What is new with the 2014

GINA update?

Gary Wong

Department of Paediatrics and School of Public Health

Chinese University of Hong Kong

Asher et al Lancet 2006;368(9537):733-43.

Guidelines from around the world

Why Asthma ICON?

Question: So many guidelines

Are there any similarities and

differences?

Are there any scientific basis for

the differences?

Writing group:

N Papadopoulos, H Arakawa,

KH Carlsen, A Custovic, J Gern, R

Lemanske, P Le Souef, M Makela

G Roberts, GW Wong, H Zar

Review group: 57 experts from around

the world

Classification of asthma: Asthma ICON

4805 patients with diagnosed asthma either with active symptoms or taking anti-asthma drugs in the past 12 months

• 3815 (79.4%) adults, i.e. >16 y

• 57.5% female

• questionnaire survey conducted 9-12/2006

Asthma in Reality in Asia-Pacific (AIRIAP) 2:Study sites

Areas for both 1 & 2

Areas for 2 only India

Sri Lanka

Thailand

Indonesia

Malaysia

Singapore

Vietnam The Philippines

Hong Kong

Taiwan

China

South Korea

Lai CK et al. Respirology 2011;16, 688–697.

Wong GW et al. Allergy April 2013

AIRIAP 2 Pediatric data

Wong GW et al. Allergy 2013;68:524-30.

2.5% 44% 53.4%

AIRIAP 2: Pediatric data (n=988)

Wong GW et al. Allergy 2013;68:524-30.

Use of urgent care

Use of medications

Rely on bronchodilators

* Between group comparisons :P<0.005

*

“Controlled asthma: Only 2.5% of the subjects

Major update in 2014

In response to feedback from end users

of the possible problems

New evidence of management of

Asthma

GINA Asthma Treatment Strategy

GINA Science Committee

Helen Reddel, Australia, Chair

12 people from around the world

Meet twice a year to review all published trials

Make recommendations of changes for the

Executives to make the final recommendations

Executive Board of Directors

12 people: assess recommendations from Science

committee, make revision and are applicable

worldwide

Members serve in a voluntary capacity

Twice-yearly meetings before ATS and ERS

conferences

Routine review of scientific literature about asthma

(treatment)

Other peer-reviewed material that has been submitted for

review

Discussion of any paper considered to impact on the GINA

report

Recommendations about therapies for which at least two good

quality clinical trials are available, and that have been approved

for asthma by a major regulator

Annual update of GINA report, generally published in

Dec/Jan

GINA Science Committee

GINA 2014

Revision of GINA documents

GINA 2014: Flow charts and tables:

Aim to help practitioners to apply in their daily

practice

Childhood Asthma: Problem with Diagnosis

Diagnosis: Primarily based on history

Lung function testing rarely done

Problems with over-diagnosis and under-

diagnosis

Diagnosis

of Asthma

Assessment: Current control vs Future risk

Current control

Symptoms

Use of bronchodilators

Sleep disturbance

Limitation of activities

Future risk

Exacerbations

Decline in lung function

© Global Initiative for Asthma

GINA assessment of asthma control

© Global Initiative for Asthma

GINA assessment of asthma control

Major problems with asthma clinical trials

Design of the trial: test the average response

of patient:

Compare mean responses in two arms

Most published asthma trials: adults or

adolescents

Do not consider individual variations of

response to each treatment

BADGER study

Lemanske et al (CARE network) NEJM 2010;362:975-85.

Comparison among the three treatments

161/165 patients showed a differential response

For most patients not well controlled

with ICS:

Addition of LABA provides significant

improvement in more than 50% of the

patients.

Some do better with increasing LABA or

the addition of LTRA

The science of picking the right drug

ICS:

A safe steroid

Combination in a single devise

Small particles getting into small airways

LABA

Long and fast acting such that your patients

can feel the bronchodilator effects early can

may be used as rescue drug

The long-term goals of asthma management are

1. Symptom control: to achieve good control of symptoms and

maintain normal activity levels

2. Risk reduction: to minimize future risk of exacerbations, fixed

airflow limitation and medication side-effects

Achieving these goals requires a partnership between

patient and their health care providers

Ask the patient about their own goals regarding their asthma

Consider the health care system, medication availability, cultural

and personal preferences

Goals of asthma management

GINA 2014

© Global Initiative for Asthma

The control-based asthma management

cycle

© Global Initiative for Asthma

Stepwise management - pharmacotherapy

*For children 6-11 years,

theophylline is not

recommended, and preferred

Step 3 is medium dose ICS

**For patients prescribed

BDP/formoterol or BUD/

formoterol maintenance and

reliever therapy

© Global Initiative for Asthma

Probability of asthma diagnosis or response

to asthma treatment in children ≤5 years

Typical

Atopic

Asthma

Typical

Viral

Induced

Wheeze

Oral steroid treatment for preschool wheezing attacks? Panickar et al. NEJM 2009;360: 329-338

Preemptive use of high dose futicasone for virus induced

wheeing in young children

Ducharme et al. NEJM 2009;360;339-353.

Results: High dose fluticasone 750 mcg BD

at the start of URI

The cost : growth rate of 6.56 down to 6.23 cm over one year

Preemptive use of high dose futicasone for virus induced

wheeing in young children

Ducharme et al. NEJM 2009;360;339-353.

What about the use of LTRA?

AJRCCM 2007;175:323-9.

Post-hoc analyses:

© Global Initiative for Asthma

Symptom patterns in children ≤5 years

For viral induced asthma

Regular usual dose of ICS – little

evidence for efficacy

High-dose ICS may have some benefits

but associated with significant side-

effects

May consider short course LTRA

© Global Initiative for Asthma

Aim To find the lowest dose that controls symptoms and exacerbations,

and minimizes the risk of side-effects

When to consider stepping down When symptoms have been well controlled and lung function stable

for ≥3 months

No respiratory infection, patient not travelling.

Prepare for step-down Record the level of symptom control and consider risk factors

Book a follow-up visit in 1-3 months

Step down through available formulations Stepping down ICS doses by 25–50% at 3 month intervals is

feasible and safe for most patients

Step down in the appropriate seasons

General principles for stepping down

controller treatment

Preschool wheezing and childood

asthma: Conclusions

Asthma: Convince the patients that they have asthma!

DO NOT over-diagnose and emphasis on the use of LFT

Under-treatment and poor control are common

Optimize currently available treatments: ICS, LTRA, LABA, ? LAMA Selection of the “best treatment” should be individualized.

ICS is the best in reducing inflammation in most patients (improves control)

In selected patients, combine with LABA reduces future risk of exacerbations.

Drugs for asthma : Safe and highly effective in most patients and your treatment can make a big difference.

Thank you