the update gina guideline 2006
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New. The Update GINA guideline 2006. ผศ. นพ. วัชรา บุญสวัสดิ์ M.D., Ph.D. ภาควิชาอายุรศาสตร์ คณะแพทย์ศาสตร์ มหาวิทยาลัยขอนแก่น. Contents. Changing concept in asthma treatment Old GINA guidelines New GINA2006 Easy Asthma Clinic. Changing concept in asthma treatment. short-acting - PowerPoint PPT PresentationTRANSCRIPT
The Update GINA The Update GINA guideline 2006 guideline 2006
ผศ . นพ . วั�ชรา บุ�ญสวั�สดิ์�� M.D., Ph.D.
ภาควั�ชาอายุ�รศาสตร� คณะแพทยุ�ศาสตร�
มหาวั�ทยุาลั�ยุขอนแก่!น
NewNew
Contents
• Changing concept in asthma treatment
• Old GINA guidelines
• New GINA2006
• Easy Asthma Clinic
1975 1980 1985 1990 1995 2000
Changing concept in asthma treatment
Airway Hyperresponsiveness
Bronchospasm Inflammation
Remodelling
short-acting b2-agonists Inh corticosteroid Combination
1995
1995
1994
1997
2002
2004
ก่ารตรวัจสมรรถภาพปอดิ์ (spirometry)
FEV1
Force Expiratory Volume in 1 second
FVC
Force Vital Capacity
Peak Flow meter (เคร&'องวั�ดิ์ควัามเร)วัส*งส�ดิ์)
Bronchodilator Test
• เป+าสมรรถภาพปอดิ์ หร&อ Peak Flow ก่!อนแลัะหลั�งพ!นยุาขยุายุหลัอดิ์ลัม 15 นาท,
• FEV1 เพ�'มข-.นมาก่ก่วั!า 12 % ถ&อวั!าเป/นโรคห&ดิ์• PEFR เพ�'มข-.นมาก่ก่วั!า 15 % ถ&อวั!าเป/นโรคห&ดิ์
PEFR =300 L/min
•Salbutamol inhaler 2 puff•รอเวัลัา 15 นาท,
PEFR =390 L/min
PEFR เพิ่��มขึ้��น
300
390-300
= 30%
เป1าหมายุของก่ารร�ก่ษาโรคห&ดิ์• สามารถควับุค�มอาก่ารของโรคให4สงบุลังไดิ์4• ป1องก่�นไม!ให4โรคก่6าเร�บุ• ท6าให4สมรรถภาพปอดิ์ไก่ลั4เค,ยุงคนปก่ต�มาก่
ท,'ส�ดิ์• ท6าให4ผ*4ป+วัยุดิ์6ารงช,วั�ตไดิ์4เหม&อนคนปก่ต�• หลั,ก่เลั,'ยุงผลัแทรก่ซ้4อนจาก่ยุา• ป1องก่�นก่ารเส&'อมของสมรรถภาพปอดิ์จน
เก่�ดิ์ก่ารอ�ดิ์ก่�.นอยุ!างถาวัร• ป1องก่�นก่ารเส,ยุช,วั�ตจาก่โรคห&ดิ์
1994
2004
ข�.นตอนก่ารดิ์6าเน�นก่ารในก่ารร�ก่ษา
1. ให4ควัามร*4แก่!ผ*4ป+วัยุแลัะญาต�2. หลั,ก่เลั,'ยุงส�'งท,'ก่!อให4เก่�ดิ์ก่ารหอบุ3. จ6าแนก่ควัามร�นแรงของโรค4. จ�ดิ์แผนก่ารร�ก่ษาท,'เหมาะสม5. จ�ดิ์แผนก่ารร�ก่ษาเม&'อม,ก่ารหอบุเฉี,ยุบุพลั�น6. ให4ก่ารดิ์*แลัร�ก่ษาต!อเน&'อง
1994
2004
Pharmacological therapy
Controllers Inhaled corticosteroids
Inhaled long-acting 2-agonists
Oral anti-leukotrienes Oral theophyllines
Relievers Inhaled fast-acting
2-agonists
Inhaled corticosteroids
BeclomethasoneBudesonideFluticasone
Classification of asthma severity: GINA 1995
Day symptoms
Night symptoms
PEFR
PF variability
Intermittent<1/wk
2< /mo
>80%
<20%
>1/wk
> 2 /
>80%
20-30%
daily
>1/wk
60-80%
>30%
dailyfrequent
<60%
>30%
Mildpersistent
Moderatepersistent
Severe Persistent
12
34
High dose ICS+other controller
B2 agonist prnLevel 1
ICS
high dose ICS
Level 2
Level 3
Level 4
GINAGINA19951995
2002
Classification of asthma severity: GINA 2002
Symptoms and lung function
Current treatment step
step1 step2 step3
intermittent intermittent Mild persistent Mod persistent
Mild persistent Mild persistent Mod persistent Severe persistent
Mod persistent Mod persistent Severe persistent
Severe persistent
Severe persistent
Severe persistent
Severe persistent
Severe persistent
High dose ICS+other controller
B2 agonist prnLevel 1
ICS
high dose ICS
ICS+LABA+other controller
Level 2
Level 3
Level 4
ICS+LABA
GINAGINA19951995GINA GINA 20022002
Aim: Asthma control
Asthma severity
Treatment
GINA 1995-2002
1995
20021. 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
Asthma Severity
Asthma Control
Day symptoms
Night symptoms
PEFR
Peak flow variability
Classification of asthma severity: GINA 1995
Day symptoms
Night symptoms
PEFR
PF variability
Intermittent<1/wk
2< /mo
>80%
<20%
>1/wk
> 2 /
>80%
20-30%
daily
>1/wk
60-80%
>30%
dailyfrequent
<60%
>30%
Mildpersistent
Moderatepersistent
Severe Persistent
TOO COMPLICATE
Asthma severity
• Too complicate
• Vary with time
• Difficult to evaluate when treated
NewNew13 Nov 2006
The recommendations for asthma management
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 ConsiderationsRevised 2006
Assessing asthma control
Treating to achieve asthma control
Monitoring to maintain control
•Day symptoms•Night symptoms•Reliever•PEFR•Exacerbation•Limitation of activity
GINA 2006
2006
1. B2-agonist prn2. ICS3. ICS (low dose) + LABA4. ICS (high dose) + LABA5. ICS (high dose) + LABA + prednisolone
•Controlled•Partly controlled•Uncontrolled
6667976202 79769
90606102245
0
20000
40000
60000
80000
100000
120000
2538 2539 2540 2543 2545
Asthma admission in Thailand (excluding Bangkok)
Health Information Division, Bureau of Health Policy and Planing
Khonkaen
Bangkok
Chiangmai
Songkhla
Survey of Survey of asthma asthma control in control in ThailandThailand Watchara Boonsawat Watchara Boonsawat
Poonkasem Charoenphan Poonkasem Charoenphan Sumalee Kaitboonsri Sumalee Kaitboonsri
Vilaivan Wiriyachaiyo Vilaivan Wiriyachaiyo Chaicharn Pothirat Chaicharn Pothirat
Somkiat Wongtim Somkiat Wongtim Nikom Thanomsieng Nikom Thanomsieng
Respirology (2004)
GINA Goal: No Emergency visits
14.8
21.723.6
0
5
10
15
20
25
admit ER visit loss work
Asthma morbidity in the past year
GINA GOAL: No limitation on activities
Activity limitation due to asthma
66.162.5
52.3 51.2
34.8
0
10
20
30
40
50
60
70
sport sleep career choice daily activities social activities
%
17.14.9
14.34.6 6.7
67.555.6
39.6
25.537
01020304050607080
%
ICS rescue
Asthma medication in past four weeks
Asthma control in Thailand. Respirology 2004
1995
1994
1997
2002 2006
2004
ImplementationImplementation
Guidelines ImplementationGuidelines Implementation
What is the problem?
?? ??
???
Not recognize asthma as an important cause of morbidity
6667976202 79769
90606102245
0
20000
40000
60000
80000
100000
120000
2538 2539 2540 2543 2545
Asthma admission in Thailand (excluding Bangkok)
Health Information Division, Bureau of Health Policy and Planing
B2
agonist
ICS
แพทยุ�ปร�บุต�วัไม!ท�นก่�บุแนวัทางก่ารร�ก่ษาท,'เปลั,'ยุนไป
Changing the brain ?
2002
Too many guidelines
1995
1994
1997
2006
2004
Classification of asthma severity: GINA 1995
Day symptoms
Night symptoms
PEFR
PF variability
Intermittent<1/wk
2< /mo
>80%
<20%
>1/wk
> 2 /
>80%
20-30%
daily
>1/wk
60-80%
>30%
dailyfrequent
<60%
>30%
Mildpersistent
Moderatepersistent
Severe Persistent
TOO COMPLICATE
BP 180/100 mmHg
= Hypertension
PEFR 200 L/Min
= ?
HYPERTENSION ASTHMA
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
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
Six-Part Asthma ManagementProgramSix-Part Asthma ManagementProgram
It’s not easy It’s not easy
Easy asthma clinic: ก่ลัยุ�ทธ์�• 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
nurse
Doctor
nurse
Pharmacist
•Register patients
•Assess asthma control
Treatment (Simplify GINA guidelines)
Appointment
Asthma education Inhaler techniqueCompliance
Questionaires
1. Day symptoms
2. Night symptoms
3. BD use
4. ER
วั�ดิ์ควัามเร)วัส*งส�ดิ์
Outcomes
• Improve quality of asthma care
• Reduced ER visits and admissions
• Reduce workload for doctors
• Asthma database and publications
Asthma clinic is now onlinehttp://eac.mykku.net
Conclusions
• Concept in asthma treatment is changing
• Old GINA guidelines using asthma severity to guide treatment.
• New GINA2006 using asthma control to guide treatment. No more severity.
• Easy Asthma Clinic is the easy way to implement guidelines
Simplified asthma treatment
Assess Control
ICS 500ug/d
Asthma Patient
Treatment
ICS 500ug/d+Other controller
No day symptomsNo night symptomsNo rescue medicationNo ER visitPEFR >80%
Total control
Levels of Asthma ControlCharacteristic 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 Three or more features
of partly controlled
asthma present
Limitations of activities None Any
Nocturnal symptoms/awakening
None Any
Need for reliever/
rescue treatment
None (twice or less/week)
More than twice/week
Lung function (PEF or FEV1)‡
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.