G IN A

1
G INA
lobal itiative for sthma
2
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

3
Executive CommitteeChair Tim Clark, MD
GINA Structure
Dissemination Committee Chair Wan Cheng Tan, MD
Science Committee Chair Paul OByrne, MD
GINA reports prepared during workshops conducted
in cooperation with the U.S. National Heart,
Lung, and Blood Institute, NIH and the World
Health Organization.
4
GINA Sponsors

• Altana Merck, Sharp Dohme
• Andi-Ventis Mitsubishi Pharma
• AstraZeneca Nikken Chemicals
• Aventis Novartis
• Bayer Schering-Plough
• Boehringer Ingelheim Sepracor
• Chiesi Viatris
• GlaxoSmithKline

5
Executive Committee

• T. Clark, UK, Chair
• E. Bateman, S. Africa P. OByrne, Canada
• J. Bousquet, France K. Ohta, Japan
• W. Busse, USA S. Pedersen, Denmark
• S. Holgate, UK R. Singh, India
• C. Lenfant, USA W. Tan, Singapore

6
Science Committee

• P. OByrne, Canada, Chair
• P. Barnes, UK P. Gibson, Australia
• E. Bateman, S. Africa J. Kips, Belgium
• J. Bousquet, France K. Ohta, Japan
• W. Busse, USA S. Pedersen, Denmark
• J. Drazen, USA S. Wenzel, USA
• M. FitzGerald, Canada

7
Science Committee Objectives

• Develop methods to track and evaluate new
  scientific research on asthma
• Develop a process to evaluate impact of new
  scientific findings on GINA documents

8
Science CommitteeObjectives (continued)

• Identify a network of individuals to serve as
  ongoing reviewers
• With the Dissemination Committee, develop
  methods to disseminate new scientific findings
  that impact on GINA documents

9
Dissemination Committee

• W. Tan, Singapore, Chair
• G. Anabwani, Botswana R. Neville, UK
• R. Beasley, N. Zealand J. Sinnadurai, Malaysia
• H. Campos, Brazil R. Singh, India
• Y. Chen, China R. Tomlins, Australia
• F. Gallefoss, Norway O. van Schyack,
  Netherlands
• M. Haida, Japan H. Zar, S. Africa
• J. Khan, Pakistan

10
Dissemination Committee Objectives

• Enhance dissemination of GINA reports
• Ensure that all concerned with care of patients
  with asthma are knowledgeable about
  recommendations
• Evaluate methods to alter health professional
  behaviour
• Recommend methods to assess and monitor outcomes

11
GINA Documents

• Workshop Report Global Strategy for Asthma
  Management and Prevention (updated 2003)
• Pocket guide for health care providers (updated
  2003)
• Pocket guide for management of pediatric asthma
  (updated 2003)
• Guide for asthma patients and their families
• All materials are available on GINA web site
  www.ginasthma.com

12
GINA Workshop Report

• Developed during workshops conducted in
  cooperation with the National Heart, Lung, and
  Blood Institute, NIH and the World Health
  Organization
• Evidence-based
• Implementation oriented
• Diagnosis
• Management
• Prevention
• Outcomes can be evaluated

13
GINA Workshop Report

• 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

14
GINA Workshop Report

• Topics
• Definition
• Burden of Asthma
• Risk Factors
• Mechanisms
• Diagnosis and Classification
• Education and Delivery of Care
• Six Part Asthma Management Plan
• Research Recommendations

15
Definition of Asthma

• A chronic inflammatory disorder of the airways
• Many cells and cellular elements play a role
• Chronic inflammation leads to an increase in
  airway hyperresponsiveness with recurrent
  episodes of wheezing, coughing, and shortness of
  breath
• Widespread, variable, and often reversible
  airflow limitation

16
Definition of Asthma

• Asthma is a chronic inflammatory disorder of the
  airways in which many cells and cellular elements
  play a role
• Chronic inflammation causes an associated
  increase in airway hyperresponsiveness that leads
  to recurrent episodes of wheezing,
  breathlessness, chest tightness, and coughing,
  particularly at night or in the early morning
• These episodes are usually associated with
  widespread but variable airflow obstruction that
  is often reversible either spontaneously or with
  treatment

17
Mechanisms Underlying the Definition of Asthma

• Risk Factors
• (for development of asthma)

INFLAMMATION
Airway Hyperresponsiveness
Airflow Obstruction
Symptoms
Risk Factors (for exacerbations)
18
Burden of Asthma

• Asthma is one of the most common chronic diseases
  worldwide
• Prevalence increasing in many countries,
  especially in children
• A major cause of school/work absence
• An overall increase in severity of asthma
  increases the pool of patients at risk for death

19
Burden of Asthma

• Health care expenditures very high
• Developed economies might expect to spend 1-2
  percent of total health care expenditures on
  asthma. Developing economies likely to face
  increased demand
• Poorly controlled asthma is expensive investment
  in prevention medication likely to yield cost
  savings in emergency care

20
Worldwide Variation in Prevalence of Asthma
Symptoms International Study of Asthma and
Allergies in Children (ISAAC) Lancet
19983511225
21
Increasing Prevalence of Asthma in
Children/Adolescents

1966
Finland (Haahtela et al)
1989

1979
Sweden (Aberg et al)
1991

1982
Japan (Nakagomi et al)
1992

1982
Scotland (Rona et al)
1992

1989
UK (Omran et al)
1994

1982
USA (NHIS)
1992

1975
New Zealand (Shaw et al)
1989

1982
Australia (Peat et al)
1992
0
5
10
15
20
25
30
35
Prevalence ()
22
Countries should enter their own data on burden
of asthma. The following three slides are US
data on prevalence, hospitalization rates and
mortality.
23
Trends in Prevalence of Asthma By Age, U.S.,
1985-1996
Rate/1,000 Persons
80
Age (years)
70
lt18 18-44 45-64 65 Total (All Ages)
60
50
40
30
20
85
86
87
88
89
90
91
92
93
94
95
96
Year
24
Hospitalization Rates for Asthma by Age, U.S.,
1974 - 1997
Rate/100,000 Persons
40
lt15 15-44 45-64 65
35
30
25
20
15
10
5
0
74
76
78
80
82
84
86
88
90
92
94
96
Year
25
Death Rates for AsthmaBy Race, Sex, U.S.,
1980-1998
Rate/100,000 Persons
5
Black Female
4
Black Male
3
White Female
2
White Male
1
0
1980
1985
1990
1995
2000
Year
26
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

27
Factors that Exacerbate Asthma

• Allergens
• Air Pollutants
• Respiratory infections
• Exercise and hyperventilation
• Weather changes
• Sulfur dioxide
• Food, additives, drugs

28
Risk Factors that Lead to Asthma Development

• Host Factors
• Genetic predisposition
• Atopy
• Airway hyper-
• responsiveness
• Gender
• Race/Ethnicity

• Environmental Factors
• Indoor allergens
• Outdoor allergens
• Occupational sensitizers
• Tobacco smoke
• Air Pollution
• Respiratory Infections
• Parasitic infections
• Socioeconomic factors
• Family size
• Diet and drugs
• Obesity

29
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

30
Asthma Diagnosis

• History and patterns of symptoms
• Physical examination
• Measurements of lung function
• Measurements of allergic status to identify risk
  factors

31
Classification of Severity
CLASSIFY SEVERITY Clinical Features Before
Treatment
Nocturnal Symptoms
FEV1 or PEF
Symptoms
Continuous Limited physical activity
STEP 4 Severe Persistent
? 60 predicted Variability gt 30
Frequent
60 - 80 predicted Variability gt 30
STEP 3 Moderate Persistent
Daily Attacks affect activity
gt 1 time week
STEP 2 Mild Persistent
? 80 predicted Variability 20 - 30
gt 2 times a month
gt 1 time a week but lt 1 time a day
lt 1 time a week Asymptomatic and normal PEF
between attacks
? 80 predicted Variability lt 20
STEP 1 Intermittent
? 2 times a month
The presence of one feature of severity is
sufficient to place patient in that category.
32
Six-Part Asthma Management Program
1. Educate Patients 2. Assess and Monitor
Severity 3. Avoid Exposure to Risk Factors 4.
Establish Medication Plans for Chronic
Management Adults and Children 5. Establish
Plans for Managing Exacerbations 6. Provide
Regular Follow-up Care
33
Six-Part Asthma Management Program
1. Educate patients to develop a partnership in
asthma management 2. Assess and monitor asthma
severity with symptom reports and measures of
lung function as much as possible 3. Avoid
exposure to risk factors 4. Establish medication
plans for chronic management in children and
adults 5. Establish individual plans for managing
exacerbations 6. Provide regular follow-up care
34
Six-part Asthma Management Program Goals of
Long-term Management

• Achieve and maintain control of symptoms
• Prevent asthma episodes or attacks
• Maintain pulmonary function as close to normal
  levels as possible
• Maintain normal activity levels, including
  exercise
• Avoid adverse effects from asthma medications
• Prevent development of irreversible airflow
  limitation
• Prevent asthma mortality

35
Six-part Asthma Management Program Control of
Asthma

• Minimal (ideally no) chronic symptoms
• Minimal (infrequent) exacerbations
• No emergency visits
• Minimal (ideally no) need for as needed use of
• ß2-agonist
• No limitations on activities, including exercise
• PEF circadian variation of less than 20 percent
• (Near) normal PEF
• Minimal (or no) adverse effects from medicine

36
.
Six-Part Asthma Management Program

• The most effective management is to prevent
  airway inflammation by eliminating the causal
  factors
• Asthma can be effectively controlled in most
  patients, although it can not be cured
• The major factors contributing to asthma
  morbidity and mortality are under-diagnosis and
  inappropriate treatment

37
Six-Part Asthma Management Program

• Any asthma more severe than intermittent asthma
  is more effectively controlled by treatment to
  suppress and reverse airway inflammation than by
  treatment only of acute bronchoconstriction and
  symptoms

38
Six-part Asthma Management ProgramPart 1
Educate Patients to Develop a Partnership

• Patient education involves a partnership between
  the patient and health care professional(s) with
  frequent revision and reinforcement
• Aim is guided self-management giving patients
  the ability to control their asthma
• Interventions, including use of written action
  plans, have been shown to reduce morbidity in
  both children and adults

39
Six-part Asthma Management ProgramPart 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

40
Six-part Asthma Management ProgramPart 1
Educate Patients to Develop a 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 patients family

41
Six-part Asthma Management ProgramFactors
Associated with Non-Compliance in Asthma Care

• Medication Usage
• Difficulties associated with inhalers
• Complicated regimens
• Fears about, or actual side effects
• Cost

• Patient/Physician
• Misunderstanding/lack of information
• Underestimation of severity
• Attitudes toward ill health
• Cultural factors
• Poor communication

42
Six-part Asthma Management Program Part 2
Assess and Monitor Asthma Severity with Symptom
Reports and Measures of Lung Function

• Symptom reports
• Use of reliever medication
• Nighttime symptoms
• Activity limitations
• Spirometry for initial assessment. Peak
  Expiratory Flow for follow-up
• Assess severity
• Assess response to therapy
• PEF monitoring at home
• Important for those with poor perception of
  symptoms
• Daily measurement recorded in a diary
• Assesses the severity and predicts worsening
• Guides the use of a zone system for asthma
  self-management
• Arterial blood gas for severe exacerbations

43
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
44
A Simple Index of PEF Variation
45
Six-part Asthma Management ProgramPart 3 Avoid
Exposure to Risk Factors

• Methods to prevent onset of asthma are not yet
  available but this remains an important goal
• Measures to reduce exposure to causes of asthma
  exacerbations (e.g. allergens, pollutants, foods
  and medications) should be implemented whenever
  possible

46
Six-part Asthma Management ProgramPart 4
Establish Medication Plans for Long-Term Asthma
Management in Infants and Children

• At present, inhaled glucocorticosteroids are the
  most effective controller medications and are
  recommended for persistent asthma at any step of
  severity
• Long-term treatment with inhaled
  glucocorticosteroids markedly reduces the
  frequency and severity of exacerbations

47
Six-part Asthma Management ProgramPart 3 Avoid
Exposure to Risk Factors

• 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

48
Six-part Asthma Management Program Part 4
Establish Medication Plans for Long-Term Asthma
Management

• 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

49
Part 4 Long-term Asthma Management Stepwise
Approach to Asthma Therapy

• The choice of treatment should be guided by
• Severity of the patients asthma
• Patients 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.

50
Part 4 Long-term Asthma Management Pharmacologic
Therapy

• Controller Medications
• Inhaled glucocorticosteroids
• Systemic glucocorticosteroids
• Cromones
• Methylxanthines
• Long-acting inhaled ß2-agonists
• Long-acting oral ß2-agonists
• Leukotriene modifiers
• Anti-IgE

51
Part 4 Long-term Asthma Management
Pharmacologic Therapy

• Reliever Medications
• Rapid-acting inhaled ß2-agonists
• Systemic glucocorticosteroids
• Anticholinergics
• Methylxanthines
• Short-acting oral ß2-agonists

52
Estimated Comparative Daily Dosages for Inhaled
Glucocorticosteroids
53
Part 4 Long-term Asthma Management Stepwise
Approach to Asthma Therapy - Adults
Outcome Best Possible Results
Outcome Asthma Control

• Controller
• Daily inhaled corticosteroid plus
• Daily long acting inhaled ß2-agonist
• plus (if needed)

• When asthma is controlled, reduce therapy
• Monitor

• Controller
• Daily inhaled corticosteroid plus
• Daily long-acting inhaled ß2-agonist

• Controller
• Daily inhaled
• corticosteroid

• Controller
• None

-Theophylline-SR -Leukotriene -Long-acting
inhaled ß2- agonist -Oral corticosteroid
Reliever
Rapid-acting inhaled ß2-agonist prn
STEP 1 Intermittent
STEP 2 Mild Persistent
STEP 3 Moderate Persistent
STEP 4 Severe Persistent
STEP Down
Alternative controller and reliever medications
may be considered (see text).
54
Recommended Asthma Medications Step 1 Adults
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
55
Recommended Asthma Medications Step 2 Adults
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
56
Recommended Asthma Medications Step 3 Adults
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
57
Recommended Asthma Medications Step 4 Adults
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
58
Part 4 Long-term Asthma Management Allergen-spec
ific Immunotherapy

• Greatest benefit of specific immunotherapy
  using allergen extracts has been obtained in the
  treatment of allergic rhinitis
• A number of questions must be addressed
  regarding the role of specific immunotherapy in
  asthma therapy
• 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

59
Six-part Asthma Management ProgramPart 4
Establish Medication Plans for Long-Term Asthma
Management in Infants and Children

• 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.

60
Six-part Asthma Management ProgramPart 4
Establish Medication Plans for Long-Term Asthma
Management in Infants and Children

• Many asthma medications (e.g. glucocorticosteroids
  , ß2- agonists, theophylline) are metabolized
  faster in children than in adults, and younger
  children tend to metabolize medications faster
  than older children

61
Six-part Asthma Management ProgramPart 4
Establish Medication Plans for Long-Term Asthma
Management in Infants and Children

• 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

62
Six-part Asthma Management ProgramPart 4
Establish Medication Plans for Long-Term Asthma
Management in Infants and Children

• Rapid-acting inhaled ß2- 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

63
Recommended Asthma Medications Step 1 Children
Younger Than 5yrs
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
64
Recommended Asthma Medications Step 2 Children
Younger Than 5 yrs
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
65
Recommended Asthma Medications Step 3 Children
Younger Than 5yrs
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
66
Recommended Asthma Medications Step 4 Children
Younger Than 5yrs
Reliever Medication Rapid-acting inhaled ß2-
agonist prn, not more than 3-4 times a day. Once
control is achieved and maintained for at least 3
months, gradual reduction of therapy should be
tried.
67
Six-part Asthma Management ProgramPart 5
Establish Plans for Managing Exacerbations

• Treatment of exacerbations depends on
• The patient
• Experience of the health care professional
• Therapies that are the most effective for the
  particular patient
• Availability of medications
• Emergency facilities

68
Six-part Asthma Management ProgramPart 5
Establish Plans for Managing Exacerbations

• Primary therapies for exacerbations
• Repetitive administration of rapid-acting inhaled
  ß2-agonist
• Early introduction of systemic glucocorticosteroid
  s
• Oxygen supplementation
• Closely monitor response to treatment
• with serial measures of lung function

69
Six-part Asthma Management ProgramPart 5
Managing Severe Asthma Exacerbations

• Severe exacerbations are life-threatening medical
  emergencies
• Care must be expeditious and treatment is often
  most safely undertaken in a hospital or
  hospital-based emergency department

70
Emergency Department ManagementAcute Asthma
Respiratory Failure
Admit to ICU
71
Six-part Asthma Management ProgramPart 6
Provide Regular Follow-up Care

• Continual monitoring is essential to assure that
• therapeutic goals are met. Frequent follow-up
  visits
• are necessary to review
• Home PEF and symptom records
• Techniques in use of medications
• Risk factors and their control
• Once asthma control is established, follow-up
• visits should be scheduled (at 1 to 6 month
  intervals
• as appropriate)

72
Six-part Asthma Management ProgramSpecial
Considerations

• Special considerations are required to
• manage asthma in relation to
• Pregnancy
• Surgery
• Physical activity
• Rhinitis, sinusitis, and nasal polyps
• Occupational asthma
• Respiratory infections
• Gastroesophageal reflux
• Aspirin-induced asthma

73
Six-part Asthma Management Program Summary

• Asthma can be effectively controlled, although it
  cannot be cured
• Effective asthma management programs include
  education, objective measures of lung function,
  environmental control, and pharmacologic therapy
• A stepwise approach to pharmacologic therapy is
  recommended. The aim is to accomplish the goals
  of therapy with the least possible medication

74
Six-part Asthma Management Program Summary
(continued)

• Anything more than mild, occasional asthma is
  more effectively controlled by suppressing
  inflammation than by only treating acute
  bronchospasm
• The availability of varying forms of treatment,
  cultural preferences, and differing health care
  systems need to be considered

75
http//www.ginasthma.com
76
Optional Therapy Slides
77
Part 4 Long-term Asthma Management Stepwise
Approach to Asthma Therapy - Adults
Outcome Best Possible Results
Outcome Asthma Control

• Controller
• Daily inhaled corticosteroid
• Daily long acting inhaled ß2-agonist
• plus(if needed)

• When asthma is controlled, reduce therapy
• Monitor

• Controller
• Daily inhaled corticosteroid
• Daily long-acting inhaled ß2-agonist

• Controller
• Daily inhaled
• corticosteroid

• Controller
• None

-Theophylline-SR -Leukotriene -Long-acting
inhaled ß2- agonist -Oral corticosteroid
Reliever
Rapid-acting inhaled ß2-agonist prn
STEP 1 Intermittent
STEP 2 Mild Persistent
STEP 3 Moderate Persistent
STEP 4 Severe Persistent
STEP Down
Alternative controller and reliever medications
may be considered (see text).
78
Stepwise Approach to Asthma Therapy Adults
Step 1 Intermittent Asthma
Reliever Medications
Daily Controller Medications
Rapid-acting inhaled ?2-agonist for symptoms (but
lt once a week) Rapid-acting inhaled
?2-agonist, cromone, or leukotriene modifier
before exercise or exposure to allergen
None required

• Continuously review medication technique,
  compliance and environmental control
• Review treatment every three months.
• Step up if control is not achieved step down if
  control is sustained for at least 3 months
• Preferred treatments are in bold print

79
Stepwise Approach to Asthma Therapy AdultsStep
2 Mild Persistent Asthma
Daily Controller Medications
Reliever Medications

• Low-dose inhaled
• glucocorticosteroid
• Other options (order by cost)
• sustained-release theophylline, or
• Cromone, or
• leukotriene modifier

• Rapid-acting inhaled ?2-agonist
• for symptoms (but lt 3-4 times/day)
• Other options
• inhaled anticholinergic, or
• short-acting oral ?2-agonist, or
• short-acting theophylline

• Continuously review medication technique,
  compliance and environmental control.
• Review treatment every three months
• Step up if control is not achieved Step down if
  control is sustained for at least 3 months
• Preferred treatments are in bold print

80
Stepwise Approach to Asthma Therapy Adults Step
3 Moderate Persistent Asthma
Daily Controller Medications
Reliever Medications

• Low- to medium-dose inhaled glucocortico-
• steroid, plus long-acting inhaled ?2-agonist
• Other options (order by cost)
• Medium-dose inhaled glucocorticosteroid plus
  sustained-release theophylline, or
• Medium-dose inhaled glucocorticosteroid plus
  long-acting inhaled ß2- agonist, or
• High-dose inhaled glucocorticosteroid, or
• Medium-dose inhaled glucocorticosteroid plus
  leukotriene modifier

• Rapid-acting inhaled
• ?2-agonist for symptoms
• (but lt 3 - 4 times/day)
• Other options
• inhaled anticholinergic or
• short-acting oral
• ?2-agonist or
• short-acting theophylline

• Continuously review medication technique,
  compliance and environmental control.
• Review treatment every three months.
• Step up if control is not achieved Step down if
  control is sustained for at least 3 months.
• Preferred treatments are in bold print.

81
Stepwise Approach to Asthma Therapy Adults Step
4 Severe Persistent Asthma
Daily Controller Medications
Reliever Medications

• High-dose inhaled glucocorticosteroid,
• plus long-acting inhaled ß2agonist
• plus one or more of the following, if
• needed (order by cost)
• sustained-release theophylline, or
• leukotriene modifier or
• oral glucocorticosteroid

• Rapid-acting inhaled
• ?2-agonist for symptoms
• (but lt 3-4 times/day)
• Other options
• inhaled anticholinergic or
• short-acting oral
• ?2-agonist or
• short-acting theophylline

• Continuously review medication technique,
  compliance and environmental control.
• Review treatment every three months.
• Step up if control is not achieved Step down if
  control is sustained for at least 3 months.
• Preferred treatments are in bold print.