® GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION REVISED 2006 Copyright © 2006 MCR VISION, Inc. All Rights Reserved Global Strategy for Asthma Management and Prevention The GINA reports are available on www.ginasthma.org. Global Strategy for Asthma Management and Prevention 2006 GINA EXECUTIVE COMMITTEE* Soren Erik Pedersen, MD Ladislav Chovan, MD, PhD Kolding Hospital President, Slovak Pneumological and Paul O'Byrne, MD, Chair Kolding, Denmark Phthisiological Society McMaster University Bratislava, Slovak Republic Hamilton, Ontario, Canada Emilio Pizzichini. MD Universidade Federal de Santa Catarina Motohiro Ebisawa, MD, PhD Eric D. Bateman, MD Florianópolis, SC, Brazil National Sagamihara Hospital/ University of Cape Town Clinical Research Center for Allergology Cape Town, South Africa. Sean D. Sullivan, PhD Kanagawa, Japan University of Washington Jean Bousquet, MD, PhD Seattle, Washington, USA Professor Amiran Gamkrelidze Montpellier University and INSERM Tbilisi, Georgia Montpellier, France Sally E. Wenzel, MD National Jewish Medical/Research Center Dr. Michiko Haida Tim Clark, MD Denver, Colorado, USA Hanzomon Hospital, National Heart and Lung Institute Chiyoda-ku, Tokyo, Japan London United Kingdom Heather J. Zar, MD University of Cape Town Dr. Carlos Adrian Jiménez Ken Ohta. MD, PhD Cape Town, South Africa San Luis Potosí, México Teikyo University School of Medicine Tokyo, Japan REVIEWERS Sow-Hsong Kuo, MD National Taiwan University Hospital Pierluigi Paggiaro, MD Louis P. Boulet, MD Taipei, Taiwan University of Pisa Hopital Laval Pisa, Italy Quebec, QC, Canada Eva Mantzouranis, MD University Hospital Soren Erik Pedersen, MD William W. Busse, MD Heraklion, Crete, Greece Kolding Hospital University of Wisconsin Kolding, Denmark Madison, Wisconsin USA Dr. Yousser Mohammad Tishreen University School of Medicine Manuel Soto-Quiroz, MD Neil Barnes, MD Lattakia, Syria Hospital Nacional de Niños The London Chest Hospital, Barts and the San José, Costa Rica London NHS Trust Hugo E. Neffen, MD London , United Kingdom Children Hospital Raj B Singh MD Santa Fe, Argentina Apollo Hospital Yoshinosuke Fukuchi, MD, PhD Chennai, India President, Asian Pacific Society of Respirology Ewa Nizankowska-Mogilnicka, MD Tokyo, Japan University School of Medicine Wan-Cheng Tan, MD Krakow, Poland St Paul's Hospital, John E. Heffner, MD Vancouver, BC, Canada President, American Thoracic Society Afshin Parsikia, MD, MPH Providence Portland Medical Center Asthma and Allergy Program GINA SCIENCE COMMITTEE* Portland, Oregon USA Iran Eric D. Bateman, MD, Chair Dr. Mark Levy Jose Eduardo Rosado Pinto, MD University of Cape Town Kenton Bridge Medical Centre Hospital Dona Estefania Cape Town, South Africa Kenton , United Kingdom Lisboa, Portugal Peter J. Barnes, MD Carlos M. Luna, MD Joaquín Sastre, MD National Heart and Lung Institute President, ALAT Universidad Autonoma de Madrid London, UK University of Buenos Aires Madrid, Spain Buenos Aires, Argentina Jean Bousquet, MD, PhD Dr. Jeana Rodica Radu Montpellier University and INSERM Dr. Helen K. Reddel N. Malaxa Hospital Montpellier, France Woolcock Institute of Medical Research Bucharest, Romania Camperdown, New South Wales, Australia Jeffrey M. Drazen, MD Mostafizur Rahman, MD Harvard Medical School Stanley Szefler, MD Director and Head, NIDCH Boston, Massachusetts, USA National Jewish Medical & Research Center Dhaka, Bangladesh Denver, Colorado USA Mark FitzGerald, MD Vaclav Spicak, MD University of British Columbia GINA Assembly Members Who Submitted Czech Initiative for Asthma Vancouver, BC, Canada Comments Prague, Czech Republic Peter Gibson, MD Professor Nguygen Nang An G.W. Wong, MD John Hunter Hospital Bachmai University Hospital Chinese University of Hong Kong NSW, New Castle, Australia Hanoi, Vietnam Hong Kong, China Paul O'Byrne, MD Professor Richard Beasley GINA Program McMaster University Medical Research Institute New Zealand Hamilton, Ontario, Canada Wellington, New Zealand Suzanne S. Hurd, PhD Scientific Director Ken Ohta. MD, PhD Yu-Zi Chen, MD Teikyo University School of Medicine Children's Hospital of The Capital Institute of Sarah DeWeerdt Tokyo, Japan Pediatrics Medical Editor Beijing, China *Disclosures for members of GINA Executive and Science Committees can be found at: i http://www.ginasthma.com/Committees.asp?l1=7&l2=2 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 this surveys provide direct evidence for suboptimal asthma chronic airway disorder that, when uncontrolled, can place control in many countries, despite the availability of severe limits on daily life and is sometimes fatal. The effective therapies. It is clear that if recommendations 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 to effectively. However, the diversity of national health care expect that in most patients with asthma, control of the service systems and variations in the availability of asthma disease can, and should be achieved and maintained.” therapies require that recommendations for asthma care To meet this challenge, in 2005, Executive Committee be adapted to local conditions throughout the global recommended preparation of a new report not only to community. In addition, public health officials require incorporate updated scientific information but to implement information about the costs of asthma care, how to an approach to asthma management based on asthma effectively manage this chronic disorder, and education control, rather than asthma severity. Recommendations to methods to develop asthma care services and programs assess, treat and maintain asthma control are provided in responsive to the particular needs and circumstances this document. The methods used to prepare this within their countries. document are described in the Introduction. In 1993, the National Heart, Lung, and Blood Institute It is a privilege 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: well as to acknowledge the superlative work of all who Global Strategy for Asthma Management and Prevention. have 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 Altana, AstraZeneca, productive and fulfilling lives. Boehringer Ingelheim, Chiesi Group, GlaxoSmithKline, Meda Pharma, Merck, Sharp & Dohme, Mitsubishi-Pharma At the same time, the Global Initiative for Asthma (GINA) Corporation, LTD., Novartis, and PharmAxis. The was implemented to develop a network of individuals, generous contributions of these companies assured that organizations, and public health officials to disseminate information about the care of patients with asthma while at Committee members could meet together to discuss the same time assuring a mechanism to incorporate the issues and reach consensus in a constructive and timely results of scientific investigations into asthma care. manner. The members of the GINA Committees are, Publications based on the GINA Report were prepared however, solely responsible for the statements and and have been translated into languages to promote conclusions presented in this publication. international collaboration and dissemination of information. To disseminate information about asthma GINA publications are available through the Internet care, a GINA Assembly was initiated, comprised of asthma (http://www.ginasthma.org). 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 addition, GINA initiated an annual World Asthma Day (in 2001) which has gained increasing attention each year to Paul O'Byrne, MD raise awareness about the burden of asthma, and to Chair, GINA Executive Committee initiate activities at the local/national level to educate McMaster University families and health care professionals about effective Hamilton, Ontario, Canada methods to manage and control asthma. ii GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION TABLE OF CONTENTS PREFACE Non-Invasive markers of airway inflammation INTRODUCTION Measurements of allergic status EXECUTIVE SUMMARY: MANAGING ASTHMA IN DIAGNOSTIC CHALLENGES AND CHILDREN 5 YEARS AND YOUNGER DIFFERENTIAL DIAGNOSIS Children 5 Years and Younger CHAPTER 1. DEFINITION AND OVERVIEW Older Children and Adults KEY POINTS The Elderly DEFINITION Occupational Asthma BURDEN OF ASTHMA Distinguishing Asthma from COPD Prevalence, Morbidity and Mortality CLASSIFICATION OF