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STASE PENYAKIT DALAM RSUD CIANJUR

ARIESTO
PEMBIMBING : DR. TOTON, SP.PD
G lobal
INitiative for
A sthma
Global Initiative for Asthma
 DEFINISI
Asma adalah penyakit heterogen yang biasanya ditandai
oleh peradangan saluran napas yang kronis. Penyakit ini
diketahui dari riwayat gejala-gejala penyakit pernapasan seperti
wheezing, sesak napas, sesak dada, dan batuk yang kadang
timbul bersama dengan keterbatasan saat eksiprasi.
(GINA Report 2015 hal 2)
 Epidemiologi

Asma merupakan masalah yang mendunia dan mengenai

kira kira 300 juta individu dengan prevalensi global sebanyak 1
18 % yang menurun pada Amerika Utara dan Eropa Barat serta
meningkat pada Afrika, Amerika Latin, dan sebagian Asia. WHO
memperkirakan 15 juta disability-adjusted life years (DALYs) hilang
setiap tahun karena asma, sebanyak 1% dari total tanggungan
penyakit global. Kematian pada penderita asma sekitar 250.000.
Etiologi
1. Alergen dari debu, bulu binatang, kecoa, jamur, dan serbuk sari dari
pohon, rumput, dan bunga
2. Iritasi seperti asap rokok, polusi udara, bahan kimia atau debu di
tempat kerja, senyawa dalam produk dekorasi rumah, dan semprotan
3. Obat-obatan seperti aspirin atau obat anti-inflamasi nonsteroid lain
dan beta-blocker selektif
4. Sulfit dalam makanan dan minuman
5. Infeksi saluran pernapasan atas seperti common cold
6. Aktivitas fisik

http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/signs
 Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES

ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2015, Box 1-1 (4/4) Global Initiative for Asthma

TANDA DAN GEJALA

Gejala yang paling umum adalah mengi. Gejala lain termasuk:

Sesak napas
Sesak dada atau nyeri
Batuk kronis
Sulit tidur karena batuk atau mengi

http://www.aaaai.org/conditions-and-treatments/asthma.aspx
 Diagnosis of asthma
symptoms
Increased probability that symptoms are due to asthma if:
More than one type of symptom (wheeze, shortness of breath, cough, chest tightness)
Symptoms often worse at night or in the early morning
Symptoms vary over time and in intensity
Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather,
laughter, irritants such as car exhaust fumes, smoke, or strong smells

Decreased probability that symptoms are due to asthma if:

Isolated cough with no other respiratory symptoms
Chronic production of sputum
Shortness of breath associated with dizziness, light-headedness or peripheral tingling
Chest pain
Exercise-induced dyspnea with noisy inspiration (stridor)

GINA 2015
 Diagnosis of asthma variable
airflow limitation
Confirm presence of airflow limitation
Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
FEV1/ FVC ratio is normally >0.75 0.80 in healthy adults, and
>0.90 in children
Confirm variation in lung function is greater than in healthy individuals
The greater the variation, or the more times variation is seen, the greater
probability that the diagnosis is asthma
Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL;
children: increase >12% predicted)
Excessive diurnal variability from 1-2 weeks twice-daily PEF monitoring (daily
amplitude x 100/daily mean, averaged)
Significant increase in FEV1 or PEF after 4 weeks of controller treatment
If initial testing is negative:
Repeat when patient is symptomatic, or after withholding bronchodilators
Refer for additional tests (especially children 5 years, or the elderly)

GINA 2015, Box 1-2

Pemeriksaan penunjang
1. Tes fungsi paru dengan spirometri
2. Tes alergi
3. Tes provokasi bronkus (dengan siprometri)
4. Tes nitrit oksida

(GINA Report 2015 hal 6-8)

 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
Daytime asthma symptoms more
than twice a week? Yes No
Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
Reliever needed for symptoms* these these these
more than twice a week? Yes No
Any activity limitation due to asthma? Yes No

*Excludes reliever taken before exercise, because many people take this routinely

This classification is the same as the GINA 2010-12 assessment

of current control, except that lung function now appears only
in the assessment of risk factors

GINA 2015, Box 2-2A Global Initiative for Asthma

 GINA assessment of symptom control

A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
Daytime asthma symptoms more
than twice a week? Yes No
Any night waking due to asthma? Yes No
None of 1-2 of 3-4 of
Reliever needed for symptoms* these these these
more than twice a week? Yes No
Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically
Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patients
personal best, then periodically for ongoing risk assessment
ASSESS PATIENTS RISKS FOR:
Exacerbations
Fixed airflow limitation
Medication side-effects
GINA 2015 Box 2-2B (1/4) Global Initiative for Asthma
 Assessment of risk factors for poor asthma
outcomes

Risk factors for exacerbations include:

Ever intubated for asthma
Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia

GINA 2015, Box 2-2B (2/4) Global Initiative for Asthma

 Assessment of risk factors for poor asthma
outcomes

Risk factors for exacerbations include:

Ever intubated for asthma
Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia

GINA 2015, Box 2-2B (3/4) Global Initiative for Asthma

 Assessment of risk factors for poor asthma
outcomes

Risk factors for exacerbations include:

Ever intubated for asthma
Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
Frequent oral steroids, high dose/potent ICS, P450 inhibitors

GINA 2015, Box 2-2B (4/4) Global Initiative for Asthma

 How to distinguish between
uncontrolled
and severe asthma Watch patient using their
inhaler. Discuss adherence
Compare inhaler technique with a device-
specific checklist, and correct errors;
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

Remove potential
risk factors. Assess and
manage comorbidities

Consider treatment
step-up

Refer to a specialist or
severe asthma clinic

GINA 2015, Box 2-4 (1/5) Global Initiative for Asthma

 How to distinguish between
uncontrolled
and severe asthma Watch patient using their
inhaler. Discuss adherence
Compare inhaler technique with a device-
specific checklist, and correct errors;
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Refer to a specialist or
severe asthma clinic

GINA 2015, Box 2-4 (2/5) Global Initiative for Asthma

 How to distinguish between
uncontrolled
and severe asthma Watch patient using their
inhaler. Discuss adherence
Compare inhaler technique with a device-
specific checklist, and correct errors;
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider treatment
step-up

Refer to a specialist or
severe asthma clinic

GINA 2015, Box 2-4 (3/5) Global Initiative for Asthma

 How to distinguish between
uncontrolled
and severe asthma Watch patient using their
inhaler. Discuss adherence
Compare inhaler technique with a device-
specific checklist, and correct errors;
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.

Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

Refer to a specialist or
severe asthma clinic

GINA 2015, Box 2-4 (4/5) Global Initiative for Asthma

 How to distinguish between
uncontrolled
and severe asthma Watch patient using their
inhaler. Discuss adherence
Compare inhaler technique with a device-
specific checklist, and correct errors;
recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.

If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.

Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

If asthma still uncontrolled after 36 months

Refer to a specialist or on Step 4 treatment, refer for expert advice.
severe asthma clinic Refer earlier if asthma symptoms severe,
or doubts about diagnosis.

GINA 2015, Box 2-4 (5/5) Global Initiative for Asthma

 Differential Diagnose

Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the history of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and cough that vary over time and in intensity,
together with variable expiratory airflow limitation. [GINA 2015]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
[GOLD 2015]
Asthma-COPD overlap syndrome (ACOS) [a description]
Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow
limitation with several features usually associated with asthma and several features
usually associated with COPD. ACOS is therefore identified by the features that it
shares with both asthma and COPD.
A specific definition for ACOS cannot be developed until more evidence is available
about its clinical phenotypes and underlying mechanisms.
GINA 2015, Box 5-1 (3/3) Global Initiative for Asthma
 Step 3 - Spirometry

Spirometric variable Asthma COPD ACOS

Normal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless
pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD
- FEV1/FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS
limitation; may improve by GOLD criteria
FEV1 80% predicted Compatible with asthma Compatible with GOLD Compatible with mild
(good control, or interval category A or B if post- ACOS
between symptoms) BD FEV1/FVC <0.7
FEV1<80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post-BD
- increase in Usual at some time in Common in COPD and Common in ACOS, and
FEV1 >12% and 200mL course of asthma; not more likely when FEV1 more likely when FEV1 is
from baseline (reversible always present is low low
airflow limitation)
Post-BD
- increase in High probability of Unusual in COPD. Compatible with
FEV1 >12% and 400mL asthma Consider ACOS diagnosis of ACOS
from baseline
GINA 2015, Box 5-3 Global Initiative for Asthma
 Modified from NHLBI EPR3 2007

Acute Asthma
Initial Assessment and Management
History
Assess Physical Exam
severity Peak flow determination

Inhaled Up to 2 treatments
SABA 20 minutes apart

Good Incomplete Poor

response response response
Peak flow 50- Peak flow <50%
Normal peak flow
80% predicted predicted
Consider brief
Start oral Start oral
trial of oral
corticosteroids corticosteroids
corticosteroids
Contact primary Contact primary
MD MD
 Klasifikasi & Severity

Derajat Asma Gejala Gejala Malam Faal paru

I. Intermiten
Bulanan APE 80%
* Gejala < 1x/minggu * 2 kali * VEP1 80% nilai prediksi
* Tanpa gejala di luar sebulan APE 80% nilai terbaik
serangan * Variabiliti APE < 20%
* Serangan singkat

II. Persisten
Ringan Mingguan APE > 80%
* Gejala > 1x/minggu, * > 2 kali * VEP1 80% nilai prediksi
tetapi < 1x/ hari sebulan APE 80% nilai terbaik
* Serangan dapat * Variabiliti APE 20-30%
mengganggu aktivitas
dan tidur
III. Persisten
Sedang Harian APE 60 80%
* Gejala setiap hari * > 1x seminggu * VEP1 60-80% nilai
*Serangan mengganggu prediksi
aktivitas dan tidur APE 60-80% nilai terbaik
*Membutuhkan * Variabiliti APE > 30%
bronkodilator
setiap hari

IV. Persisten
Berat Kontinyu APE 60%
* Gejala terus menerus * Sering * VEP1 60% nilai prediksi
* Sering kambuh APE 60% nilai terbaik
* Aktiviti fisik terbatas * Variabiliti APE > 30%
 Treatment of acute severe asthma
requiring hospitalization
Why do patients develop respiratory failure with severe asthma attacks?

Air trapping
Mucus plugging
Increased work of breathing

NHLBI Asthma web educ resources

 The control-based asthma
management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

GINA 2015, Box 3-2

 Step 1 as-needed inhaled short-
acting
beta2-agonist (SABA)
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*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
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 1 (4/8)
Step 1 as-needed reliever
inhaler
Preferred option: as-needed inhaled short-acting beta2-agonist (SABA)
SABAs are highly effective for relief of asthma symptoms
However . there is insufficient evidence about the safety of treating asthma with
SABA alone
This option should be reserved for patients with infrequent symptoms (less than
twice a month) of short duration, and with no risk factors for exacerbations

Other options
Consider adding regular low dose inhaled corticosteroid (ICS) for patients at risk of
exacerbations

GINA 2015
 Step 2 low-dose controller + as-
needed
inhaled SABA
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*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
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 2 (5/8)
Step 2 Low dose controller + as-
needed SABA
Preferred option: regular low dose ICS with as-needed inhaled SABA
Low dose ICS reduces symptoms and reduces risk of exacerbations and asthma-related
hospitalization and death

Other options
Leukotriene receptor antagonists (LTRA) with as-needed SABA
Less effective than low dose ICS
May be used for some patients with both asthma and allergic rhinitis, or if patient will not use ICS
Combination low dose ICS/long-acting beta2-agonist (LABA)
with as-needed SABA
Reduces symptoms and increases lung function compared with ICS
More expensive, and does not further reduce exacerbations
Intermittent ICS with as-needed SABA for purely seasonal allergic asthma with no
interval symptoms
Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends

GINA 2015
 Step 3 one or two controllers +
as-needed inhaled reliever
STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*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
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 3 (6/8) Global Initiative for Asthma
 Step 3 one or two controllers +
as-needed inhaled reliever
Before considering step-up
Check inhaler technique and adherence, confirm diagnosis

Adults/adolescents: preferred options are either combination low dose ICS/LABA

maintenance with as-needed SABA, OR combination low dose ICS/formoterol
maintenance and reliever regimen*
Adding LABA reduces symptoms and exacerbations and increases FEV1, while allowing lower
dose of ICS
In at-risk patients, maintenance and reliever regimen significantly reduces exacerbations
with similar level of symptom control and lower ICS doses compared with other regimens

Children 6-11 years: preferred option is medium dose ICS with

as-needed SABA
Other options
Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less effective than
ICS/LABA)
Children 6-11 years add LABA (similar effect as increasing ICS)

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015
 Step 4 two or more controllers
+ as-needed inhaled reliever UPDATED!

STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*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
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 4 (7/8) Global Initiative for Asthma
 Step 4 two or more controllers +
as-needed inhaled reliever UPDATED!

Before considering step-up

Check inhaler technique and adherence

Adults or adolescents: preferred option is combination low dose ICS/formoterol

as maintenance and reliever regimen*, OR
combination medium dose ICS/LABA with as-needed SABA
Children 611 years: preferred option is to refer for expert advice
Other options (adults or adolescents)
Tiotropium by soft-mist inhaler may be used as add-on therapy for adult patients
(18 years) with a history of exacerbations
Trial of high dose combination ICS/LABA, but little extra benefit and increased risk of
side-effects
Increase dosing frequency (for budesonide-containing inhalers)
Add-on LTRA or low dose theophylline

*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015
 Step 5 higher level care UPDATED!

and/or add-on treatment

STEP 5

STEP 4

PREFERRED
STEP 3 Refer for
STEP 1 STEP 2
CONTROLLER add-on
CHOICE treatment
Med/high e.g.
ICS/LABA anti-IgE
Low dose
Low dose ICS ICS/LABA*

Other Consider low Med/high dose ICS Add tiotropium# Add

Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose ICS+LTRA High dose ICS
tiotropium#
Low dose theophylline* Add low
options (or + theoph*) + LTRA
(or + theoph*) dose OCS

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or

low dose ICS/formoterol**

*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
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.

GINA 2015, Box 3-5, Step 5 (8/8)

Step 5 higher level care and/or
add-on treatment UPDATED!

Preferred option is referral for specialist investigation and consideration of add-

on treatment
If symptoms uncontrolled or exacerbations persist despite Step 4 treatment, check
inhaler technique and adherence before referring
Add-on omalizumab (anti-IgE) is suggested for patients with moderate or severe
allergic asthma that is uncontrolled on Step 4 treatment

Other add-on treatment options at Step 5 include:

Tiotropium: for adults (18 years) with a history of exacerbations despite Step 4
treatment; reduces exacerbations
Sputum-guided treatment: this is available in specialized centers; reduces
exacerbations and/or corticosteroid dose
Add-on low dose oral corticosteroids (7.5mg/day prednisone equivalent): this may
benefit some patients, but has significant systemic side-effects. Assess and monitor
for osteoporosis
See Severe Asthma Guidelines (Chung et al, ERJ 2014) for more detail

GINA 2015
 Low, medium and high dose inhaled
corticosteroids
Adults
Inhaled and adolescents (12 Total
corticosteroid years)daily dose (mcg)
Low Medium High

Beclometasone dipropionate (CFC) 200500 >5001000 >1000

Beclometasone dipropionate (HFA) 100200 >200400 >400
Budesonide (DPI) 200400 >400800 >800
Ciclesonide (HFA) 80160 >160320 >320
Fluticasone propionate (DPI or HFA) 100250 >250500 >500
Mometasone furoate 110220 >220440 >440
Triamcinolone acetonide 4001000 >10002000 >2000

This is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low doses
High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects

GINA 2015, Box 3-6 (1/2)

 Low, medium and high dose
inhaled corticosteroids
Children
Inhaled corticosteroid 611 years Total daily dose (mcg)
Low Medium High

Beclometasone dipropionate (CFC) 100200 >200400 >400

Beclometasone dipropionate (HFA) 50100 >100200 >200
Budesonide (DPI) 100200 >200400 >400
Budesonide (nebules) 250500 >5001000 >1000
Ciclesonide (HFA) 80 >80160 >160
Fluticasone propionate (DPI) 100200 >200400 >400
Fluticasone propionate (HFA) 100200 >200500 >500
Mometasone furoate 110 220<440 440
Triamcinolone acetonide 400800 >8001200 >1200

This is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low doses
High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with
increased risk of systemic side-effects

GINA 2015, Box 3-6 (2/2)

 Management of severe asthma
Optimize dose of ICS/LABA
Complete resistance to ICS is rare
Consider therapeutic trial of higher dose

Consider low dose maintenance oral corticosteroids

Monitor for and manage side-effects, including osteoporosis

Add-on treatments without phenotyping

Tiotropium - reduces exacerbations (adults with history of exacerbations)
Theophylline, LTRA limited benefit

Phenotype-guided treatment
Sputum-guided treatment to reduce exacerbations and/or steroid dose
Severe allergic asthma: suggest add-on anti-IgE treatment (omalizumab)
Aspirin-exacerbated respiratory disease: consider add-on LTRA

Non-pharmacological interventions
Consider bronchial thermoplasty for selected patients
Comprehensive adherence-promoting program

For detailed guidelines, see Chung et al, ERJ 2014

GINA 2015, Box 3-14 (2/2)