Contents Changing concept in asthma treatment Old GINA

Contents • Changing concept in asthma treatment • Old GINA guidelines • New GINA 2006 • Easy Asthma Clinic

Changing concept in asthma treatment short-acting b 2 -agonists Inh corticosteroid Bronchospasm Inflammation Airway Hyperresponsiveness 1975 1980 Combination 1985 Remodelling 1990 1995 2000

1995

2002 1995 1997 2004 94 9 1

FEV 1 Force Expiratory Volume in 1 second FVC Force Vital Capacity ��������� (spirometry)

Peak Flow meter (�����

Pharmacological therapy n Relievers n Inhaled fast-acting b 2 -agonists n Controllers n Inhaled corticosteroids Inhaled long-acting b 2 -agonists n Oral anti-leukotrienes n Oral theophyllines n

Inhaled corticosteroids Fluticasone Budesonide Beclomethasone

Classification of asthma severity: GINA 1995 3 1 Day symptoms Night symptoms PEFR PF variability 2 Intermittent Mild persistent /1>wk /2>mo /1<wk /2<mo 80%< 20%> 20 -30% Moderate persistent daily /1<wk 4 Severe Persistent daily frequent 60 -80% 60%> 30%<

GINA 1995 Level 4 Level 3 Level 2 Level 1 High dose ICS +other controller high dose ICS B 2 agonist prn

2002

Classification of asthma severity: GINA 2002 Symptoms and lung function Current treatment step 1 step 2 step 3 intermittent Mild persistent Mod persistent Severe persistent Mod persistent Severe persistent Severe persistent

GINA 1995 2002 Level 4 Level 3 Level 2 Level 1 High ICS+LABA dose ICS +other controller high dose ICS+LABA ICS B 2 agonist prn

GINA 1995 -2002 Aim: Asthma control Asthma severity • Day symptoms • Night symptoms • Reliever • PEFR • Exacerbation • Limitation of activity 1995 4. Severe persistent 3. Moderate persistent 2. Mild persistent 1. Intermittent 2002 Treatment 4. SABA+ICS+LABA+pred 3. SABA+ICS+LABA 2. SABA +ICS 1. SABA prn

Day symptoms Asthma Severity Night symptoms PEFR Peak flow variability Asthma Control

Classification of asthma severity: GINA 1995 Day symptoms Night symptoms PEFR PF variability Moderate persistent Intermittent Mild persistent /1>wk /2>mo /1<wk /2<mo daily /1<wk 20%> 20 -30% 30%< Severe Persistent daily frequent TOO 80%< COMPLICATE 80%< 60 -80% 60%> 30%<

Asthma severity • Too complicate • Vary with time • Difficult to evaluate when treated

New 13 Nov 2006

The recommendations for asthma management Revised 2006 1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat, and Monitor Asthma 4. Manage Asthma Exacerbations 5. Special Considerations

GINA 2006 • Day symptoms • Night symptoms • Reliever Assessing asthma control • PEFR • Exacerbation • Limitation of activity 2006 • Controlled • Partly controlled Treating to achieve asthma control • Uncontrolled 1. 2. 3. 4. 5. B 2 -agonist prn ICS (low dose) + LABA ICS (high dose) + LABA + prednisolone Monitoring to maintain control

Asthma admission in Thailand (excluding Bangkok) Health Information Division, Bureau of Health Policy and Planing

Chiangmai Khonkaen Bangkok Survey of asthma control in Thailand Watchara Boonsawat Poonkasem Charoenphan Sumalee Kaitboonsri Vilaivan Wiriyachaiyo Chaicharn Pothirat Somkiat Wongtim Nikom Thanomsieng Songkhla Respirology (2004)

GINA Goal: No Emergency visits Asthma morbidity in the past year

GINA GOAL: No limitation on activities

Asthma medication in past four weeks Asthma control in Thailand. Respirology 2004

1995 2002 2006 n o i t a t n e m e l p Im 1997 2004 1994

Guidelines Implementation ? ? ? ? What is the problem?

Not recognize asthma as an important cause of morbidity Asthma admission in Thailand (excluding Bangkok) Health Information Division, Bureau of Health Policy and Planing

�������� ICS B 2 agonist Changing the brain ?

Too many guidelines 1995 2002 2006 1997 1994 2004

Classification of asthma severity: GINA 1995 Day symptoms Night symptoms PEFR PF variability Moderate persistent Intermittent Mild persistent /1>wk /2>mo /1<wk /2<mo daily /1<wk 20%> 20 -30% 30%< Severe Persistent daily frequent TOO 80%< COMPLICATE 80%< 60 -80% 60%> 30%<

HYPERTENSION ASTHMA BP 180/100 mm. Hg PEFR 200 L/Min = Hypertension = ?

Six-Part Asthma Management Program It’s not easy 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

Easy asthma clinic: ������ • Make the treatment of asthma as easy as possible • Run by GP in general hospitals throughout the country • Emphasize the role of pharmacist and nurse in asthma management • Organize the system

• Register patients nurse Doctor nurse • Assess asthma control 1. 2. 3. 4. Questionaires Day symptoms Night symptoms BD use ER Treatment (Simplify GINA guidelines) Appointment Asthma education Pharmacist Inhaler technique Compliance ������

Outcomes • Improve quality of asthma care • Reduced ER visits and admissions • Reduce workload for doctors • Asthma database and publications

Asthma clinic is now online http: //eac. mykku. net

Conclusions • Concept in asthma treatment is changing • Old GINA guidelines using asthma severity to guide treatment. • New GINA 2006 using asthma control to guide treatment. No more severity. • Easy Asthma Clinic is the easy way to implement guidelines

Simplified asthma treatment Asthma Patient Total control Assess Control Treatment No day symptoms No night symptoms No rescue medication No ER visit PEFR >80% ICS 500 ug/d + ICS 500 ug/d Other controller

Levels of Asthma Control Characteristic Controlled (All of the following) Partly Controlled (Any measure present in any week) Uncontrolled Daytime symptoms None (twice or less/week) More than twice/week Limitations of activities None Any Nocturnal symptoms/awakening None Any Three or more features of partly controlled asthma present Need for reliever/ rescue treatment None (twice or less/week) More than twice/week Lung function (PEF or FEV 1)‡ Normal < 80% predicted or personal best (if known) Exacerbations None One or more/year* One in any week† * 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. ‡ Lung function is not a reliable test for children 5 years and younger.