gina 2019 latest

1. GINA GUIDELINES 2019
Dr Prateek Singh
PGY2 medicine

2.  Global initiative for asthma (GINA) was established to
increase awareness about asthma among health
professionals, public health authorities and community,
and improve prevention and management through a
worldwide effort.

3. Making diagnosis of asthma

4. Criteria

6. Making diagnosis in patient
taking controller treatment
 Repeat reversibility testing for symptomatic
patients (withheld bronchodilator for >12 hrs or
24 hrs if patient is taking ultra long
bronchodilator.

7. Diagnosing asthma in other
context
1. Occupational asthma or work related.- occupational
exposure and if symptoms relieve if away from work.
2. Pregnant women
3. Elderly- under diagnosed and poor perception (old age,
lack of fitness, reduced fitness) , over diagnosed (left
ventricle failure, IHD)
4. Smoker & Ex-smoker- asthma- COPD overlap- h/o
pattern of symptoms and past records will help to
distinguish

8. Assessing a patient with
asthma

9. Managemant
 Long term goal of asthma management is
-reduction risk of asthma related death.
-reduce exacerbations.
-decrease the airway damage.
-lower medication side affects.

11. Landmark Changes in Asthma
management in 2019
1. SABA-only treatment increases the risk of severe
exacerbations and addition of ICS significantly reduces
the risk.Therefore,GINA no longer recommends SABA-
only treatment for Step-1
2. GINA now recommends that all adults and adolescents
with asthma should receive symptom-driven or regular
low dose ICS-containing controller treatment, to reduce
the risk of serious exacerbations

12. Starting asthma treatment
 For best possible outcome ICS treatment should be
started as soon as possible once the diagnosis is made.
- patient with even mild asthma can have severe
exacerbations.
-low dose ICS effectively prevent severe exacerbations
and reduces asthma hospitalisation and death.
-better lung function.

13. Gina 2018

14. Gina 2019

18. Reviewing response and
adjusting treatment
 Patient should seen 1-3 mths after starting treatment.
and 3-12 mths after that.
 In pregnancy every 4-6 weeks.

19. Stepping up asthma treatment
 Sustained step up -If symptoms / exacerbations persist
despite 2-3 mths of controller treatment.
access for
-incorrect inhaler technique.
-poor adherence
-modifiable risk factor
if symptoms are due to other co morbid condition. E.g.
allergic rhinitis

20.  Short term step up- by clinician or patient during viral
infection or allergen exposure.

21.  The written asthma action plan include
1. How to use usual asthma medication
2. When and how to increase medication and start OCS.
3. How to access medical care if symptoms fail to respond

22. Step down treatment for well
controlled asthma
 Good asthma control achieved and maintained for 3
mths.
 Lowest treatment that controls both symptoms
treatment and has minimal side effect.
Consider –
1. Appropriate time ( no repi infection, not travelling , non
pregnant)
2. Document baseline status( symptom control and lung
function)

23.  Step down through available formulations to reduce ICS
dose by 25-50 % at 2-3 months period.
 Do not completely stop ICS in adult and adolecents with
a diagnosis of asthma.

24. Medication change
 Increase frequency of inhaled -
(SABA or low dose ICS formoterol) or add spacer for
pMDI.
 Increase controller.
1. Adult quadruple dose
2. Maintenance ICS – formoterol quadruple dose.(max 72
mcg/day)
3. Maintenance ICS –other LABA . Step up to high dose
configuration or add other separate ICS inhaler.
4. Maintenance and reliever ICS . Formoterol. Continue
maintenance dose and increase reliever
dose(formoterol max 72 mcg/day)

25.  Oral corticosteroids (preferably morning dose )
- prednisolone - 40 – 50 mg * 5- 7 days.
Tapering not needed if given for less then 2 weeks.

26. Exacerbations
 Identifying patient
1. History- h/o near fatal asthma (requiring intubation).
Hospitalisation or ER visit in last 1 year.
2. Medication-
 Not currently using ICS
 Poor adherence
 Currently using OCS or recently stopped OCS
 Over use of SABA (1 can / mth)
3. Co morbidities – psychosocial problems, confirmed
food allergy.

28.  For severe exacerbation- add ipratropium bromide, and
give SABA vianebuliser.
 IV mgso4 can also be given.

29. Medications

36.  Thank you.