2017 GINA哮喘管理和用药指南

  PART A. GENERAL PRINCIPLES OF ASTHMA MANAGEMENT

• The long-term goals of asthma management are to achieve good symptom control, and to minimize future risk of exacerbations, fixed airflow limitation and side-effects of treatment. The patient’s own goals regarding their asthma and its treatment should also be identified.
• Effective asthma management requires a partnership between the person with asthma (or the parent/carer) and their health care providers.
• Teaching communication skills to health care providers may lead to increased patient satisfaction, better health outcomes, and reduced use of health care resources.
• The patient’s ‘health literacy’ – that is, the patient’s ability to obtain, process and understand basic health information to make appropriate health decisions – should be taken into account.
• Control-based management means that treatment is adjusted in a continuous cycle of assessment, treatment, and review of the patient’s response in both symptom control and future risk (of exacerbations and side-effects)
• For population-level decisions about asthma treatment, the ‘preferred option’ at each step represents the best treatment for most patients, based on group mean data for efficacy, effectiveness and safety from randomized controlled trials, meta-analyses and observational studies, and net cost.
• For individual patients, treatment decisions should also take into account any patient characteristics or phenotype that predict the patient’s likely response to treatment, together with the patient’s preferences and practical issues (inhaler technique, adherence, and cost to the patient).

PART B. MEDICATIONS AND STRATEGIES FOR SYMPTOM CONTROL AND RISK REDUCTION

• At present, Step 1 treatment is with as-needed short-acting beta2-agonist (SABA) alone. However, chronic airway inflammation is found even in patients with infrequent or recent-onset asthma symptoms, and there is a striking lack of studies of inhaled corticosteroids (ICS) in such populations.
• Treatment with regular daily low dose ICS is highly effective in reducing asthma symptoms and reducing the risk of asthma-related exacerbations, hospitalization and death
• For patients with persistent symptoms and/or exacerbations despite low dose ICS, consider step up but first check for common problems such as inhaler technique, adherence, persistent allergen exposure and comorbidities

o For adults and adolescents, the preferred step-up treatment is combination ICS/long-acting beta2-agonist (LABA).
o For adults and adolescents with exacerbations despite other therapies, the risk of exacerbations is reduced with combination low dose ICS/formoterol (with beclometasone or budesonide) as both maintenance and reliever, compared with maintenance controller treatment plus as-needed SABA.

o For children 6–11 years, increasing the ICS dose is preferred over combination ICS/LABA.
• Consider step down once good asthma control has been achieved and maintained for about 3 months, to find the patient’s lowest treatment that controls both symptoms and exacerbations
o Provide the patient with a written asthma action plan, monitor closely, and schedule a follow-up visit
o Do not completely withdraw ICS unless this is needed temporarily to confirm the diagnosis of asthma.
• For all patients with asthma:
o Provide inhaler skills training: this is essential for medications to be effective, but technique is often incorrect.
o Encourage adherence with controller medication, even when symptoms are infrequent.
o Provide training in asthma self-management (self-monitoring of symptoms and/or PEF, written asthma action plan and regular medical review) to control symptoms and minimize the risk of exacerbations and need for health care utilization.
• For patients with one or more risk factors for exacerbations:
o Prescribe regular daily ICS-containing medication, provide a written asthma action plan, and arrange review more frequently than for low-risk patients.
o Identify and address modifiable risk factors, (e.g. smoking, low lung function)
o Consider non-pharmacological strategies and interventions to assist with symptom control and risk reduction,(e.g. smoking cessation advice, breathing exercises, some avoidance strategies）.