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Global strategy for asthma management and prevention: GINA executive summary

E. D. Bateman, S. S. Hurd, P. J. Barnes, J. Bousquet, J. M. Drazen, M. FitzGerald, P. Gibson, K. Ohta, P. O'Byrne, S. E. Pedersen, E. Pizzichini, S. D. Sullivan, S. E. Wenzel, H. J. Zar
European Respiratory Journal 2008 31: 143-178; DOI: 10.1183/09031936.00138707
E. D. Bateman
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S. S. Hurd
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P. J. Barnes
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J. Bousquet
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J. M. Drazen
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M. FitzGerald
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P. Gibson
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K. Ohta
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P. O'Byrne
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S. E. Pedersen
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E. Pizzichini
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S. D. Sullivan
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S. E. Wenzel
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H. J. Zar
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  • Fig. 1—
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    Fig. 1—

    Management approach based on control for children >5 yrs of age, adolescents and adults. Alternative reliever treatments include inhaled anticholinergics, short-acting oral β2-agonists, some long-acting β2-agonists and short-acting theophylline. Regular dosing with short- and long-acting β2-agonist is not advised unless accompanied by regular use of an inhaled glucocorticosteroid (ICS). The available literature on treatment of asthma in children aged ≤5 yrs precludes treatment recommendations. The best-documented treatment to control asthma in this age group is ICS and, at step 2, a low-dose ICS is recommended as the initial controller treatment. Equivalent doses of ICSs, some of which may be given as a single daily dose, are provided in table 5⇓. ░: preferred controller options. #: receptor antagonist or synthesis inhibitors.

  • Fig. 2—
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    Fig. 2—

    Management of asthma exacerbations in the acute care setting. PEF: peak expiratory flow; FEV1: forced expiratory volume in one second; PCO2: carbon dioxide tension; PO2: oxygen tension. 1 mmHg = 0.133 kPa.

Tables

  • Figures
  • Table 1—

    Description of levels of evidence

    Evidence categorySources of evidenceDefinition
    ARCTsRich body of dataEvidence is from end-points of well-designed RCTs that provide a consistent pattern of findings in the population for which the recommendation is made. Evidence Category A requires substantial numbers of studies involving substantial numbers of participants.
    BRCTsLimited body of dataEvidence is from end-points of intervention studies that include only a limited number of patients, post hoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general, Evidence Category B pertains when few randomised trials exist, they are small in size, they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat inconsistent.
    CNonrandomised trialsObservational studiesEvidence is from outcomes of uncontrolled or nonrandomised trials or from observational studies.
    DPanel consensus judgmentThis Evidence Category is used only in cases where the provision of some guidance was deemed valuable but the clinical literature addressing the subject was insufficient to justify placement in one of the other categories. The Panel Consensus is based on clinical experience or knowledge that does not meet the aforementioned criteria.
    • RCT: randomised controlled trial.

  • Table 2—

    Classification of asthma severity by clinical features before treatment

    Intermittent
     Symptoms less than once a week
     Brief exacerbations
     Nocturnal symptoms not more than twice a month
     FEV1 or PEF ≥80% pred
     PEF or FEV1 variability <20%
    Mild persistent
     Symptoms more than once a week but less than once a day
     Exacerbations may affect activity and sleep
     Nocturnal symptoms more than twice a month
     FEV1 or PEF ≥80% pred
     PEF or FEV1 variability <20–30%
    Moderate persistent
     Symptoms daily
     Exacerbations may affect activity and sleep
     Nocturnal symptoms more than once a week
     Daily use of inhaled short-acting β2-agonist
     FEV1 or PEF 60–80% pred
     PEF or FEV1 variability >30%
    Severe persistent
     Symptoms daily
     Frequent exacerbations
     Frequent nocturnal asthma symptoms
     Limitation of physical activities
     FEV1 or PEF ≤60% pred
     PEF or FEV1 variability >30%
    • FEV1: forced expiratory volume in one second; PEF: peak expiratory flow; % pred: % predicted.

  • Table 3—

    Levels of asthma control

    CharacteristicControlled (all of the following)Partly controlled (any measure present in any week)Uncontrolled
    Daytime symptomsNone (twice or less per week)More than twice a weekThree or more features of partly controlled asthma present in any week
    Limitations of activitiesNone (twice or less per week)AnyThree or more features of partly controlled asthma present in any week
    Nocturnal symptoms/awakeningNoneAnyThree or more features of partly controlled asthma present in any week
    Need for reliever/rescue treatmentNone (twice or less per week)More than twice a weekThree or more features of partly controlled asthma present in any week
    Lung function (PEF or FEV1)#Normal<80% pred or personal best (if known)Three or more features of partly controlled asthma present in any week
    ExacerbationsNoneOne or more per year¶One in any week+
    • PEF: peak expiratory flow; FEV1: forced expiratory volume in one second; % pred: % predicted. #: lung function is not a reliable test for children aged ≤5 yrs; ¶: any exacerbation should prompt review of maintenance treatment to ensure that it is adequate; +: by definition, an exacerbation in any week makes that an uncontrolled asthma week.

  • Table 4—

    Estimated equipotent daily doses of inhaled glucocorticosteroids for adults#

    DrugLow daily dose μgMedium daily dose μgHigh daily dose μg¶
    Beclomethasone dipropionate200–500>500–1000>1000–2000
    Budesonide+200–400>400–800>800–1600
    Ciclesonide+80–160>160–320>320–1280
    Flunisolide500–1000>1000–2000>2000
    Fluticasone propionate100–250>250–500>500–1000
    Mometasone furoate+200–400>400–800>800–1200
    Triamcinolone acetonide400–1000>1000–2000>2000
    • Notes. 1) The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects. 2) Designation of low, medium and high doses is provided from manufacturers' recommendations where possible. Clear demonstration of dose–response relationships is seldom provided or available. The principle is, therefore, to establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse effects. 3) As CFC preparations are taken from the market, medication inserts for hydrofluoroalkane preparations should be carefully reviewed by the clinician for the equivalent correct dosage, as a low dose may be indicated. #: Comparisons based upon efficacy data. ¶: Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side-effects. +: Approved for once-daily dosing in milder patients.

  • Table 5—

    Estimated equipotent daily doses of inhaled glucocorticosteroids for children#

    DrugLow daily dose μgMedium daily dose μgHigh daily dose μg¶
    Beclomethasone dipropionate100–200>200–400>400
    Budesonide+100–200>200–400>400
    Ciclesonide+80–160>160–320>320
    Flunisolide500–750>750–1250>1250
    Fluticasone propionate100–200>200–500>500
    Mometasone furoate+100–200>200–400>400
    Triamcinolone acetonide400–800>800–1200>1200
    • Notes. 1) The most important determinant of appropriate dosing is the clinician's judgment of the patient's response to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects. 2) Designation of low, medium and high doses is provided from manufacturers' recommendations where possible. Clear demonstration of dose–response relationships is seldom provided or available. The principle is, therefore, to establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse effects. 3) As CFC preparations are taken from the market, medication inserts for hydrofluoroalkane preparations should be carefully reviewed by the clinician for the equivalent correct dosage. #: Comparisons based upon efficacy data. ¶: Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side-effects. +: Approved for once-daily dosing in mild patients.

  • Table 6—

    Summary of glucocorticosteroids and growth in children

    Uncontrolled or severe asthma adversely affects growth and final adult height
    No long-term controlled studies have reported any statistically or clinically significant adverse effects on growth of 100–200 μg·day−1 of inhaled glucocorticosteroids
    Growth retardation may be seen with all inhaled glucocorticosteroids when a high dose is administered
    Growth retardation in both short- and medium-term studies is dose dependent
    Important differences seem to exist between the growth-retarding effects of various inhaled glucocorticosteroids and inhalers
    Different age groups seem to differ in their susceptibility to the growth-retarding effects of inhaled glucocorticosteroids; children aged 4–10 yrs are more susceptible than adolescents
    Glucocorticosteroid-induced changes in growth rate during the first year of treatment appear to be temporary
    Children with asthma treated with inhaled glucocorticosteroids attain normal adult height (predicted from family members) but at a later age
    • Data are taken from 157–159.

  • Table 7—

    Summary of bones and glucocorticosteroids in children

    No studies have reported any statistically significant increased risk of fractures in children taking inhaled glucocorticosteroids
    Oral or systemic glucocorticosteroid use increases the risk of fracture. The risk of fracture increases along with the number of treatments, with a 32% increase at four courses ever. Use of inhaled glucocorticosteroids reduces the need for systemic courses
    Controlled longitudinal studies of 2–5 yrs’ duration and several cross-sectional studies found no adverse effects of inhaled glucocorticosteroid treatment on bone mineral density
    No prospective studies have followed children on inhaled glucocorticosteroid treatment until peak bone mineral density has been reached
    • Data are taken from 52, 160, 161.

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Global strategy for asthma management and prevention: GINA executive summary
E. D. Bateman, S. S. Hurd, P. J. Barnes, J. Bousquet, J. M. Drazen, M. FitzGerald, P. Gibson, K. Ohta, P. O'Byrne, S. E. Pedersen, E. Pizzichini, S. D. Sullivan, S. E. Wenzel, H. J. Zar
European Respiratory Journal Jan 2008, 31 (1) 143-178; DOI: 10.1183/09031936.00138707

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Global strategy for asthma management and prevention: GINA executive summary
E. D. Bateman, S. S. Hurd, P. J. Barnes, J. Bousquet, J. M. Drazen, M. FitzGerald, P. Gibson, K. Ohta, P. O'Byrne, S. E. Pedersen, E. Pizzichini, S. D. Sullivan, S. E. Wenzel, H. J. Zar
European Respiratory Journal Jan 2008, 31 (1) 143-178; DOI: 10.1183/09031936.00138707
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