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POCKET GUIDE FORASTHMA MANAGEMENTAND PREVENTION

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(for Adults and Children Older than 5 Years)

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A Pocket Guide for Physicians and NursesRevised 2014

BASED ON THE GLOBAL STRATEGY FOR ASTHMAMANAGEMENT AND PREVENTION Global Initiative for Asthma

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GLOBAL INITIATIVEFOR ASTHMA

GINA Board of Directors

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POCKET GUIDE FOR PHYSICIANSAND NURSES 2014

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Chair: J Mark FitzGerald, MD

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GINA Science Committee

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Chair: Helen Reddel, MBBS PhDGINA Dissemination and Implementation Committee

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Chair: Louis-Philippe Boulet, MD

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GINA Assembly

The GINA Assembly includes members from 45 countries, listed on theGINA website www.ginasthma.org.GINA Program

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Scientific Director: Suzanne Hurd, PhD

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Names of members of the GINA Committees are listed on page 28.

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TABLE OF CONTENTS3

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Preface

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Making the diagnosis of asthmaCriteria for making the diagnosis of asthmaDiagnosing asthma in special populationsAssessing a patient with asthmaHow to assess asthma controlHow to investigate uncontrolled asthmaManagement of asthma general principlesTreating to control symptoms and minimize riskInitial controller treatmentStepwise approach for adjusting treatmentReviewing response and adjusting treatmentInhaler skills and adherenceTreating modifiable risk factorsNon-pharmacological strategies and interventionsTreatment in special populations or contextsAsthma flare-ups (exacerbations)Written asthma action plansManaging exacerbations in primary or acute careFollow-up after an exacerbationGlossary of asthma medication classes

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What is known about asthma?

Acknowledgements

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TABLE OF FIGURES

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GINA publications

56789101111131617181919202122232526

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Box 1. Diagnostic flow-chart for asthma in clinical practice........................... 5Box 2. Features used in making the diagnosis of asthma............................. 6Box 3. How to assess a patient with asthma................................................. 8Box 4. Assessment of symptom control and future risk ................................ 9Box 5. How to investigate uncontrolled asthma in primary care.................. 10Box 6. The control-based asthma management cycle ................................ 12Box 7. Stepwise approach to asthma treatment ......................................... 14Box 8. Low, medium and high daily doses of inhaled corticosteroids (mcg) 14Box 9. Self-management with a written action plan .................................... 22Box 10. Management of asthma exacerbations in primary care ................. 24

Abbreviations used in this Pocket Guide are found on page 27.2

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PREFACE

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Asthma affects an estimated 300 million individuals worldwide. It is a seriousglobal health problem affecting all age groups, with increasing prevalence inmany developing countries, rising treatment costs, and a rising burden forpatients and the community. Asthma still imposes an unacceptable burden onhealth care systems, and on society through loss of productivity in theworkplace and, especially for pediatric asthma, disruption to the family.

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Health care providers managing asthma face different issues around theworld, depending on the local context, the health system, and access toresources.

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The Global Initiative for Asthma (GINA) was established to increaseawareness about asthma among health professionals, public healthauthorities and the community, and to improve prevention and managementthrough a coordinated worldwide effort. GINA prepares scientific reports onasthma, encourages dissemination and implementation of therecommendations, and promotes international collaboration on asthmaresearch.

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The Global Strategy for Asthma Management and Prevention 2014 hasbeen extensively revised to provide a comprehensive and integratedapproach to asthma management that can be adapted for local conditionsand for individual patients. It focuses not only on the existing strong evidencebase, but also on clarity of language and on providing tools for feasibleimplementation in clinical practice.

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This Pocket Guide is a brief summary of the GINA 2014 report for primaryhealth care providers. It does NOT contain all of the information required formanaging asthma, for example, about safety of treatments, and should beused in conjunction with the full GINA report.

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The GINA 2014 report and other GINA publications (listed on page 28) can beobtained from www.ginasthma.org.

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Implementation of the treatment recommendations in thisPocket Guide is subject to local resources and regulations.

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WHAT IS KNOWN ABOUT ASTHMA?

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Asthma is a common and potentially serious chronic disease thatimposes a substantial burden on patients, their families and the community. Itcauses respiratory symptoms, limitation of activity, and flare-ups (attacks) thatsometimes require urgent health care and may be fatal.

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Fortunatelyasthma can be effectively treated, and most patients canachieve good control of their asthma. When asthma is under good control,patients can:

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Avoid troublesome symptoms during day and nightNeed little or no reliever medicationHave productive, physically active livesHave normal or near normal lung functionAvoid serious asthma flare-ups (exacerbations, or attacks)

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What is asthma? Asthma causes symptoms such as wheezing, shortness ofbreath, chest tightness and cough that vary over time in their occurrence,frequency and intensity.

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These symptoms are associated with variable expiratory airflow, i.e. difficultybreathing air out of the lungs due to bronchoconstriction (airway narrowing),airway wall thickening, and increased mucus. Some variation in airflow canalso occur in people without asthma, but it is greater in asthma.

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Factors that may trigger or worsen asthma symptoms include viralinfections, domestic or occupational allergens (e.g. house dust mite, pollens,cockroach), tobacco smoke, exercise and stress. These responses are morelikely when asthma is uncontrolled. Some drugs can induce or trigger asthma,e.g. beta-blockers, and (in some patients), aspirin or other NSAIDs.

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Asthma flare-ups (also called exacerbations or attacks) may occur, even inpeople taking asthma treatment. When asthma is uncontrolled, or in somehigh-risk patients, these episodes are more frequent and more severe, andmay be fatal.

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A stepwise approach to treatment takes into account the effectiveness ofavailable medications, their safety, and their cost to the payer or patient.

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Regular controller treatment, particularly with inhaled corticosteroid (ICS)containing medications, markedly reduces the frequency and severity ofasthma symptoms and the risk of having a flare-up.

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Asthma is a common condition, affecting all levels of society. Olympicathletes, famous leaders and celebrities, and ordinary people live successfuland active lives with asthma.

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MAKING THE DIAGNOSIS OF ASTHMA

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Asthma is a disease with many variations (heterogeneous), usuallycharacterized by chronic airway inflammation. Asthma has two key definingfeatures:

a history of respiratory symptoms such as wheeze, shortness of breath,chest tightness and cough that vary over time and in intensity, AND

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variable expiratory airflow limitation.

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A flow-chart for making the diagnosis in clinical practice is shown in Box 1,with the specific criteria for diagnosing asthma in Box 2.

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Box 1. Diagnostic flow-chart for asthma in clinical practice

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The diagnosis of asthma should be confirmed and, for future reference, theevidence documented in the patients notes. Depending on clinical urgencyand access to resources, this should preferably be done before startingcontroller treatment. Confirming the diagnosis of asthma is more difficult aftertreatment has been started (see p7).5

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CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMABox 2. Features used in making the diagnosis of asthma

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1. A history of variable respiratory symptoms

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Typical symptoms are wheeze, shortness of breath, chest tightness, coughPeople with asthma generally have more than one of these symptomsThe symptoms occur variably over time and vary in intensityThe symptoms often occur or are worse at night or on wakingSymptoms are often triggered by exercise, laughter, allergens or cold airSymptoms often occur with or worsen with viral infections

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2. Evidence of variable expiratory airflow limitation

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At least once during the diagnostic process when FEV1 is low,document that the FEV1/FVC ratio is reduced. The FEV1/FVC ratio isnormally more than 0.750.80 in adults, and more than 0.90 in children.

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Document that variation in lung function is greater than in healthypeople. For example:o FEV1 increases by more than 12% and 200mL (in children, >12%of the predicted value) after inhaling a bronchodilator. This iscalled bronchodilator reversibility.o Average daily diurnal PEF variability* is >10% (in children, >13%)o FEV1 increases by more than 12% and 200mL from baseline (inchildren, by >12% of the predicted value) after 4 weeks of antiinflammatory treatment (outside respiratory infections)The greater the variation, or the more times excess variation is seen,the more confident you can be of the diagnosis

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Testing may need to be repeated during symptoms, in the earlymorning, or after withholding bronchodilator medications.

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Bronchodilator reversibility may be absent during severe exacerbationsor viral infections. If bronchodilator reversibility is not present when it isfirst tested, the next step depends on the clinical urgency andavailability of other tests.

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For other tests to assist in diagnosis, including bronchial challengetests, see Chapter 1 of the GINA 2014 report.

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*Calculated from twice daily readings (best of 3 each time), as ([the days highest PEFminus the days lowest PEF]) divided by the mean of the days highest and lowest PEF,and averaged over 1-2 weeks. If using PEF at home or in the office, use the same PEFmeter each time.

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Physical examination in people with asthma is often normal, but the mostfrequent finding is wheezing on auscultation, especially on forced expiration.

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DIAGNOSING ASTHMA IN SPECIAL POPULATIONSPatients with cough as the only respiratory symptom

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This may be due to chronic upper airway cough syndrome (post-nasal drip),chronic sinusitis, gastroesophageal reflux (GERD), vocal cord dysfunction, oreosinophilic bronchitis, or cough variant asthma. Cough variant asthma ischaracterized by cough and airway hyperresponsiveness, and documentingvariability in lung function is essential to make this diagnosis. However, lack ofvariability at the time of testing does not exclude asthma. For other diagnostictests, see Box 2, and Chapter 1 of the GINA 2014 report, or refer the patientfor specialist opinion.Occupational asthma and work-aggravated asthma

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Every patient with adult-onset asthma should be asked about occupationalexposures, and whether their asthma is better when they are away from work.It is important to confirm the diagnosis objectively (which often needsspecialist referral) and to eliminate exposure as soon as possible.Pregnant women

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Ask all pregnant women and those planning pregnancy about asthma, andadvise them about the importance of asthma treatment for the health of bothmother and baby.

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The elderly

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Asthma may be under-diagnosed in the elderly, due to poor perception, anassumption that dyspnea is normal in old age, lack of fitness, or reducedactivity. Asthma may also be over-diagnosed in the elderly through confusionwith shortness of breath due to left ventricular failure or ischemic heartdisease. If there is a history of smoking or biomass fuel exposure, COPD orasthma-COPD overlap syndrome (ACOS) should be considered (see Chapter5 of the GINA 2014 report).Smokers and ex-smokers

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Asthma and COPD may co-exist or overlap (asthma-COPD overlapsyndrome, ACOS), particularly in smokers and the elderly. The history andpattern of symptoms and past records can help to distinguish asthma withfixed airflow limitation from COPD. Uncertainty in diagnosis should promptearly referral, as ACOS has worse outcomes than asthma or COPD alone.

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Confirming an asthma diagnosis in patients taking controller treatment:

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For many patients (2535%) with a diagnosis of asthma in primary care, thediagnosis cannot be confirmed. If the basis of the diagnosis has not alreadybeen documented, confirmation with objective testing should be sought.If standard criteria for asthma (Box 2) are not met, consider otherinvestigations. For example, if lung function is normal, repeat reversibility7

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testing after withholding medications for 12 hours. If the patient has frequentsymptoms, consider a trial of step-up in controller treatment and repeat lungfunction testing after 3 months. If the patient has few symptoms, considerstepping down controller treatment, but ensure the patient has a writtenasthma action plan, monitor them carefully, and repeat lung function testing.

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ASSESSING A PATIENT WITH ASTHMA

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Box 3. How to assess a patient with asthma

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Take every opportunity to assess patients with a diagnosis of asthma,particularly when they are symptomatic or after a recent exacerbation, butalso when they ask for a prescription refill. In addition, schedule a routinereview at least once a year.

1. Asthma control assess both symptom control and risk factors

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Assess symptom control over the last 4 weeks (Box 4, p9)Identify any other risk factors for poor outcomes (Box 4)Measure lung function before starting treatment, 36 months later, andthen periodically, e.g. yearly

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2. Treatment issues

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Record the patients treatment (Box 7, p14), and ask about side-effectsWatch the patient using their inhaler, to check their technique (p18)Have an open empathic discussion about adherence (p18)Check that the patient has a written asthma action plan (p22)Ask the patient about their attitudes and goals for their asthma

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3. Are there any comorbidities?

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These include rhinitis, rhinosinusitis, gastroesophageal reflux (GERD),obesity, obstructive sleep apnea, depression and anxiety.

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Comorbidities should be identified as they may contribute to respiratorysymptoms and poor quality of life. Their treatment may complicateasthma management.

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HOW TO ASSESS ASTHMA CONTROL

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Asthma control means the extent to which the effects of asthma can be seenin the patient, or have been reduced or removed by treatment. Asthma controlhas two domains: symptom control (previously called current clinical control)and risk factors for future poor outcomes.

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Poor symptom control is a burden to patients and a risk factor for flare-ups.Risk factors are factors that increase the patients future risk of havingexacerbations (flare-ups), loss of lung function, or medication side-effects.

A. Level of asthma symptom control

YesYesYesYes

NoNoNoNo

Uncontrolled

12of these

34of these

Noneof these

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Daytime symptoms more than twice/week?Any night waking due to asthma?Reliever needed* more than twice/week?Any activity limitation due to asthma?

Partlycontrolled

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Wellcontrolled

In the past 4 weeks, has the patient had:

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Box 4. Assessment of symptom control and future risk

B. Risk factors for poor asthma outcomes

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Assess risk factors at diagnosis and periodically, particularly for patients experiencingexacerbations.Measure FEV1 at start of treatment, after 36 months of controller treatment to recordpersonal best lung function, then periodically for ongoing risk assessment.

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Potentially modifiable independent risk factors for exacerbations include:

Having one or moreof these risk factorsincreases the risk ofexacerbations evenif symptoms are wellcontrolled.

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Uncontrolled asthma symptoms (as above)ICS not prescribed; poor ICS adherence; incorrect inhaler techniqueExcessive SABA use (>1x200-dose canister/month)Low FEV1, especially if 5001000 N >1000100200>200400>400O>400Beclometasone dipropionate (HFA)100200>20040050-100>100-200>200TABudesonide (DPI)200400>400800>800>200400>400LT100200Budesonide (nebules)250500>5001000>1000E80RCiclesonide (HFA)80160>160320>320>80-160>160Fluticasone propionate( DPI)100250>250500>500100200O>200400>400R >200500Fluticasone propionate (HFA)100250>250500>500100200>500RE220440>440110PR >1200Triamcinolone acetonide4001000>10002000>2000400800>8001200ODCFC: chlorofluorocarbon propellant; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant.UC*Included for comparison with older literature.E

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STEPWISE APPROACH FOR ADJUSTING TREATMENT

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Once asthma treatment has been started, ongoing decisions are based on acycle to assess, adjust treatment and review response. The preferredtreatments at each step are summarized below and in Box 7 (p14); for details,see full GINA 2014 report. See Box 8 (p14) for ICS dose categories.

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STEP 1: As-needed SABA with no controller (this is indicated only ifsymptoms are rare, there is no night waking due to asthma, noexacerbations in the last year, and normal FEV1).Other options: regular low dose ICS for patients with exacerbation risks.

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STEP 2: Regular low dose ICS plus as-needed SABAOther options: LTRA are less effective than ICS; ICS/LABA leads to fasterimprovement in symptoms and FEV1 than ICS alone but are moreexpensive and the exacerbation rate is similar. For purely seasonal allergicasthma, start ICS immediately and cease 4 weeks after end of exposure.

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STEP 3: Low dose ICS/LABA either as maintenance treatment plus asneeded SABA, or as ICS/formoterol maintenance and reliever therapy

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or BUD/formoterol maintenance and reliever strategy is more effective thanmaintenance ICS/LABA with as-needed SABA.Other options: Medium dose ICSChildren (611 years): Medium dose ICS. Other options: low doseICS/LABA

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STEP 4: Low dose ICS/formoterol maintenance and reliever therapy, ormedium dose ICS/LABA as maintenance plus as-needed SABAOther options: high dose ICS/LABA, but more side-effects and little extrabenefit; extra controller, e.g. LTRA or slow-release theophylline (adults)Children (611 years): Refer for expert assessment and advice.

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STEP 5: Refer for expert investigation and add-on treatmentAdd-on treatments include anti-IgE (omalizumab) for severe allergic asthma.Sputum-guided treatment, if available, improves outcomes.Other options: Some patients may benefit from low dose OCS but long-termsystemic side-effects occur.

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REVIEWING RESPONSE AND ADJUSTING TREATMENTHow often should patients with asthma be reviewed?

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Patients should preferably be seen 13 months after starting treatment andevery 312 months after that, except in pregnancy when they should bereviewed every 46 weeks. After an exacerbation, a review visit within 1 weekshould be scheduled. The frequency of review depends on the patients initiallevel of control, their response to previous treatment, and their ability andwillingness to engage in self-management with an action plan.

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Stepping up asthma treatment

Asthma is a variable condition, and periodic adjustment of controller treatmentby the clinician and/or patient may be needed.

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Sustained step-up (for at least 23 months): if symptoms and/orexacerbations persist despite 23 months of controller treatment, assessthe following common issues before considering a step-upo Incorrect inhaler techniqueo Poor adherenceo Modifiable risk factors, e.g. smokingo Are symptoms due to comorbid conditions, e.g. allergic rhinitisShort-term step-up (for 12 weeks) by clinician or by patient with writtenasthma action plan (p22), e.g. during viral infection or allergen exposureDay-to-day adjustment by patient for patients prescribed low dosebeclometasone/formoterol or budesonide/formoterol as maintenance andreliever therapy.

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Stepping down treatment when asthma is well-controlled

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Consider stepping down treatment once good asthma control has beenachieved and maintained for 3 months, to find the lowest treatment thatcontrols both symptoms and exacerbations, and minimizes side-effects.

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Choose an appropriate time for step-down (no respiratory infection,patient not travelling, not pregnant)Document baseline status (symptom control and lung function), provide awritten asthma action plan, monitor closely, and book a follow-up visitStep down through available formulations to reduce the ICS dose by2550% at 23 month intervals (see full GINA report for details)Do not completely withdraw ICS (in adults or adolescents) unless it isneeded temporarily to confirm the diagnosis of asthma

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INHALER SKILLS AND ADHERENCEProvide skills training for effective use of inhaler devices

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Most patients (up to 80%) cannot use their inhaler correctly. This contributesto poor symptom control and exacerbations. To ensure effective inhaler use:

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Choose the most appropriate device for the patient before prescribing:consider medication, physical problems e.g. arthritis, patient skills, andcost; for ICS by pressurized metered dose inhaler, prescribe a spacer.

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Check inhaler technique at every opportunity. Ask the patient to showyou how they use the inhaler. Check their technique against a devicespecific checklist.

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Correct using a physical demonstration, paying attention to incorrectsteps. Check technique again, up to 23 times if necessary.Confirm that you have checklists for each of the inhalers you prescribe,and can demonstrate correct technique on them.

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Information about inhaler devices and techniques for their use can be foundon the GINA website (www.ginasthma.org) and the ADMIT website(www.admit-online.info).Check and improve adherence with asthma medications

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Around 50% of adults and children do not take controller medications asprescribed. Poor adherence contributes to poor symptom control andexacerbations. It may be unintentional (e.g. forgetfulness, cost,misunderstandings) and/or non-intentional (e.g. not perceiving the need fortreatment, fear of side-effects, cultural issues, cost).

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To identify patients with adherence problems:

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Ask an empathic question, e.g. Most patients dont take their inhalerexactly as prescribed. In the last 4 weeks, how many days a week haveyou been taking it? 0 days a week, or 1, or 2 days [etc]?, or Do you findit easier to remember your inhaler in the morning or night?Check medication usage, from prescription date, inhaler date/dosecounter, dispensing recordsAsk about attitudes and beliefs about asthma and medicationsOnly a few adherence interventions have been studied closely in asthma.

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Shared decision-making for medication and dose choiceInhaler reminders for missed dosesReduced complexity of the regimen (once- vs twice-daily)Comprehensive asthma education with home visits by asthma nursesClinicians reviewing feedback on their patients dispensing records

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TREATING MODIFIABLE RISK FACTORS

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Exacerbation risk can be minimized by optimizing asthma medications, andby identifying and treating modifiable risk factors. Some examples of riskmodifiers with consistent high quality evidence are:

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Guided self-management: self-monitoring of symptoms and/or PEF, awritten asthma action plan (p22), and regular medical reviewUse of a regimen that minimizes exacerbations: prescribe an ICScontaining controller. For patients with 1 or more exacerbations in the lastyear, consider a low dose ICS/formoterol maintenance and relieverregimenAvoidance of exposure to tobacco smokeConfirmed food allergy: appropriate food avoidance; ensure availabilityof injectable epinephrine for anaphylaxisFor patients with severe asthma: refer to a specialist center, ifavailable, for consideration of add-on medications and/or sputum-guidedtreatment.

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NON-PHARMACOLOGICAL STRATEGIES AND INTERVENTIONS

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In addition to medications, other therapies and strategies may be consideredwhere relevant, to assist in symptom control and risk reduction. Someexamples with consistent high quality evidence are:

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Smoking cessation advice: at every visit, strongly encourage smokers toquit. Provide access to counselling and resources. Advise parents andcarers to exclude smoking in rooms/cars used by children with asthmaPhysical activity: encourage people with asthma to engage in regularphysical activity because of its general health benefits. Provide adviceabout management of exercise-induced bronchoconstriction.Occupational asthma: ask all patients with adult-onset asthma about theirwork history. Identify and remove occupational sensitizers as soon aspossible. Refer patients for expert advice, if available.NSAIDs including aspirin: always ask about asthma before prescribing.Breathing techniques: may be a useful supplement to medications

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Although allergens may contribute to asthma symptoms in sensitized patients,allergen avoidance is not recommended as a general strategy for asthma.These strategies are often complex and expensive, and there are no validatedmethods for identifying those who are likely to benefit.

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Some common triggers for asthma symptoms (e.g. exercise, laughter) shouldnot be avoided, and others (e.g. viral respiratory infections, stress) aredifficult to avoid and should be managed when they occur.

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TREATMENT IN SPECIAL POPULATIONS OR CONTEXTS

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Pregnancy: asthma control often changes during pregnancy. For baby andmother, the advantages of actively treating asthma markedly outweigh anypotential risks of usual controller and reliever medications. Down-titration hasa low priority in pregnancy. Exacerbations should be treated aggressively.

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Rhinitis and sinusitis often coexist with asthma. Chronic rhinosinusitis isassociated with more severe asthma. For some patients, treatment withintranasal corticosteroids improves asthma control.

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Obesity: to avoid over- or under-treatment, it is important to document thediagnosis of asthma in the obese. Asthma is more difficult to control inobesity. Weight reduction should be included in the treatment plan for obesepatients with asthma; even 510% weight loss can improve asthma control.

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The elderly: comorbidities and their treatment should be considered and maycomplicate asthma management. Factors such as arthritis, eyesight,inspiratory flow, and complexity of treatment regimens should be consideredwhen choosing medications and inhaler devices.

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Gastroesophageal reflux (GERD) is commonly seen in asthma.Symptomatic reflux should be treated for its general health benefits, but thereis no benefit from treating asymptomatic reflux in asthma.

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Anxiety and depression: these are commonly seen in people with asthma,and are associated with worse symptoms and quality of life. Patients shouldbe assisted to distinguish between symptoms of anxiety and of asthma.

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Aspirin-exacerbated respiratory disease (AERD): a history of exacerbationfollowing ingestion of aspirin or other NSAIDs is highly suggestive. Patientsoften have severe asthma and nasal polyposis. Confirmation of the diagnosisof AERD requires challenge in a specialized center with cardiopulmonaryresuscitation facilities, but avoidance of NSAIDs may be recommended on thebasis of a clear history. ICS are the mainstay of treatment, but OCS may berequired. Desensitization under specialist care is sometimes effective.

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Food allergy and anaphylaxis: food allergy is rarely a trigger for asthmasymptoms. It must be assessed with specialist testing. Confirmed food allergyis a risk factor for asthma-related death. Good asthma control is essential;patients should also have an anaphylaxis plan and be trained in appropriateavoidance strategies and use of injectable epinephrine.

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Surgery: whenever possible, good asthma control should be achieved preoperatively. Ensure that controller therapy is maintained throughout the perioperative period. Patients on long-term high dose ICS, or having more than 2weeks OCS in the past 6 months, should receive intra-operativehydrocortisone to reduce the risk of adrenal crisis.

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ASTHMA FLARE-UPS (EXACERBATIONS)

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A flare-up or exacerbation is an acute or sub-acute worsening in symptomsand lung function from the patients usual status; occasionally it may be theinitial presentation of asthma.

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For discussion with patients, the word flare-up is preferred. Episodes,attacks and acute severe asthma are often used, but they have variablemeanings, particularly for patients.

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The management of worsening asthma and exacerbations should beconsidered as a continuum, from self-management by the patient with awritten asthma action plan, through to management of more severesymptoms in primary care, the emergency department and in hospital.

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Identifying patients at risk of asthma-related death

These patients should be identified, and flagged for more frequent review.

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A history of near-fatal asthma requiring intubation and ventilationHospitalization or emergency care for asthma in last 12 monthsNot currently using ICS, or poor adherence with ICSCurrently using or recently stopped using OCS (this indicates the severityof recent events)Over-use of SABAs, especially more than 1 canister/monthLack of a written asthma action planHistory of psychiatric disease or psychosocial problemsConfirmed food allergy in a patient with asthma

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WRITTEN ASTHMA ACTION PLANS

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All patients should be provided with a written asthma action plan appropriatefor their level of asthma control and health literacy, so they know how torecognize and respond to worsening asthma.

ALTER

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Box 9. Self-management with a written action plan

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The written asthma action plan should include:

-DO

The patients usual asthma medicationsWhen and how to increase medications, and start OCSHow to access medical care if symptoms fail to respond

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The action plan can be based on symptoms and/or (in adults) PEF. Patientswho deteriorate quickly should be advised to go to an acute care facility orsee their doctor immediately.

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Medication changes for written asthma action plans

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Increase frequency of inhaled reliever (SABA, or low dose ICS/formoterol ifusing maintenance and reliever regimen); add spacer for pMDI.

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Increase controller: Rapid increase in ICS component up to max. 2000mcgBDP equivalent. Options depend on usual controller medication, as follows:ICS: At least double dose, consider increasing to high dose.Maintenance ICS/formoterol: Quadruple maintenance ICS/formoteroldose (to maximum formoterol dose of 72 mcg/day).Maintenance ICS/salmeterol: Step up at least to higher dose formulation;consider adding separate ICS inhaler to achieve high ICS dose.Maintenance and reliever ICS/formoterol: Continue maintenance dose;increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day).

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Oral corticosteroids (preferably morning dosing):Adults - prednisolone 1mg/kg/day up to 50mg, usually for 57 days.For children, 12 mg/kg/day up to 40mg, usually for 35 days.Tapering not needed if treatment has been given for less than 2 weeks.22

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MANAGING EXACERBATIONS IN PRIMARY OR ACUTE CARE

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Assess exacerbation severity while starting SABA and oxygen. Assessdyspnea (e.g. is the patient able to speak sentences, or only words),respiratory rate, pulse rate, oxygen saturation and lung function (e.g. PEF).Check for anaphylaxis.

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Consider alternative causes of acute breathlessness (e.g. heart failure,upper airway dysfunction, inhaled foreign body or pulmonary embolism).

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Arrange immediate transfer to an acute care facility if there are signs ofsevere exacerbation, or to intensive care if the patient is drowsy, confused, orhas a silent chest. For these patients, immediately give inhaled SABA, inhaledipratropium bromide, oxygen and systemic corticosteroids.

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Start treatment with repeated doses of SABA (usually by pMDI and spacer),early oral corticosteroids, and controlled flow oxygen if available. Checkresponse of symptoms and saturation frequently, and measure lung functionafter 1 hour. Titrate oxygen to maintain saturation of 9395% in adults andadolescents (9498% in children 612 years).

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For severe exacerbations, add ipratropium bromide, and consider givingSABA by nebulizer. In acute care facilities, intravenous magnesium sulfatemay be considered if the patient is not responding to intensive initialtreatment.

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Do not routinely perform chest X-ray or blood gases, or prescribe antibiotics,for asthma exacerbations.

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REVIEWING RESPONSE

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Monitor patients closely and frequently during treatment, and titratetreatment according to response. Transfer the patient to higher level care ifworsening or failing to respond.

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Decide about need for hospitalization based on clinical status,symptomatic and lung function, response to treatment, recent and past historyof exacerbations, and ability to manage at home.

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Before discharge, arrange ongoing treatment. For most patients, prescriberegular controller therapy (or increase current dose) to reduce the risk offurther exacerbations. Continue increased controller doses for 24 weeks,and reduce reliever to as-needed. Check inhaler technique and adherence.Provide an interim written asthma action plan.

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Arrange early follow-up after any exacerbation, preferably within 1 week.Consider referral for specialist advice for patients with an asthmahospitalization, or repeated emergency department presentations.23

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Box 10. Management of asthma exacerbations in primary care

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FOLLOW-UP AFTER AN EXACERBATION

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Exacerbations often represent failures in chronic asthma care, and theyprovide opportunities to review the patients asthma management. All patientsmust be followed up regularly by a health care provider until symptoms andlung function return to normal.

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Take the opportunity to review:The patients understanding of the cause of the exacerbationModifiable risk factors for exacerbations, e.g. smokingUnderstanding of purposes of medications, and inhaler technique skillsReview and revise written asthma action plan

ALTER

Discuss medication use, as adherence with ICS and OCS may fall to 50%within a week after discharge.

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Comprehensive post-discharge programs that include optimal controllermanagement, inhaler technique, self-monitoring, written asthma action planand regular review are cost-effective and are associated with significantimprovement in asthma outcomes.

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GLOSSARY OF ASTHMA MEDICATION CLASSES

Action and use

Adverse effects

Inhaled corticosteroids(ICS) (pMDIs or DPIs) e.g.beclometasone,budesonide, ciclesonide,fluticasone propionate,fluticasone furoate,mometasone, triamcinolone

The most effective anti-inflammatorymedications for persistent asthma. ICSreduce symptoms, increase lung function,improve quality of life, and reduce the riskof exacerbations and asthma-relatedhospitalizations or death. ICS differ intheir potency and bioavailability, but mostof the benefit is seen at low doses (seeBox 8 (p14) for low, medium and highdoses of different ICS).

Most patients using ICS donot experience side-effects.Local side-effects includeoropharyngeal candidiasis anddysphonia. Use of spacer withpMDI, and rinsing with waterand spitting out afterinhalation, reduce local sideeffects. High doses increasethe risk of systemic sideeffects.

ICS and long-acting beta2agonist bronchodilatorcombinations (ICS/LABA)(pMDIs or DPIs) e.g.beclometasone/ formoterol,budesonide/formoterol,fluticasone furoate/vilanterol, fluticasonepropionate/formoterol,fluticasone propionate/salmeterol, andmometasone/formoterol.

When a medium dose of ICS alone fails toachieve good control of asthma, theaddition of LABA to ICS improvessymptoms, lung function and reducesexacerbations in more patients, morerapidly, than doubling the dose of ICS.Two regimens are available: maintenanceICS/LABA with SABA as reliever, and lowdose combination beclometasone orbudesonide with formoterol formaintenance and reliever treatment.

Leukotriene modifiers(tablets) e.g. montelukast,pranlukast, zafirlukast,zileuton

Target one part of the inflammatoryFew side-effects exceptpathway in asthma. Used as an option for elevated liver function testscontroller therapy, particularly in children. with zileuton and zafirlukast.Used alone: less effective than low doseICS; added to ICS: less effective thanICS/LABA.

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Medications

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For more details, see full GINA 2014 report and Appendix (www.ginasthma.org) andProduct Information from manufacturers.

The LABA component may beassociated with tachycardia,headache or cramps. Currentrecommendations are thatLABA and ICS are safe forasthma when used incombination. Use of LABAwithout ICS in asthma isassociated with increased riskof adverse outcomes.

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CONTROLLER MEDICATIONS

Very limited role in long-term treatment ofasthma. Weak anti-inflammatory effect,less effective than low-dose ICS. Requiremeticulous inhaler maintenance.

Anti-IgE (omalizumab)

A treatment option for patients with severe Reactions at the site ofpersistent allergic asthma uncontrolled on injection are common butStep 4 treatment (high dose ICS/LABA). minor. Anaphylaxis is rare.

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Chromones (pMDIs orDPIs) e.g. sodiumcromoglycate andnedocromil sodium

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Side effects are uncommonbut include cough uponinhalation and pharyngealdiscomfort.

Action and use

Adverse effects

Systemic corticosteroids(tablets,suspension orintramuscular (IM) orintravenous (IV) injection)e.g. prednisone,prednisolone,methylprednisolone,hydrocortisone

Short-term treatment (usually 57 days inadults) is important early in the treatmentof severe acute exacerbations, with maineffects seen after 46 hours. Oralcorticosteroid (OCS) therapy is preferredand is as effective as IM or IV therapy inpreventing relapse. Tapering is required iftreatment given for more than 2 weeks.Long-term treatment with OCS may berequired for some patients with severeasthma.

Short-term use: some adverseeffects e.g. hyperglycaemia,gastro-intestinal side-effects,mood changes.Long-term use: limited by therisk of significant systemicadverse effects e.g. cataract,glaucoma, osteoporosis,adrenal suppression. Patientsshould be assessed forosteoporosis risk and treatedappropriately.

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Medications

RELIEVER MEDICATIONSInhaled SABAs are medications of choicefor quick relief of asthma symptoms andbronchoconstriction including in acuteexacerbations, and for pre-treatment ofexercise-induced bronchoconstriction.SABAs should be used only as-needed atthe lowest dose and frequency required.

Tremor and tachycardia arecommonly reported with initialuse of SABA, but tolerance tothese effects usually developsrapidly. Excess use, or poorresponse indicate poorasthma control.

Short-actinganticholinergics (pMDIsor DPIs) e.g. ipratropiumbromide,oxitropium bromide

Long-term use: ipratropium is a lessDryness of the mouth or aeffective reliever medication than SABAs. bitter taste.Short-term use in acute asthma: inhaledipratropium added to SABA reduces therisk of hospital admission

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Short-acting inhaledbeta2-agonistbronchodilators (SABA)(pMDIs, DPIs and, rarely,solution for nebulization orinjection) e.g. salbutamol(albuterol), terbutaline.

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Abbreviations used in this pocket guideBeclometasone dipropionate

BUD

Budesonide

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BDP

Dry powder inhaler

FEV1

Forced expiratory volume in 1 second

FVC

Forced vital capacity

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LABA Long-acting beta2-agonistsO2

Oxygen

Oral corticosteroids

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Peak expiratory flow

pMDI

Pressurized metered dose inhaler

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SABA Short-acting beta2-agonists

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ACKNOWLEDGEMENTS

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The activities of the Global Initiative of Asthma are supported by the work of membersof the GINA Board of Directors and Committees (listed below). The work was alsosupported in 20122013 by unrestricted educational grants from the followingcompanies: Almirall, Boehringer Ingelheim, Boston Scientific, CIPLA, Chiesi, ClementClarke, GlaxoSmithKline, Merck Sharp & Dohme, Novartis and Takeda.

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The members of the GINA committees are solely responsible for the statements andrecommendations presented in this and other GINA publications.

GINA Board of Directors (2014)

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J Mark FitzGerald, Canada, Chair; Eric Bateman, South Africa; Louis-Philippe Boulet*,Canada; Alvaro Cruz*, Brazil; Tari Haahtela*, Finland; Mark Levy*, United Kingdom;Paul O'Byrne, Canada; Pierluigi Paggiaro*, Italy; Soren Pedersen, Denmark; ManuelSoto-Quiroz*, Costa Rica; Helen Reddel, Australia; Gary Wong*, Hong Kong ROC.

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GINA Scientific Director: Suzanne Hurd, USAGINA Science Committee (2014)

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Helen Reddel, Australia, Chair; Eric Bateman, South Africa.; Allan Becker, Canada ;Johan de Jongste, The Netherlands; Jeffrey M. Drazen, USA ; J. Mark FitzGerald,Canada; Hiromasa Inoue, Japan; Robert Lemanske, Jr., USA; Paul O'Byrne, Canada;Soren Pedersen, Denmark; Emilio Pizzichini, Brazil; Stanley J. Szefler, USA.Consultant to the Science Committee: Brian Rowe, Canada.

GINA Dissemination and Implementation Committee (2014)

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Louis-Philippe Boulet, Canada, Chair; other members indicated by asterisks (*) above.

GINA Assembly

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The GINA Assembly includes members from 45 countries. Their names are listed onthe GINA website, www.ginasthma.org.

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Global Strategy for Asthma Management and Prevention (2014). This majorrevision provides an integrated approach to asthma that can be adapted for a widerange of health systems. The report has a user-friendly format with practicalsummary tables and flow-charts for use in clinical practice.GINA Online Appendix. Detailed background information to support the main report.

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Pocket Guide for asthma management and prevention for adults and childrenolder than 5 years (2014). Summary for primary health care providers, to be used inconjunction with the main GINA report.Pocket guide for asthma management and prevention in children 5 years andyounger (2014). A summary of patient care information about pre-schoolers withasthma or wheeze, to be used in conjunction with the main GINA 2014 report.Diagnosis of asthma-COPD overlap syndrome (ACOS) (2014). This is a standalone copy of the corresponding chapter in the main GINA report. It is co-publishedby GINA and GOLD (the Global Initiative for Chronic Obstructive Lung Disease,www.goldcopd.org).Clinical practice aids and implementation tools will be available on the GINAwebsite.GINA publications and other resources are available from www.ginasthma.org

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Visit the GINA website at www.ginasthma.org 2014 Global Initiative for Asthma