update in intrnational asthm guideline 2012(อ.ฉันชาย)

7/30/2019 update in intrnational asthm guideline 2012( . )

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Update in International

Asthma Guidelines (Adult)


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Why do we need guideline?


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Asthma diagnosis

History of Asthma Guidelines

Clinical practice guidelines aresystematically developed statements

designed to help practitioners and patients

make appropriate health care decisions inspecific circumstances

First opinion based asthma guidelinepublished in Australia and New Zealand inmid 1989 (published in Medical Journal of

Australia)


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Asthma diagnosis

First Asthma Guidelines (1989)


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Asthma diagnosis

Principle of asthma guideline

1. Practical asthma guidelines should beconstructed on a strong foundation

from scientific or evidenced-based

therapies or discoveries.

2. Guideline should be widelydisseminated and implemented

throughout the health care community.


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Asthma diagnosis

Principle of asthma guideline

3. Guideline implementation shouldultimately benefit patient outcomes.

4. To ensure that guidelines remain

current and based on knowledge and

evidence, they should have amechanism for regular scheduled

update.


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Asthma diagnosisNational Asthma Guidelines

The Global Asthma Report 2011


8/36The Global Asthma Report 2011


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Asthma diagnosisInternational Asthma Guidelines

New Zealand and Australia guideline Canadian Guideline

British Guideline (NICE) Global Initiative for Asthma Guideline

(GINA)

National Asthma Education andPrevention Program Guidelines (NAEPP)


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the GINA guidelines focused on internationalasthma, the different financial statuses of various

countries led the GINA panel to produce a

comprehensive document that highlighted preferredtreatment categories for acute and chronic asthma

but did not focus on specific medications.


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GINA NICE


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Asthma diagnosisGINA Guideline

The GINA programs mission was to developrecommendations on asthma care and

management that would be based on the best

available scientific evidence so that it could becustomized or adapted to meet the needs and

resources of local health care systems.

The GINA program was a collaboration of theWorld Health Organization and the National

Heart, Lung, and Blood Institute of the United

States National Institutes of Health.


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Asthma diagnosisGINA Guideline 2011

GINA established in 1993

1st GINA guideline 1995

Revised in 2002,2006

Revised version of 2006version annually, last

update in December 2001


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Asthma diagnosisGINA Guideline 2011: Overview

Chapter 1: Definition and overviewChapter 2: Diagnosis and classificationChapter 3: Asthma medicationsChapter 4: Asthma management and prevention

Component 1: develop doctor-patientrelationship

Component 2: identification and reduceexposure to risk factors

Component 3: Assess, treat and monitor asthmaComponent 4: Manage asthma exacerbationComponent 5: Special considerations

Chapter 5: Implementation of asthma guidelines inhealth systems


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Asthma diagnosisGINA Guideline 2011: Changes

GINA science committee meet twice yearly todiscuss new evidences in asthma managementBetween July,1st,2010 and June, 30th, 2011 317

articles met the search criteria. Of the 317, 23were identified to have the impact on the GINAreport.

A) Modifying, that is, changing the text or

introducing a concept requiring a newrecommendation to the report.

B) Confirming, that is, adding to or replacing an

existing evidence


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Asthma management

Act Plan

Study Do

Same concept of asthma control

Set goal

treatmonitor

adjust

Patient with AsthmaDiagnosis


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Evaluation of Asthma Control

Characteristic Controlled

(All of the following)

Partly Controlled

(Any measurepresent in any week)

Uncontrolled

Daytime symptoms None(twice or less/wk)

More than twice/week Three or morefeatures of partlycontrolled asthmapresent in any weekLimitations of

activitiesNone Any

Nocturnal symptoms None Any

Need for reliever/rescue medication

None(twice or less/ week)

More than twice/week

Lung function (PEF orFEV1)

Normal


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REDUCE INCREASE

Asthma education Environmental controlGINA 2010

As-needed rapid-

acting 2-agonist As-needed rapid-acting 2-agonist

Controller

options

Select one Select one Add one or more Add either

Low-dose inhaled

ICS

Low-dose ICS plus

long-acting2-agonistMedium-or high-

dose ICS plus long-

acting 2-agonistOral

glucocorticosteroid

(lowest dose)

Leukotriene

modifier

Medium-or high-

dose ICS

Leukotriene

modifierAnti-IgE treatment

Low-dose ICS plus

leukotriene modifier

Sustained release

theophylline

Low-dose ICS plus

sustained release

theophylline

Treatment steps

Step 1 Step 2 Step 3 Step 4 Step 5

GINA Report 2007 (www.ginasthma.org)


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REDUCE INCREASE

Asthma education Environmental controlIf step up treatment is being considered for poor asthma control, first check

inhaler technique, check adherence and confirms symptoms are due to asthma

As-needed rapid-

acting 2-agonist As-needed rapid-acting 2-agonist

Controller

options

Select one Select one Add one or more Add either

Low-dose inhaled

ICS

Low-dose ICS plus

long-acting2-agonistMedium-or high-

dose ICS plus long-

acting 2-agonistOral

glucocorticosteroid

(lowest dose)

Leukotriene

modifier

Medium-or high-

dose ICS

Leukotriene

modifierAnti-IgE treatment

Low-dose ICS plus

leukotriene modifier

Sustained release

theophylline

Low-dose ICS plus

sustained release

theophylline

Treatment steps

Step 1 Step 2 Step 3 Step 4 Step 5

GINA Report 2007 (www.ginasthma.org)Recommended treatment (shaded boxes) based on group mean data. Individual patients needs, preferences and


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Asthma diagnosisWhat is new in GINA 2011?

Asthma education Environmental control If step up treatment is being considered for

poor asthma control, first check inhaler

technique, check adherence and confirmssymptoms are due to asthma

Recommended treatment (shaded boxes)based on group mean data. Individual patients

needs, preferences and circumstances

(including costs) should be considered

Controller option should bepersonalized


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Asthma diagnosisStep up or down treatment

If controlled > 3 months step down

If controlled for 12 months with low dose ICS may consider stop Rx


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Safety of anti-IgE in asthma..anti-IgE appears to be safe as add-on therapy,including patients generally considered to be athigh risk for exacerbation

Mobile telephone-based interactive self-caresystem improve asthma control Teleheathcare follow up may be of benefit in

those with severe disease at risk for hospitaladmission Providing adherence information to clinicians

does not improve use of ICS among patients with

asthma


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Consensus recommendation regardingthermoplasty in severe asthma

In adult patients whose asthma remain

uncontrolled despite application of thistherapeutic paradigm, and referral toasthma specialty center, bronchialthermoplasty is now a possible option in

some countries. Treatment has beenshown to decrease exacerbation but notsignificant effect on lung function orasthma symptoms


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Asthma diagnosisConclusion: GINA 2011

No major changes from previous report Need to find causes of uncontrolled, notjust increase step of treatment

Asthma controller can be personalizedAdopt new technology in asthma controlAccept thermoplasty as an option for

severe asthma


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Asthma diagnosisNICE Asthma Guidelines


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Asthma diagnosisNICE Asthma Guidelines

1. Introduction2. Diagnosis

3. Non-pharmacological management

4. Pharmacological management5. Inhaler devices

6. Management of acute asthma

7. Special situations8. Organization, delivery of care and audit

9. Patient education and self management

10. Development of guideline


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Asthma diagnosisMonitoring asthma update


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Asthma diagnosisAim of asthma treatment


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Asthma diagnosisPharmacological management


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Asthma diagnosisPharmacological management


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Asthma diagnosisAsthma in adolescents: new


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Asthma diagnosisConclusion: NICE 2011

No major changes from previous reportAsthma controller can start at most

appropriate step

Oral beta-2 agonist can be used as add-on controller

ACT can be used to assess control Specific sub-group such as adolescent


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Thank you for your attention!

Documents

update in intrnational asthm guideline 2012(อ.ฉันชาย)