The first real international guidelines prepared by an international group of experts were the Global Initiative of Asthma (GINA) - a collaboration between the National Institutes of Health (NIH) and the World Health Organisation (WHO). They were published in 1995 (1) and have been widely recognized as the golden standard in this area.

As research goes on and experiences grow Guidelines rapidly becomes out of date. An up-dated version of the GINA guidelines was recently issued in 2002 (2).

Regarding severity and management asthma is divided into four categories: mild intermittent asthma, mild persistent, moderate persistent and severe persistent asthma. Each category has its own recommendations for management and treatment.

1. Global Initiative for Asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report (based on a March 1995 meeting). NIH Publication number 95-3659, 1995.

2. Global Initiative for Asthma. Global strategy for asthma management and prevention. NIH Publication number 02-3659, 2002.

GINA Guidelines

Patients with mild intermittent asthma don't have daytime symptoms every week. Night-time symptoms occur less frequently than twice a month. Their airway function is normal between attacks (PEF >80% predicted normal) and the diurnal variability in PEF is <20% (i.e., difference between evening and morning PEF). These patients don't need regular treatment with anti-inflammatory medication, but are relieved by temporary use of rapid-acting inhaled sympathomimetic drugs (ß₂-adrenoceptor agonists).

According to GINA Guidelines patients with mild persistent asthma should be treated with inhaled corticosteroids up to daily doses of 500 µg beclomethasone dipropionate (BDP) or its equivalents (1).

400-500 µg BDP delivered via a pressurized metered dose inhaler corresponds roughly to 200-250 µg Pulmicort Turbuhaler (2,3,4). Pulmicort Turbuhaler and fluticasone propionate delivered via Diskus or Diskhaler are equally effective on a µg basis (5,6). The daily dose of Pulmicort Turbuhaler for the treatment of mild persistent asthma is 100-400 µg, given once daily or divided into two equal doses in the morning and in the evening.

References:

1. Global Initiative for Asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report. NIH Publication number 02-3659, 2002.

2. Selroos O, Backman R, Forsén K-O, et a. Clinical efficacy of budesonide Turbuhaler compared with that of beclomethasone dipropionate pMDI with Volumatic spacer: a 2-year randomized study in 102 patients. Allergy 1994; 49: 833-836.

3. Brambilla C, Lacronique J, Allaert FA, et al. and the French budesonide trial group. A 3-month comparative dose-reduction study with inhaled beclomethasone dipropionate and budesonide in the management of moderate to severe adult asthma. Drug Invest 1994; 8: 49-56.

4. Miyamoto T, Takahashi T, Nakajima, S. Et al.: Efficacy of budesonide Turbuhaler compared with that of beclomethasone dipropionate pMDI in Japanese patients with moderately severe asthma. Respirology 2001; 6: 27-35.

5. Pedersen S, O´Byrne P. A comparison of the efficacy and safety of inhaled corticosteroids in asthma. Allergy 1997; 52, suppl 39: S1-S34.

6. Kuna P, Magnussen H, Joubert J, Greefhorst APM. Same minimal effective dose of budesonide Turbuhaler and fluticasone Diskus/Accuhaler in adult asthmatics. Eur Respir J 2001; 18, suppl 33: 158s.

GINA Guidelines

Patients with moderate persistent asthma have daily symptoms requiring treatment with a rapid-acting inhaled ß₂-agonist and night-time symptoms more than once a week. The PEF values are between 60 and 80% predicted normal and the PEF variability >30%.

The pharmacological basis for treatment of moderate persistent asthma is an inhaled corticosteroid, BDP 500-1000 µg daily, or its equivalents. The doses of Pulmicort Turbuhaler are usually 400-800 µg daily. To this treatment some other medication is added: the first choice is a long-acting inhaled ß₂-agonist. Other options include theophylline, a long-acting oral ß₂-agonist or a leukotriene receptor antagonist. If, for some reason, a combination therapy must be avoided, the doses of the inhaled corticosteroid may be as much as twice as high (1).

These patients require doses of inhaled corticosteroids >1000 µg daily of BDP or its equivalents. Usually more than one other asthma drug has to be added. Even with all available medications patients may remain symptomatic.

1. Global Initiative for Asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report. NIH Publication number 02-3659, 2002.

GINA Guidelines