DISTRIBUTE OR COPY NOT DO ® MATERIAL- COPYRIGHTED GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION NATIONAL INSTITUTES OF HEALTH National Heart, Lung, and Blood Institute REVISED 2002 DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTED Updated from: NHLBI/WHO Workshop Report: Global Strategy for Asthma Management and Prevention Issued January, 1995 The 2002 report is available on www NIH Publication No 02-3659 .ginasthma.com Global Strategy for Asthma Management and Prevention GINA Executive Committee Albert L. Sheffer, M.D. Brigham and Women’s Hospital T.J.H. Clark, M.D., Chair Boston, Massachusetts, USA Imperial College London, UK Wan-Cheng Tan, M.D. National University Hospital Singapore Carlos Baena Cagnani, M.D. Hospital Infantil Cordoba Cordoba, Argentina John Warner, M.D. Southampton General Hospital South Hampton, London, UK Jean Bousquet, M.D., Ph.D. Montpellier University/INSERM Montpellier, France Ann Woolcock, M.D. (‡ February, 2001) Institute of Respiratory Medicine Sydney, Australia William W. Busse, M.D. University of Wisconsin Consultant Contributors Madison, Wisconsin, USA Peter J. Barnes, D.M.,DISTRIBUTE D.Sc., F.R.C.P. Leonardo Fabbri, M.D. Imperial CollegeOR University of Modena/Reggio Emilia London, UK Modena, Italy Richard Beasley, M.D. Larry Grouse, M.D., Ph.D. WellingtonCOPY School of Medicine University of Washington Wellington South, New Zealand Seattle, Washington, USA NOT Hans Bisgaard, M.D. Stephen T. Holgate, M.D., D.Sc. DO Copenhagen University Hospital Copenhagen, Denmark Southampton General Hospital South Hampton, London, UK Homer A. Boushey, Jr., M.D. University of California SF Claude Lenfant, M.D. San Francisco, California, USA National Heart, Lung, and Blood Institute MATERIAL- National Institutes of Health Bethesda, Maryland, USA Adnan Custovic, M.D. Wythenshawe Hospital Manchester, UK Sohei Makino, M.D., Ph.D. Dokkyo University School of Medicine J. Mark FitzGerald, M.D. Mibu, Toshigi, Japan University of British Columbia Vancouver, British Columbia, Canada Paul O’Byrne, M.D. COPYRIGHTED McMaster University Robert Lemanske, M.D. Hamilton, Ontario, Canada University of Wisconsin Hospital Madison, Wisconsin, USA Martyn R. Partridge, M.D. Whipps Cross Hospital Fernando Martinez, M.D. London, UK University of Arizona Tucson, Arizona, USA Romain Pauwels, M.D., Ph.D. Ron Neville, M.D. University Hospital General Practicioner, Dundee Ghent, Belgium Dundee, Scotland, United Kingdom Soren Erik Pedersen, M.D. Mike Silverman, M.D. Kolding Hospital University of Leicester Kolding, Denmark Leicester, UK iii Peter Sterk, M.D., Ph.D. Virginia Taggart Leiden University National Heart, Lung, and Blood Institute Leiden, The Netherlands Bethesda, Maryland, USA Onno C.P. van Schayck, Ph.D. Charles K. Naspitz, M.D. Maastricht University President, Latin American Society of Maastricht, The Netherlands Pediatric Allergy, Asthma, and Immunology Escola Paulista de Medicina Sao Paulo, Brazil Antonio M. Vignola, M.D., Ph.D. Consiglio Nazionale delle Richerche Palermo, Italy Hugo Neffen, M.D. President, Argentine Association of Allergy and Clinical Immunology Erica Von Mutius, M.D. Clinica Alergia E Immunologie Dr. von Haunerschen Kinderspital Cordoba, Argentina Munich, Germany Sankei Nishima, M.D. Kevin Weiss, M.D. Japanese Society of Pediatric Allergy and Northwestern University Clinical Immunology Chicago, Illinois, USA National Minami-Fukuoka Hospital Fukuoka, Japan Sally E. Wenzel, M.D. National Jewish Medical/Research Center Ken Ohta, M.D., Ph.D. Denver, Colorado, USA Teikyo University School of Medicine Tokyo, Japan DISTRIBUTE Reviewers OR Arjun Padmanabhan, M.D. Mitsuru Adachi, M.D., Ph.D. Fort Trivandrum, Kerala, India. Showa University School of Medicine Tokyo, Japan HarishCOPY K. Pemde, M.D. BJRM Hospital Mohammed Bartal, M.D. Delhi,NOT India Casablanca, Morocco DO Klaus Rabe, M.D., Ph.D. Kai-Hakon Carlsen, M.D. Leiden University Leiden, The Netherlands Voksentoppen Centre and Research Institute for Asthma, Allergy and Chronic Lung Diseases in Children Oslo, Norway Josep Roca, M.D. President, European Respiratory Society Barcelona, Spain Suchai Charoenratanakul, M.D. MATERIAL- Siriraj Hospital Bangkok, Thailand Gail Shapiro, M.D. President, American Academy of Allergy, Asthma, and Immunology Fan Chung, M.D. University of Washington Imperial College Seattle, Washington, USA London, UK COPYRIGHTED Raj B. Singh, M.D. Takishi Fukuda, M.D., Ph.D. Apollo Hospital Dokkyo University School of Medicine Chennai, India Mibu-machi, Tochigi-ken, Japan Jeyaindran Sinnadurai, M.D. Rita Gupta, M.D. Hospital Kuala Lumpur Delhi-110088, India Kuala Lumpur, Malaysia Andrzej Szczeklik, M.D. Surinder K. Jinda, M.D. Copernicus Academy of Medicine Chandigarh, India Krakow, Poland Allen P. Kaplan, M.D. Adam Wanner, M.D. President, World Allergy Organization President, American Thoracic Society Medical College of South Carolina University of Miami Charleston, South Carolina, USA Miami, Florida, USA iv PREFACE Asthma is a serious global health problem. People of all held seminars at national and international meetings, and ages in countries throughout the world are affected by this helped support a “train the trainer” program through the chronic airway disorder that can be severe and sometimes National Research Training Center in the UK. fatal. The prevalence of asthma is increasing everywhere, especially among children. Asthma is a significant burden, In 2000, the GINA Executive Committee recommended not only in terms of health care costs but also of lost updating the 1995 Workshop Report to incorporate new productivity and reduced participation in family life. scientific information. The methods used to prepare the update are described in the Introduction. It is a privilege During the past two decades, we have witnessed many for me to acknowledge the work of the many people who scientific advances that have improved our understanding participated in this update project, as well as to of asthma and our ability to manage it effectively. acknowledge the superlative work of all who have However, the diversity of national health care service contributed to the success of the GINA program. systems and variations in the availability of asthma therapies require that recommendations for asthma care The GINA program has been conducted through be adapted to local conditions throughout the global educational grants from AstraZeneca, Aventis, Bayer, community. In addition, public health officials require Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Merck information about the costs of asthma care, how to Sharp & Dohme, Miat, Mitsubishi-Tokyo Pharmaceuticals, effectively manage this chronic disease, and best Nikken Chemicals,DISTRIBUTE Novartis, Schering-Plough, Sepracor, education methods in order to develop asthma care Viatris, and Yamanouchi. The generous contributions of OR services and programs responsive to the particular needs these companies assured that workshop members could and circumstances within their countries. meet together to discuss issues and reach consensus in a constructiveCOPY and timely manner. The workshop members Accordingly, in 1993, the National Heart, Lung, and Blood are, however, solely responsible for the statements and Institute collaborated with the World Health Organization to conclusionsNOT presented in this publication. convene a workshop that led to the Global Strategy for Asthma Management and Prevention, a Workshop Report DO The GINA publications are available through the Internet that presented a comprehensive plan to manage asthma (http://www.ginasthma.com). with the goal of reducing chronic disability and premature deaths while allowing patients with asthma to lead Claude Lenfant, M.D. productive and fulfilling lives. Director MATERIAL- National Heart, Lung, and Blood Institute At the same time, a program called the Global Initiative for National Institutes of Health Asthma (GINA) was implemented to develop a network of Bethesda, Maryland, USA individuals, organizations, and public health officials to disseminate information about the care of patients with asthma while at the same time assuring a mechanism to incorporate the results of scientificCOPYRIGHTED investigations into asthma care. Three publications based on the Workshop Report were prepared to promote international collaboration and dissemination of information: • Asthma Management and Prevention: A Practical Guide for Public Health Officials and Health Care Professionals • Pocket Guide for Asthma Management and Prevention • What You and Your Family Can Do About Asthma These documents have been widely disseminated, and translated into several languages. GINA has conducted workshops with local doctors and national opinion leaders, v DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTED vi TABLE OF CONTENTS INTRODUCTION ..............................................................xi REFERENCES ................................................................21 CHAPTER 1 DEFINITION ................................................1 CHAPTER 3 RISK FACTORS ......................................27 KEY POINTS ....................................................................2 KEY POINTS ..................................................................28 DEFINITION OF ASTHMA ................................................2 HOST FACTORS ............................................................28 Genetic Predisposition to the Development of Asthma ..28 AIRWAY PATHOLOGY IN ASTHMA ................................2 Genetic control of the immune