Global Strategy for Asthma Management and Prevention Media Backgrounder

On World Asthma Day, May 6, 2014, the Global Initiative for Asthma (GINA) is launching a major revision of its Global Strategy for Asthma Management and Prevention. This comprehensive and practical resource about one of the most common chronic lung diseases worldwide contains extensive citations from the scientific literature and forms the basis for other GINA documents and programs. The GINA strategy report was first published in 1993. Over the past decade it has been updated annually, based on a twice-yearly review of scientific literature by an international panel of experts on the GINA Science Committee. This is the first major revision of the report in eight years. This media backgrounder summarizes the major changes and new areas of content included in the report. Definition of Asthma The 2014 Global Strategy for Asthma Management and Prevention defines asthma as follows: 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. The GINA Science Committee crafted this definition to portray the characteristics that are typical of asthma and highlight the features that distinguish it from other lung diseases. The definition means that asthma is:

characterized by recurrent respiratory symptoms especially wheezing, shortness of breath, chest tightness, and coughing.

heterogeneous its symptoms and their intensity are different from person to person. Most people with asthma have signs of inflammation in the airways of their lungs.

variable the symptoms wax and wane over time for each individual with asthma. Measurements of lung function also vary over time.

Diagnosis of Asthma The 2014 revision emphasizes the need for health care providers to confirm the diagnosis of asthma in their patients in order to avoid both under- and over-treatment. A key strategy for confirming the diagnosis of asthma is lung function testing, preferably spirometry. This brief, painless test is performed in a doctors office or lung function laboratory and measures a patients forced expiratory volume in one second (FEV1). In individuals with asthma, FEV1 can be lower than normal, reflecting the fact that their airways are inflamed and air does not move easily into and out of the lungs. The GINA strategy report contains specific advice about how to document lung function abnormalities that are variable over time or reversible with treatment in order to confirm a diagnosis of asthma. A more specialized test of airway hyper-responsiveness, or twitchiness of the airways, can also be helpful to confirm the diagnosis of asthma. The report also details how to confirm the diagnosis in special populations including smokers, the elderly, and patients already on treatment. Assessment of Asthma Control The report reflects the current scientific understanding that asthma control has two components: symptom control and future risk. This means that a persons asthma is under good control when he or she has:

No (or minimal) asthma symptoms. No waking at night due to asthma. No (or minimal) need to use reliever medication. The ability to do normal physical activity and exercise. Normal (or near-normal) lung function test results. No (or very infrequent) asthma attacks. Low risk of future asthma attacks or other negative outcomes.

The meaning of asthma symptom control is generally understood among both patients and health care providers. Future risk is a newer concept, though it has been endorsed by GINA since 2009. To build widespread familiarity with this concept, the report details the many factors that need to be considered when evaluating future risk. A few examples include a persons history of severe asthma attacks, smoking, side effects of asthma medications, and how regularly a person takes their asthma medication as prescribed.

Asthma Management GINA endorses a comprehensive approach to asthma management that is based on a continuous cycle of assessment, treatment, and review. This cycle is a widely accepted concept in asthma management. As in previous versions, the report emphasizes that inhaled corticosteroids are the foundation of long-term asthma management. However, this version of the report provides more detailed guidance about individualizing therapy based on a patients characteristics, risk factors, and preferences, as well as the availability of medications and structure of the health care system in different parts of the world. Asthma is treated in a stepwise manner based on the number and dose of medications necessary to maintain control of the disease. This stepwise treatment system is very similar to previous versions of the report. However, this version contains specific advice to help clinicians troubleshoot issues like incorrect inhaler technique and the failure of patients to always adhere to their medication regimen as prescribed. Addressing these common problems can often help avoid the need to step up treatment. Providing asthma education and teaching correct inhaler technique is important for all individuals with asthma. However, the report also emphasizes the need to adapt treatment recommendations to take into account the health literacy, ethnicity, cultural beliefs, and availability of medications to individual patients. Management of Worsening Asthma and Exacerbations The report lays out a streamlined yet comprehensive approach to care for patients with worsening asthma and exacerbations, or flare-ups. This system begins with self-management according to a written asthma action plan, and progresses if necessary through primary care management and acute care in the emergency department or hospital. In this section and throughout the report, there are substantial changes to the structure and layout of the report, with many new tables and flow-charts to communicate key messages for clinical practice. The GINA Science Committee has designed these figures, tables, and flowcharts to provide greater clarity and usefulness for busy clinicians at all levels.

Management of Asthma in Children 5 Years and Younger The report includes a chapter on management of asthma in young children. Much of this material was published as a separate report in 2009. Bringing it into the main report means that a single document covers diagnosis and management of asthma across all age groups. Diagnosis of Asthma, COPD, and Asthma-COPD Overlap Syndrome This new chapter in the report is a joint effort between GINA and the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It is necessary because distinguishing asthma from chronic obstructive pulmonary disease (COPD) can be problematic, especially in smokers and older adults. This discussion reflects the evolving scientific understanding that diseases of the airways in the lungs are a continuum and sometimes involve related risk factors and disease processes. The chapter aims to help clinicians identify patients who have chronic airways disease; distinguish between asthma, COPD, and the Asthma-COPD Overlap Syndrome; and decide on next steps whether initial treatment or referral to a specialist.