Maria Bea Merscher – Interna en Medicina Interna – Estudiante de Intercambio

GINA – Management and Treatment of Asthma

Publish guidelines

What is GINA?

How does GINA define asthma?

“Asthma is a chronic inflammatory disorder of the airways in which many cells

and cellular elements play a role. The chronic inflammation is associated with

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 within the lung that is often reversible either

spontaneously or with treatment.”

What is the aim of GINA?

Guided self-management (1A)

What is the aim of GINA?

Improve

the

Improve

the

patient’s

patient’s

compliance!

!

compliance!

!

Don’t forge

t the

Don’t forge

t the

education of o

thers!

education of o

thers!

Levels of Control Characteristics

Controlled (all of the following)

Partially controlled Not controlled

Daily symptoms No (≤ 2x per week) >2 per week

≥3 characteristics of partially controlled asthma in any week

Limitation of activities

No Any

Nighttime symptoms / patient

is woken by symptoms

No Any

Use of short-acting β2-agonists for

symptom control

No (≤ 2x per week) >2 per week

Pulmonary function (FEV1 or peak flow)

>80% predicted/personal

best

<80% predicted/personal

best

Exacerbations No ≥1 1x per week

Impairment

Risk

Severity

Severity Frequency of

symptomsNighttime symptoms

FEV1Variety of

FEV1

Usage of short-acting β2-agonists

Intermittent ≤ 2x per week≤ 2x per month

≥ 80% < 20%≤ 2 days per

week

Mild persistent

> 2x per week but not daily

3-4 x per month

≥ 80% 20-30%> 2 days per

week but not daily

Moderate persistent

Daily > 1x per week

but not at nighttime

60-80% > 30% Daily

Severe persistent

Throughout the day

Frequent (~7x per week)

< 60% > 30%Several times

a day

Controllers vs Relievers

Management Based on Control

Management Based on Control

Routes of Administration

Inhaled Glucocorticosteroids

Equipotency of Inhaled Glucocorticosteroids

Side effects: Inhaled Glucocorticosteroids

Leukotriene Modifiers

Side effects: Leukotriene Modifiers

Long-acting inhaled β2-agonists

Long-acting inhaled β2-agonists

Theophylline

Theophylline

Theophylline• Xanthin derivative• Competitive nonselective phosphodiesterase inhibitor raises

intracellular cAMP activates PKA inhibits TNF-alpha and inhibits leukotriene synthesis reduces inflammation and innate immunity

• Nonselective adenosine receptor antagonist, antagonizing A1, A2, A3 receptors almost equally explains cardiac side effects

• Inhibits TGF (transforming growth factor)-beta-mediated conversion of pulmonary fibroblasts into myofibroblasts in COPD and asthma via cAMP-PKA pathway which codes for collagen

• Directly activates HDAC2 (histone deacetylase) repackaging of DNA promoter regions of inflammatory genes are unavailable for binding of transcription factors such as NF-kappa-B

• Smoking inhibits the HDAC2-activity theophylline should be considered in smoking asthmatics

Systemic glucocorticosteroids

Systemic glucocorticosteroids

Patients with long-term systemic glucocorticosteroids should receive osteoporosis-profilaxis!

Systemic glucocorticosteroids and osteoporosis

Anti-IgE

Anti-IgE

Severity of Asthma Exacerbations

Rapid-acting inhaled β2-agonists

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Systemic glucocorticosteroids

Anticholinergics

Anticholinergics

Theophylline

Short-acting oral β2-agonists