1. GINA – Management and
Treatment of Asthma
Maria Bea Merscher – Interna en Medicina
Interna – Estudiante de Intercambio

2. What is GINA?
Publish
guidelines

3. 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.”

4. What is the aim of GINA?
Guided self-
management (1A)

5. What is the aim of GINA?
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6. Levels of Control
Controlled (all of
Characteristics Partially controlled Not controlled
the following)
Daily symptoms No (≤ 2x per week) >2 per week
Limitation of
No Any
activities
Nighttime
symptoms / patient
No Any
is woken by ≥3 characteristics of
symptoms partially controlled
Impairment
Use of short-acting asthma in any week
No (≤ 2x per week) >2 per week
β2-agonists for
symptom control
>80%
<80%
Pulmonary function predicted/personal
predicted/personal
(FEV1 or peak flow) best
best
Exacerbations No ≥1 1x per week
Risk

7. Severity
Usage of
Frequency of Nighttime Variety of
Severity FEV1 short-acting
symptoms symptoms FEV1
β2-agonists
≤ 2x per ≤ 2 days per
Intermittent ≤ 2x per week ≥ 80% < 20%
month week
> 2 days per
Mild > 2x per week 3-4 x per
≥ 80% 20-30% week but not
persistent but not daily month
daily
> 1x per week
Moderate
Daily but not at 60-80% > 30% Daily
persistent
nighttime
Severe Throughout Frequent (~7x Several times
< 60% > 30%
persistent the day per week) a day

8. Controllers vs Relievers

9. Management Based on Control

10. Management Based on Control

11. Routes of Administration

12. Inhaled Glucocorticosteroids

13. Equipotency of Inhaled
Glucocorticosteroids

14. Side effects: Inhaled Glucocorticosteroids

15. Leukotriene Modifiers

16. Side effects: Leukotriene Modifiers

17. Long-acting inhaled β2-agonists

18. Long-acting inhaled β2-agonists

19. Theophylline

20. Theophylline

21. 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

22. Systemic glucocorticosteroids

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

24. Systemic glucocorticosteroids and
osteoporosis

25. Anti-IgE

26. Anti-IgE

27. Severity of Asthma Exacerbations

28. Rapid-acting inhaled β2-agonists

29. Rapid-acting inhaled β2-agonists

30. Systemic glucocorticosteroids

31. Systemic glucocorticosteroids

32. Anticholinergics

33. Anticholinergics

34. Theophylline

35. Short-acting oral β2-agonists