全球氣喘創議組織 GINA (Global Initiative For Asthma)
2016全球氣喘處置及預防策略更新版摘要

全球氣喘創議組織GINA (Global Initiative For Asthma)所公布全球氣喘處置及預防策略在2016年更新部分資訊，將相關改變內容摘要如下。
 

 前     言
 2016年發表的氣喘處置及預防策略更新，所根據的文獻資料如下：
  • 由GINA 科學委員會在2015年中進行了兩次回顧PubMed文獻。246篇隨機對照試驗、實用性、真實世界及觀察性臨床試驗被鑑定出來，最後經由專家選出32篇進一步討論。在整合分析臨床試驗資料中，有71篇被鑑定出來，專家討論後，19篇被選出做進一步出討論 (方法學請見第9及10頁)。

 

GINA氣喘處置及預防策略2016更新 – 重點摘錄:

階梯式治療
Stepwise Treatment

第三階:

  • 增加低劑量fluticasone furoate/vilanterol之選擇
 44頁

第四階: Other controller options

  • 附加治療Tiotropium目前為12歲以上青少年及成人有氣喘惡化的病史之其他控制治療選擇 (Evidence A)
 43及 46頁

第五階: Preferred controller option

  • 針對十二歲以上有氣喘惡化病史，使用附加治療之霧狀吸入器tiotropium (preferred controller choice) (≥12 years) (Evidence B)
  • 針對嚴重過敏型氣喘，使用附加治療omalizumab (anti-IgE)
  • 針對嚴重嗜酸性型氣喘，使用附加治療mepolizumab (anti-IL5) (≥12 years) (Evidence B)
 43及 47頁

ICS 劑量表之低，中，高劑量

  • Fluticasone furoate: 100mcg (低劑量); 暫無資料(中劑量); 200mcg (高劑量)
 44及 46頁

降低ICS劑量

  • 在氣喘良好控制的狀況下，可降低ICS劑量(Hagan et al, Allergy 2014) (Evidence A)
 49頁
 

醫療資源不足之氣喘處置

 

何處屬於醫療資源不足?1

低或中收入國家以及富裕國家

 23及 64頁

醫療資源不足之氣喘診斷

  • 50%氣喘潛在患者未被診斷，34%氣喘患者接受過度氣喘診斷 (José 2014)

Peak flow meters (PEF meters)被世界衛生組織(WHO)列為Package of Essential Non-communicable(PEN) Diseases Interventions之必要診斷工具

氣喘處置

  • GINA階梯式治療包含對醫療資源不足的策略
  • 以經濟/療效為主的方式;包括ICS及SABA的使用
  • 增加第一線醫療團隊對發展常見疾病及症狀之整合能力，包括氣喘

WHO-PEN 建議使用 peak flow meters 為必要診斷工具; 如果資源許可狀況時，可使用oximeters
     
初級氣喘預防

母親懷孕期間之飲食

  • 沒有絕對的證據指出懷孕期間針對特別食物的食用會增加氣喘風險
  • 反而，母親食用一般認知為過敏性的食物(花生，牛奶) 與降低子女過敏及氣喘有關聯 (Bunyavanich et al, JACI 2014; Maslova et al, JACI 2012, 2013)

因此，懷孕期間對於避免過敏或氣喘的建議，飲食方面並沒有特別需要改變

 120頁

母親懷孕期間的肥胖

  • 母親的肥胖及體重增加和增加子女氣喘的風險有關聯 (Forno et al, Pediatrics 2014)

然而，目前沒有針對體重改變建議，因為無指示的減輕體重不應該被鼓勵

 119頁

濕氣及黴菌

家中潮溼及可見的黴菌、黴菌味與增加小孩氣喘風險有關聯 (Quansah et al, PLoS ONE 2012)

 52及121頁
     
其他治療

氣喘病人之非藥物治療

減少家中潮溼及可見的黴菌、黴菌味，可減少成人氣喘症狀及藥物使用 (Evidence A) (Sauni et al, Cochrane 2015)

 51頁

 

氣喘病人之其他治療

  • 在隨機控制臨床試驗，維他命D補充物與增進氣喘症狀控制及降低氣喘惡化無關聯

過敏原免疫治療, 疫苗, 氣管熱切術部分已納入報告正文中(之前是在附錄中)

 51及52頁



References added to GINA 2015

  1. Apter AJ, Wan F, Reisine S, et al. The association of health literacy with adherence and outcomes in moderate-severe asthma. J Allergy Clin Immunol. 2013;132:321-327
  2. Chauhan BF, Ducharme FM. Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev. 2014;1:CD003137. (replacing earlier Cochrane review, reference 164)
  3. Griffiths B, Ducharme FM. Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Cochrane Database Syst Rev. 2013;8:CD000060
  4. Keeney GE, Gray MP, Morrison AK, et al. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133:493-499. (replacing previous reference 336 Kravitz et al 2011)
  5. Kerstjens HA et al. Tiotropium improves lung function in patients with severe uncontrolled asthma: a randomized controlled trial. J Allergy Clin Immunol. 2011;128:308-314.
  6. Kew KM, Karner C, Mindus SM, et al. Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children. Cochrane Database Syst Rev. 2013;12:CD009019
  7. Lim AS, Stewart K, Abramson MJ, et al. Multidisciplinary Approach to Management of Maternal Asthma (MAMMA): a randomized controlled trial. Chest. 2014;145:1046-1054
  8. Murphy VE, Powell H, Wark PA, et al. A prospective study of respiratory viral infection in pregnant women with and without asthma. Chest. 2013;144:420-427.
  9. Nelson-Piercy C. Asthma in pregnancy. Thorax. 2001;56:325-328.
  10. Nguyen JM, Holbrook JT, Wei CY, et al. Validation and psychometric properties of the Asthma Control Questionnaire among children. J Allergy Clin Immunol. 2014;133:91-97.e91-96.
  11. Normansell R, Walker S, Milan SJ, et al. Omalizumab for asthma in adults and children. Cochrane Database Syst Rev. 2014;1:CD003559. (replacing previous reference 174, Rodrigo et al, Chest 2011)
  12. Nuijsink M, Hop WC, Jongste JC, et al. Perception of bronchoconstriction: a complementary disease marker in children with asthma. J Asthma. 2013;50:560-564.
  13. Patel M, Pilcher J, Reddel HK, et al. Metrics of salbutamol use as predictors of future adverse outcomes in asthma. Clin Exp Allergy. 2013;43:1144-1151.
  14. Peters SP et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med. 2010;363:1715-1726.
  15. Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven beta2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014;112:29-34. (replacing previous reference 336 Colebourne et al 2007).
  16.  Selroos O. Dry-powder inhalers in acute asthma. Ther Deliv. 2014;5:69-81. Travers J, et al. External validity of randomised controlled trials in asthma: to whom do the results of the trials apply? Thorax. 2007;62:219-223.
  17. Travers J, et al. External validity of randomized controlled trials in COPD. Respir Med. 2007;101:1313-1320.

Peer-reviewed publications about the GINA report

The following articles, summarizing key changes in the GINA report in 2014—15, have been published in peer-reviewed journals.

  1. Reddel HK et al. World Asthma Day. GINA 2014: a global asthma strategy for a global problem. Int J Tuberc Lung Dis 2014; 18: 505-6 (open access: doi.org/10.5588/ijtld.14.0246)
  2. Boulet LP et al. The revised 2014 GINA strategy report: opportunities for change. Curr Opin Pulm Med 2015; 21: 1-7
  3. Reddel HK, Levy ML. The GINA asthma strategy report: what's new for primary care? NPJ Prim Care Respir Med 2015; 25: 15050 (open access: doi 10.1038/npjpcrm.2015.50)
  4. Reddel HK et al. A summary of the new GINA strategy: a roadmap to asthma control. Eur Respir J 2015; 46: 622-39 (open access; doi 10.1183/13993003.00853-2015). It is suggested that this article should be read as a companion piece to the GINA report, as it explains the rationale behind key changes in GINA 2014-15.

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