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2012 GINA Report, Global Strategy for Asthma Management and Prevention DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTED ASTHMA MANAGEMENT AND PREVENTION GLOBAL STRATEGY FOR ® © 2012 Global InitiativeUPDATED for Asthma 2012 DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTED Global Strategy for Asthma Management and Prevention The GINA reports are available on www.ginasthma.org. Global Strategy for Asthma Management and Prevention 2012 (update) GINA BOARD OF DIRECTORS* GINA SCIENCE COMMITTEE* Mark FitzGerald, MD, Chair Helen Reddel, MD, Chair University of British Columbia Woolcock Institute of Medical Research Vancouver, BC, Canada Camperdown, NSW, Australia Eric D. Bateman, MD Neil Barnes, MD University Cape Town Lung Institute London Chest Hospital Cape Town, South Africa London, England, UK Louis-Philippe Boulet, MD Peter J. Barnes, MD Hôpital Laval National Heart and Lung Institute Sainte-Foy, Quebec, Canada London, England, UK Alvaro A. Cruz, MD Eric D. Bateman, MD Federal University of Bahia University Cape Town Lung Institute School of Medicine Cape Town, South Africa Salvador, Brazil Allan Becker, MD Tari Haahtela, MD University of Manitoba Winnipeg, Manitoba, Canada Helsinki University Central Hospital DISTRIBUTE Helsinki, Finland Elisabeth Bel, MD OR Mark L. Levy, MD University of Amsterdam University of Edinburgh Amsterdam, The Netherlands London, England, UK Jeffrey M.COPY Drazen, MD Paul O’Byrne, MD Harvard Medical School McMaster University Boston,NOT Massachusetts, USA Hamilton, Ontario, Canada DOMark FitzGerald, MD Ken Ohta, MD, PhD University of British Columbia National Hospital Organization Tokyo National Hospital Vancouver, BC, Canada Tokyo, Japan Johan C. de Jongste, MD, PhD Pierluigi Paggiaro, MD Erasmas University Medical Center University of Pisa MATERIAL- Rotterdam, The Netherlands Pisa, Italy Robert F. Lemanske, Jr., MD Soren Erik Pedersen, M.D. University of Wisconsin School of Medicine Kolding Hospital Madison, Wisconsin, USA Kolding, Denmark Paul O’Byrne, MD McMaster University Helen Reddel, MD COPYRIGHTED Woolcock Institute of Medical Research Hamilton, Ontario, Canada Camperdown, NSW, Australia Ken Ohta, MD, PhD Manuel Soto-Quiro, MD National Hospital Organization Tokyo National Hospital Hospital Nacional de Niños Tokyo, Japan San José, Costa Rica Soren Erik Pedersen, MD Gary W. Wong, MD Kolding Hospital Chinese University of Hong Kong Kolding, Denmark Hong Kong ROC Emilio Pizzichini, MD Universidade Federal de Santa Catarina Florianópolis, SC, Brazil Sally E. Wenzel, MD University of Pittsburgh Pittsburgh, Pennsylvania, USA *Disclosures for members of GINA Board of Directors and Science Committees can be found at http://www.ginasthma.org i PREFACE Asthma is a serious global health problem. People of all In spite of these dissemination efforts, international ages in countries throughout the world are affected by surveys provide direct evidence for suboptimal asthma this chronic airway disorder that, when uncontrolled, can control in many countries, despite the availability of place severe limits on daily life and is sometimes fatal. effective therapies. It is clear that if recommendations The prevalence of asthma is increasing in most countries, contained within this report are to improve care of people especially among children. Asthma is a significant burden, with asthma, every effort must be made to encourage not only in terms of health care costs but also of lost health care leaders to assure availability of and access to productivity and reduced participation in family life. medications, and develop means to implement effective asthma management programs including the use of During the past two decades, we have witnessed many appropriate tools to measure success. scientific advances that have improved our understanding of asthma and our ability to manage and control it In 2002, the GINA Report stated that “It is reasonable effectively. However, the diversity of national health to expect that in most patients with asthma, control care service systems and variations in the availability of the disease can, and should be achieved and of asthma therapies require that recommendations for maintained.” To meet this challenge, in 2005, Executive asthma care be adapted to local conditions throughout Committee recommended preparation of a new report the global community. In addition, public health officials not only to incorporate updated scientific information require information about the costs of asthma care, how but to implement an approach to asthma management to effectively manage this chronic disorder, and education based on asthma control,DISTRIBUTE rather than asthma severity. methods to develop asthma care services and programs Recommendations to assess, treat and maintain asthma responsive to the particular needs and circumstances control are providedOR in this document. The methods used within their countries. to prepare this document are described in the Introduction. In 1993, the National Heart, Lung, and Blood Institute It is a privilegeCOPY for me to acknowledge the work of the collaborated with the World Health Organization to many people who participated in this update project, as convene a workshop that led to a Workshop Report: wellNOT as to acknowledge the superlative work of all who Global Strategy for Asthma Management and Prevention. DOhave contributed to the success of the GINA program. This presented a comprehensive plan to manage asthma with the goal of reducing chronic disability and premature The GINA program has been conducted through deaths while allowing patients with asthma to lead unrestricted educational grants from Almirall, AstraZeneca, productive and fulfilling lives. Boehringer-Ingelheim, Chiesi, CIPLA, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Quintiles, Takeda. The At the same time, the Global Initiative for AsthmaMATERIAL- (GINA) generous contributions of these companies assured that was implemented to develop a network of individuals, Committee members could meet together to discuss organizations, and public health officials to disseminate issues and reach consensus in a constructive and timely information about the care of patients with asthma while manner. The members of the GINA Committees are, at the same time assuring a mechanism to incorporate however, solely responsible for the statements and the results of scientific investigations into asthma conclusions presented in this publication. care. Publications based on the GINA Report were prepared and have been translatedCOPYRIGHTED into languages to GINA publications are available through the Internet promote international collaboration and dissemination of (http://www.ginasthma.org). information. To disseminate information about asthma care, a GINA Assembly was initiated, comprised of asthma care experts from many countries to conduct workshops with local doctors and national opinion leaders and to hold seminars at national and international meetings. In Mark FitzGerald, MD addition, GINA initiated an annual World Asthma Day (in Professor of Medicine 2001) which has gained increasing attention each year Head, UBC and VGH Divisions of Respiratory Medicine to raise awareness about the burden of asthma, and to Director, Centre for Lung Health initiate activities at the local/national level to educate Co-Director Institute for Heart and Lung Health families and health care professionals about effective The Lung Centre, 7th Floor methods to manage and control asthma. Gordon and Leslie Diamond Health Care Centre, 2775 Laurel Street Vancouver, B.C. V5Z 1M9 Canada ii GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION Table of Contents PREFACE ii Medical History 16 Symptoms 16 METHODOLOGY AND SUMMARY OF NEW Cough variant asthma 16 RECOMMENDATION, 2011 UPDATE vi Exercise-Induced bronchospasm 17 Physical Examination 17 INTRODUCTION x Tests for Diagnosis and Monitoring 17 Measurements of lung function 17 CHAPTER 1. DEFINITION AND OVERVIEW 1 Spirometry 18 Peak expiratory flow 18 KEY POINTS 2 Measurement of airway responsiveness 19 Non-Invasive markers of airway inflammation 19 DEFINITION 2 Measurements of allergic status 19 THE BURDEN OF ASTHMA 3 DIAGNOSTIC CHALLENGES AND Prevalence, Morbidity and Mortality 3 DIFFERENTIAL DIAGNOSIS 20 Social and Economic Burden 3 Children 5 Years and Younger 20 Older Children and Adults 20 FACTORS INFLUENCING THE DEVELOPMENT AND The Elderly 21 EXPRESSION OF ASTHMA 4 Occupational AsthmaDISTRIBUTE 21 Host Factors 4 Distinguishing Asthma from COPD 21 OR Genetic 4 Obesity 5 CLASSIFICATION OF ASTHMA 21 Sex 5 EtiologyCOPY 21 Environmental Factors 5 Phenotype 22 Allergens 5 NOTAsthma Control 22 Infections 5 Asthma Severity 23 Occupational sensitizers 6 DO Tobacco smoke 6 REFERENCES 24 Outdoor/Indoor air pollution 7 Diet 7 CHAPTER 3. ASTHMA MEDICATIONS 29 MECHANISMS OF ASTHMA MATERIAL-7 KEY POINTS 30 Airway Inflammation In Asthma 7 Inflammatory cells 8 INTRODUCTION 30 Structural changes in airways 8 Pathophysiology 8 ASTHMA MEDICATIONS: ADULTS 30 Airway hyperresponsiveness 8 Route of Administration 30 Special Mechanisms COPYRIGHTED 9 Controller Medications 31 Acute exacerbations 9 Inhaled glucocorticosteroids 31 Nocturnal Asthma 9 Leukotriene modifiers 32 β Irreversible airflow asthma 9 Long-acting inhaled 2-agonists 33 Difficult-to-treat asthma 9 Theophylline 33 Smoking and asthma 9 Cromones: sodium cromoglycate and nedocromil sodium 34 β REFERENCES 9 Long-acting oral 2-agonists 34 Anti-IgE 34 CHAPTER 2. DIAGNOSIS AND CLASSIFICATION 15 Systemic glucocorticosteroids 34 Oral anti-allergic compounds 35 KEY POINTS 16 Other controller therapies 36 Allergen-specific
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