The document discusses asthma control and management. It provides tools for assessing asthma control, such as the Asthma Control Test. It identifies risk factors for exacerbations and poor outcomes. It also outlines the stepwise approach to asthma management, with Steps 1 through 5 representing increasing treatment intensity. Initial treatment is usually with a low-dose inhaled corticosteroid, but may be at a higher step depending on symptom frequency and risk factors. The preferred option for Step 3 treatment in children ages 6-11 is a medium-dose inhaled corticosteroid, while options for adults include increasing the corticosteroid dose or adding a long-acting beta-2 agonist or other controller.
Bronchial Asthma: Definition,Pathophysiology and ManagementMarko Makram
Definition and Pathophysiology of Asthma in addition to classification and recent updates in the management of asthma based on GINA-2019 Guidelines, by Dr. Marco Makram.
Obesity - Pathophysiology, Etiology and management Aneesh Bhandary
Obesity is a state of excess adipose tissue mass. A massive psychosocial, pathophysiological problem that results in a high rate of mortality as well as morbidity. The basic mechanisms of the illness and its management as of 2017 are described in this presentation
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
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Bronchial Asthma: Definition,Pathophysiology and ManagementMarko Makram
Definition and Pathophysiology of Asthma in addition to classification and recent updates in the management of asthma based on GINA-2019 Guidelines, by Dr. Marco Makram.
Obesity - Pathophysiology, Etiology and management Aneesh Bhandary
Obesity is a state of excess adipose tissue mass. A massive psychosocial, pathophysiological problem that results in a high rate of mortality as well as morbidity. The basic mechanisms of the illness and its management as of 2017 are described in this presentation
These lecture notes were prepared by Dr. Hamdi Turkey- Pulmonologist- Department of internal medicine - Taiz university
Do Not Forget To Visit Our Pages On Facebook on the following Links:
https://www.facebook.com/groups/569435236444761/
AND
https://www.facebook.com/groups/690331650977113/
Act training 15 aug 2011 m sills editsMarion Sills
Educational materials (slide-set and accompanying script) used to train-the-trainers in SAFTINet practices on incorporating the Asthma Control Test into their clinical workflow and decision-making for patients with asthma.
For more information on SAFTINet, please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
7. Assessment of Asthma Control – Symptom control
Simple
Screening
Tools
Numerical
Control
Tools
eg, Asthma Control Test (ACT)
A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week?
Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma?
Yes No
• Reliever needed for symptoms*
more than twice a week?
Yes No
10. 10
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
• Elevated FeNO in adults with allergic asthma
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Assessment of risk factors for poor asthma outcomes
11. 11
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
• Elevated FeNO in adults with allergic asthma
• 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
Assessment of risk factors for poor asthma outcomes
12. 12
• How?
– Asthma severity is assessed retrospectively from the
level of treatment required to control symptoms and
exacerbations
• When?
– Assess asthma severity after patient has been on
controller treatment for several months
– Severity is not static – it may change over months or
years, or as different treatments become available
Assessment of Asthma Severity
13. 13
Categories of asthma severity
– Mild asthma:
well-controlled with Steps 1 or 2 (as-needed SABA
or low dose ICS)
– Moderate asthma:
well-controlled with Step 3 (low-dose ICS/LABA)
– Severe asthma:
requires Step 4/5 (moderate or high dose
ICS/LABA ± add-on), or remains uncontrolled despite
this treatment
14. Step 1
Step 2
Step 3
Step 4
Step 5
NoYes
NoYes
NoYes
NoYes
Was required treatment provided, symptoms controlled and
exacerbations prevented?
Control Severity
Mild
Moderate
Severe
Treatment
Severity is not static. It may change over months or years
18. How do we apply the
stepwise approach?
•
Maintain control
by stepping up
treatment as
necessary.
19. Stepping down
Ensure regular review of
patients as treatment is
stepped down
Decide which drug to step
down first and at what rate
When control is
good,
step down
24. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
PREFERRED
CONTROLLER
CHOICE
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
*Not for children <12 years
**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
25. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
• 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
26. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 2 (5/8)
PREFERRED
CONTROLLER
CHOICE
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol#
Low dose
ICS/LABA**
Med/high
ICS/LABA
*Not for children <12 years
**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
Step 2 – low-dose controller + as-needed
inhaled SABA
29. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Start controller treatment early
– For best outcomes, initiate controller treatment as early
as possible after making the diagnosis of asthma
Indications for regular low-dose ICS - any of:
– Asthma symptoms more than twice a month
– Waking due to asthma more than once a month
– Any asthma symptoms plus any risk factors for
exacerbations
Recommended Initial Treatment Step
32. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Consider starting at a higher step if:
– Troublesome asthma symptoms on most days
– Waking from asthma once or more a week,
especially if any risk factors for exacerbations
If initial asthma presentation is with an exacerbation:
– Give a short course of oral steroids and start regular
controller treatment (e.g. high dose ICS or medium
dose ICS/LABA, then step down)
Recommended Initial Treatment Step
34. Recommended Initial Treatment Step
Step Frequency of Asthma Symptoms /
Frequency of SABA Use
Risk Factors for
Exacerbations
1 < Twice a month ---
2 Twice a month – twice a week ---
2 < Twice a month +
3 Twice a month – twice a week +
4 Troublesome asthma symptoms most days +
5 Initial presentation with severely
uncontrolled asthma or an asthma
exacerbation
+
35. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Practical issues
• Inhaler technique - can the patient use the device correctly after
training?
• Adherence: how often is the patient likely to take the medication?
• Cost: can the patient afford the medication?
After starting initial controller treatment
– Review response after 2-3 months, or according to clinical
urgency
– Adjust treatment (including non-pharmacological treatments)
– Consider stepping down when asthma has been well-controlled
for 3 months
37. Treatment Options for adult Patients
Not Controlled on Iow dose ICS
Patients not controlled on inhaled steroids (ICS)Patients not controlled on inhaled steroids (ICS)Patients not controlled on inhaled steroids (ICS)Patients not controlled on inhaled steroids (ICS)
Increase theIncrease the
dose of inhaleddose of inhaled
steroidsteroid
Add leukotrieneAdd leukotriene
receptorreceptor
antagonistsantagonists
Add long-acting
beta2-agonists
Add SRAdd SR
theophyllinetheophylline
38. 38
Step 3 – one or two controllers + as-needed inhaled reliever
39. 39
Step 3 – one or two controllers + as-needed inhaled reliever
40. Children’s Healthcare of Atlanta 40
Step 3 – one or two controllers + as-needed inhaled reliever
• 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 SR
theophylline (less effective than ICS/LABA)
– Adults: consider adding SLIT ( Non-pharmacological
interventions)
– Children 6-11 years – add LABA (similar effect as
increasing ICS)
UPDATED
2017
42. Children’s Healthcare of Atlanta
ICS/LABA combination therapy
Different ICS/LABA combinations
• Fluticasone propionate/salmeterol MDI and DPI
– Different strenght, standard dosing
• Budesonide/formoterol DPI
– Single strenght, different dosing
• BDP/formoterol MDI and DPI
– Single strenght, different dosing
• Fluticasone propionate/formoterol MDI
– Different strenght, standard dosing
• Fluticasone furoate/vilanterol DPI
– Different strenght, once daily
Different indications
– Traditional treatment vs maintenance and reliever treatment
– Different severity ?
54. Children’s Healthcare of Atlanta
Evolution in Asthma Management
Therapy used over time
MedicationUse
Maintenance
+ prn SABA
Maintenance
+ prn Symbicort
One inhaler:
Maintenance &
relief
Rapid adjustments in
controller replacing
SABA
No adjustment in
controller
SMART =
Single inhaler Maintenance
And Reliever Therapy
GOAL
55. Shaded green - preferred controller options
TO STEP 3 TREATMENT,
SELECT ONE OR MORE:
TO STEP 4 TREATMENT,
ADD EITHER
GINA 2013
64. 64
• Add-on tiotropium by soft-mist
inhaler is a new ‘other controller
option’ for Steps 4 and 5, in patients
≥ 18 years with history of
exacerbations
What’s new in GINA 2015
65. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Step 4 – two or more controllers + as-needed
inhaled reliever
• 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
*Approved only for low dose beclometasone/formoterol and low dose
budesonide/formoterol
66. Children’s Healthcare of AtlantaGINA 2017, Box 3-5, Step 1
Other options (adults or adolescents)
– Tiotropium by mist inhaler may be used as add-on therapy
for patients aged ≥12 years with a history of exacerbations
– Adults: consider adding SLIT (Non-pharmacological therapy)
– 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
Step 4 – two or more controllers + as-needed
inhaled reliever
UPDATED
2017
67. 67
Consider adding SLIT sublingual immunotherapy (SLIT)
in adult HDM-sensitive patients with allergic rhinitis
and asthma who have exacerbations despite ICS
treatment, provided FEV1 is 70% predicted
In such patients with exacerbations despite taking step 3
or step 4 therapy (according to GINA),SLIT can
now be considered as add on therapy
UPDATED
2017
68. Children’s Healthcare of Atlanta
Step 5 – higher level care and/or add-on
treatment
GINA 2017, Box 3-5, Step 5 (8/8)
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA)
Low dose
ICS/LABA**
Med/high
ICS/LABA
PREFERRED
CONTROLLER
CHOICE
UPDATED
2017
*Not for children <12 years
**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
Refer for
add-on
treatment
e.g.
tiotropium,*
anti-IgE,
anti-IL5*
As-needed SABA or
low dose ICS/formoterol#
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
69. Children’s Healthcare of Atlanta
• 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 tiotropium for patients ≥12 years with history of exacerbations
– Add-on omalizumab (anti-IgE) for patients with severe allergic asthma
– Add-on mepolizumab (anti-IL5) for severe eosinophilic asthma (≥12
yrs)
• Other add-on treatment options at Step 5 include:
– 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 ERS/ATS Severe Asthma Guidelines (Chung et al, ERJ 2014) for more
detail
GINA 2016
Step 5 – higher level care and/or add-on treatment
2016
70. Children’s Healthcare of AtlantaGINA 2016
Step 5 – higher level care and/or add-on treatment
2017
• 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 tiotropium for patients ≥12 years with history of exacerbations
– Add-on anti-IgE (omalizumab) for patients with severe allergic asthma
– Add-on anti-IL5 (mepolizumab (SC) or reslizumab (IV) for severe
eosinophilic asthma (≥12 yrs)
• Other add-on treatment options at Step 5 include:
– 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 ERS/ATS Severe Asthma Guidelines (Chung et al, ERJ 2014) for more
detail
UPDATED
2017
72. 72
Omalizumab
Recombinant DNA-derived, humanized antibody
First FDA-approved biologic : 2003
Age ≥ 12 yr --> In July 2016, FDA approved Age ≥ 6
yr Moderate-to- severe persistent asthma whose
disease is not adequately controlled with ICSs +
LABA
73. 73
Mepolizumab
Humanized IgG1 mAb against IL-5 FDA
Approved : Nov 2015
Age ≥ 12 yr
Severe eosinophilic asthma
- Blood eosinophils ≥ 150 cells/µl at initiation of Rx
OR ≥ 300 cells/µl in the past 12 months
100 mg SC q 4 wk
NUCALA
(mepolizumab)
74. 74
CINQUIR (Reslizumab)
Humanized IgG4 kappa mAb against IL-5 FDA
approved : March 2016
Age > 18 yr
Severe eosinophilic asthma
Blood eosinophils > 400 cells/µl at initiation of
Rx 3 mg/kg q 4 wk IV infusion over 20-50 min
Reslizumab
Both severity and control are assessed based on treatment.
Severity Is assessed according to treatment required.
Control is assessed according to how far the required treatment is implemented and how far the expected therapeutic response is achieved.
To get the best results it is necessary to establish the optimal treatment for each patient on an individual basis.
It is important to control symptoms as quickly as possible, so starting treatment at a very low level and building up slowly is not appropriate.
Ask the audience if they have real case histories to demonstrate stepping up treatment to achieve optimal control.
It is equally important not to over-treat.
The point being made by this slide is that Symbicort single inhaler therapy (SSIT) or Symbicort maintenance and reliever therapy (SMART) is different from any other adjustable approach such as SAMD, GOAL or the Sont and Green studies which were all dependent on a complex algorithm to adjust maintenance treatment.
With SMART adjustment becomes automatic based on the need for reliever