Scope Guideline for Asthma

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Asthma admission in Thailand (excluding Asthma admission in Thailand (excluding Bangkok)Bangkok)

6667976202 79769

90606102245

0

30000

60000

90000

120000

2538 2539 2540 2543 2545

Year

Pat

ien

t

Health Information Division, Bureau of Health Policy and Planing

Burden in Thailand*Burden in Thailand*• Cost of health care (exclude testing)

– 990 million Bahts in 2546– 1,087 million Bahts in 2547

*Association of Allergy & Immunology of Thailand*Association of Allergy & Immunology of Thailand

Asthma

Reversible inflammation & obstruction Intermittent attacks Sudden onset Varies from person to person Severity can vary from shortness of

breath to death

6

Asthma Diagnosis

•History and patterns of symptomsHistory and patterns of symptoms

•Physical examinationPhysical examination

•Measurements of lung functionMeasurements of lung function

7199

5

http://www.ginasthma.org

1995 2002 2004 2006 2007 2008

1995 2002 2004 2006 2007 2008

NewNew

1975 1980 1985 1990 1995 2000

Changing concept in asthma treatmentChanging concept in asthma treatment

AirwayHyperresponsiveness

Bronchospasm Inflammation

Remodelling

short-acting short-acting bb22-agonists-agonists Inh corticosteroidInh corticosteroid CombinationCombination

GINA 1995-2005

• Severity classification

• Stepwise treatment according to severity

11

Classification of Asthma SeverityClassification of Asthma Severity(GINA 1995)(GINA 1995)

Intermittent

Mildpersistent

Moderatepersistent

SeverePersistent

ßß2 2 prnprn

Inh steroidsInh steroidsLABALABA

Treatment in GINA 2002

Aim: Asthma control

Asthma severity

Treatment

GINA 1995-2002

1995

2002

1. Intermittent

2. Mild persistent

3. Moderate persistent

4. Severe persistent

1. SABA prn

4. SABA+ICS+LABA+pred

3. SABA+ICS+LABA

2. SABA +ICS

•Day symptoms•Night symptoms•Reliever•PEFR•Exacerbation•Limitation of activity

Treatment in GINA 2004

Step 1Intermittent

None

Controller

Step 2Mild persistent

Low-doseinhaled

corticosteroid(theophylline,

leukotriene modifier, cromolyn)

Controller

Step 3Moderate

persistent

Low-to-medium-dose inhaled

corticosteroid +long-acting inhaled 2-

agonist (theophylline,

leukotriene modifier,

oral 2-agonist)

Controller

Step 4Severe persistent

High-dose inhaled corticosteroid + long-actinginhaled 2-agonistplus if needed

Theophylline-SRLeukotriene

modifierOral 2-agonistOral

corticosteroidAnti-IgE

Controller

Reliever: rapid-acting inhaled Reliever: rapid-acting inhaled ββ22-agonist prn-agonist prn

Outcome: asthma controlOutcome: best possible results

Global Initiative for Asthma (2004 update published 2005)

2006

Assess asthma control

Adjust treatments according to level of asthma control

Revised 2006

Asthma Management and PreventionProgram: Five Components

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: AR, AS

Levels of Asthma Control: Levels of Asthma Control: GINA 2006GINA 2006

Characteristic Controlled Partly Controlled

Uncontrolled

Daytime symptoms ≤ 2/wk > 2/wk Three or more features of partly controlled

asthma presentLimitations of activities

None Any

Nocturnal symptoms None Any

Need for reliever ≤ 2/wk > 2/wk

Lung function (PEF or FEV1)‡ Normal

< 80% predicted or personal best(if known)

Exacerbations None ≥ 1 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.

Management approach based on control

Treatment action

Maintain, use lowest controller

Consider step-up

Step-up Rx

Level of control

Controlled

Partly controlled

Uncontrolled

Red

uce

Incr

ease

GINA 2006

Step 1Step 1 Step 2Step 2 Step 3Step 3 Step 4Step 4 Step 5Step 5

As needed rapid-acting As needed rapid-acting 22-agonist-agonist

Select oneSelect one Select oneSelect one Add one or Add one or moremore

Add one or Add one or moremore

Low-dose Low-dose ICSICS

Low-dose Low-dose ICS/LABAICS/LABA

Med-high Med-high ICS/LABAICS/LABA Oral steroidsOral steroids

Leukotriene Leukotriene modifiermodifier

Med-high Med-high dose ICSdose ICS

Leukotriene Leukotriene modifiermodifier Anti-IgEAnti-IgE

Low Low ICS+LTMICS+LTM TheophyllineTheophylline

Low Low ICS+TheoICS+Theo

GINA 2006

Cont

rolle

r Opti

ons

Cont

rolle

r Opti

ons

20

Assessing asthma control

Treating to achieve asthma control

Monitoring to maintain control

•Day symptoms•Night symptoms•Reliever•PEFR•Exacerbation•Limitation of activity

GINA 2006GINA 20062006

1. B2-agonist prn2. ICS or LTM3. ICS (low dose) + LABA4. ICS (high dose) + LABA, LTM,

theophylline5. ICS (high dose) + LABA + prednisolone

•Controlled•Partly controlled•Uncontrolled

In treatment-naïve patients started at Step 2. In very symptomatic (uncontrolled) started at Step 3.