GINA 2019: A paradigm shift Dr Dermot Nolan, GP, ICGP/HSE National Clinical Lead for Asthma Asthma remains a significant disease in Ireland with over 450,000 patients, and the fourth highest rate of asthma prevalence in the world. Despite advances in both understanding and in new medications, it continues to have a significant burden on the overall well-being of patients. We have about 70 patients dying every year with asthma and over 5,000 patients admitted to hospital every year with asthma. This however hides the real morbidity with asthma control remaining poor for the majority of patients. This causes children to be unable to partake in sport and adults to miss school and life events due to uncontrolled asthma. Doctors and carers often underestimate the effect that asthma has on patients as it may be asked in a short way such as “how is your asthma”, to which patients may reply “fine or good”, despite having many symptoms which they may feel is part of the normal asthma experience. Patients and indeed many doctors are shocked to hear that one salbutamol (short-acting beta agonist, SABA) canister contains 200 puffs of the drug and that this should last patients at least a year with well-controlled asthma, in which they use it less than twice per week. There has been some concern about overuse of SABA inhalers for some time in that whilst they do give immediate bronchodilator relief – they fail to address the underlying pathophysiology, which is an inflammatory process.
ment, including prevention of exacerbations across the spectrum of asthma severity. 3. To avoid a pattern of patient over-reliance on SABA early in the course of the disease.
Why are there concerns about SABA-only treatment? Many guidelines over the past 50 years have recommended SABA as the first line to treat asthma and to move on to ICS when that proved to be unsuccessful in controlling symptoms. Early on in asthma, it was felt that the disease was one principally of bronchoconstriction, however, we now know that it is principally a disease of inflammation, even in those with infrequent or intermittent symptoms. Although SABA provides a quick relief of symptoms, it is associated with increased risk of exacerbations and lower lung function. Regular use increases allergic responses and airway inflammation. Over-use of SABA (eg, >three canisters dispensed in a year) is associated with risk of severe exacerbations and dispensing >12 canisters per year is associated with increased risk of asthma deaths.
Is this the end of the blue inhaler on its own? The new GINA (Global Initiative for Asthma) 2019 guidelines have just been published and represent a significant change for the management of asthma in adolescents and adults. It recommends for the first time that SABAs (eg, salbutamol) should no longer be used alone for the treatment of asthma. GINA recommends that all adults and adolescents with asthma should receive ICS- (inhaled corticosteroids) containing controller medications to reduce their risk of serious exacerbations and to control symptoms. This has been included in the NICE guidelines in the UK in their last asthma guideline. This will have repercussions in Ireland where salbutamol alone remains in the top 10 drugs prescribed in the country and where over reliance on salbutamol is commonplace. The new guidelines represent the culmination of a 12-year campaign by GINA to obtain evidence for new strategies for the treatment of mild asthma. Their aims were to: 1. Reduce risk of asthma-related exacerbations and death, including in patients with so called mild asthma. 2. To provide a consistent message about the aims of treat-
Starting asthma treatment For the best outcomes, ICS-containing treatment should be initiated as soon as possible after the diagnosis has been made because: • Patients with mild asthma can have severe exacerbations. • Low-dose ICS reduces risk of hospitalisation and death. • Low-dose ICS is effective at preventing exacerbations, improving lung function and preventing exerciseinduced bronchoconstriction, even in patients with mild asthma. • Early treatment with ICS leads to better lung function
Clinical Journal for all healthcare professionals specialising in, or with an interest in, respiratory medicine