent Asthma exacerbation ● Prevent Loss of lung function ● Minimal side effects of medications such as palpitations and tremors.
- 21. Stopping treatment Good control.No symptoms for 6-12 m & No risk factors. ● Stop controller regimen ● Trigger avoidance continues ● Written Home management plan for acute episodes (Step 1 regime) ● Follow up 3-6 monthly for 1-2 years ● Counsel regarding possible future resumption of controller, if recurrences.
- 22. Very Important: ● GiveAsthma Action plan ● Always prescribe for long term ● Demonstrate technique ● Green – breathing is good, no cough or wheeze, sleep through the night, can work and play. ● Yellow – first signs of cold, exposure to known trigger, cough, mild wheeze, tight chest, coughing at night. ● Red – Asthma is getting worse fast, medicine is not helping, breathing is hard and fast, nose opens wide and ribs show, cannot talk well.
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