HHS Conflict of interest: J. Lin has nothing to disclose. Levy is lead on asthma and joint lead for COPD in developing dashboards for clinical care for general practitioners in London, outside the submitted work. Response: The most fundamental change in asthma management in 30 years? 53, Eur Resp J. England; 2019. We do not capture any email address. Ugeskr Laeger. Gani F, Caminati M, Bellavia F, Baroso A, Faccioni P, Pancera P, Batani V, Senna G. Clin Mol Allergy. Evidence to date for as-needed ICS–formoterol is based on studies with low dose combination budesonide–formoterol, but low dose BDP–formoterol could potentially be used in the same way, given its efficacy in maintenance and reliever therapy [28]. GINA 2019: a fundamental change in asthma management: treatment of asthma with short-acting bronchodilators alone is no longer rec-ommended for adults and adolescents. Controller treatment for mild asthma represents a population-level risk reduction strategy, similar to treatment of hypertension or hypercholesterolaemia, where one cannot know whether any individual patient has avoided a serious outcome. Pedersen reports personal fees for lectures and consultancy from Astrazeneca, personal fees for consultancy from ALK and Thermofisher, outside the submitted work. 2019… 1.  |  Nebulisers or spacers for the administration of bronchodilators to those with asthma attending emergency departments? For this purpose, the combination of ICS–formoterol was preferred over ICS–SABA as it was more widely available, and because of adverse outcomes with regular use of ICS–SABA in the study by Papi et al. Reddel HK, FitzGerald JM, Bateman ED, et al. Conflict of interest: F.W. The option of taking ICS whenever SABA is taken is based on one study with as-needed combination BDP–salbutamol [22], and two studies (one in 5–18 year olds [29] and one in adults [30]) with separate ICS and salbutamol inhalers, in which exacerbations were reduced compared with SABA alone and reduced or the same compared with regular ICS, at an average of ∼15–25% of the ICS dose. Eur Respir J 2019… Epub 2020 Dec 1. The paradoxes of asthma management: time for a new approach? Respir Res. In April 2019, the Global Initiative for Asthma (GINA) (box 1) published new recommendations that might be considered the most fundamental change in asthma management in … Conflict of interest: S.E. Sci Rep. 2020 Dec 11;10(1):21805. doi: 10.1038/s41598-020-77791-8. Impact of comorbid asthma on severity of coronavirus disease (COVID-19). GINA 2019: a fundamental change in asthma management Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents Helen K. Reddel 1, J. Q2. Print 2019 Nov. Reddel HK; members of the GINA Science Committee and Board. 2020 Dec 18;21(24):9658. doi: 10.3390/ijms21249658. The new guideline states that, for safety, “[Global Initiative for Asthma] no longer recommends treatment of asthma … Oral health in asthmatic patients: a review : Asthma and its therapy may impact on oral health. The further paradoxes of asthma management: time for a new approach across the spectrum of asthma severity, Combination formoterol and budesonide as maintenance and reliever therapy, Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma, As-needed budesonide-formoterol versus maintenance budesonide in mild asthma, Inhaled combined budesonide-formoterol as needed in mild asthma, Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study, Combination of budesonide/formoterol on demand improves asthma control by reducing exercise-induced bronchoconstriction, Beclometasone–formoterol as maintenance and reliever treatment in patients with asthma: a double-blind, randomised controlled trial, Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial, Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial, Anti-leukotriene agents compared to inhaled corticosteroids in the management of recurrent and/or chronic asthma in adults and children, Association of inhaled corticosteroids and long-acting beta-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: A systematic review and meta-analysis, Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations, Controlled trial of budesonide-formoterol as needed for mild asthma, Description of the protocol for the PRACTICAL study: a randomised controlled trial of the efficacy and safety of ICS/LABA reliever therapy in asthma, Household air pollution and adult respiratory health, www.rcplondon.ac.uk/file/868/download?token=3wikiuFg. The new recommendations follow a decade-long programme of work by GINA, prompted by concerns about the risks and consequences of the long-standing approach of commencing asthma … Mild asthma is estimated to accounts for ….. of the asthma population. … An overview of the new GINA treatment recommendations introduced in 2019 – the most fundamental change in asthma care in over 30 years. Paradigm Shift in Asthma Therapy for Adolescents: Should It Apply to Younger Children as Well? Several treatment options for achieving this are recommended in the GINA 2019 strategy report (figure 1). Conflict of interest: J. Lin has nothing to disclose. However, the safety of ICS–formoterol has been established over many years, including with maintenance and reliever therapy [32], and no new safety signals emerged in the recent large studies [24, 25]. Multiple factors contribute to poor adherence [17], including lack of perceived necessity (especially if symptoms are few [18]), perceived and actual side-effects, and cost; few interventions have been effective in improving adherence. Exacerbations are infrequent events in mild asthma; in the closely monitored SYGMA 1 study, only 12% of patients receiving as-needed SABA experienced a severe exacerbation in 12 months [25]. The most fundamental change in asthma management in 30 years? Conflict of interest: E.D. Conflict of interest: G. Brusselle reports personal fees for lecturing and advisory board work from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva, personal fees for advisory board work from Sanofi, outside the submitted work. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. COVID-19 is an emerging, rapidly evolving situation. a) 25-50% b) 10-30% c) 70-90% d) < 10% e)... 4. This was the most fundamental change in … Eur Respir J. Eur Respir J. Conflict of interest: S.E. Other populations in whom as-needed ICS–formoterol should be investigated include pregnant women, where protection from exacerbations with a very low dose of ICS may be particularly attractive, and patients with seasonal allergic asthma. Concern about β2-agonist risk in asthma largely shifted to long-acting β2-agonists (LABA), with recommendations against LABA-only treatment, but in guidelines, SABA-only treatment remained unchallenged as the initial therapy for mild asthma, with ICS use recommended only for patients with frequent symptoms. The new recommendations follow a decade-long programme of work by GINA, prompted by concerns about the risks and consequences of the long-standing approach of commencing asthma treatment with short-acting β2-agonists (SABA) alone. 2019; 53 … GINA no longer recommends treating adults/adolescents with asthma with short-acting bronchodilators alone. [Long-acting beta 2-agonists in addition to inhaled corticosteroids in children and adults with chronic asthma. Which of the following statement is true concerning mild asthma? Step 1 is for patients with symptoms less than twice a month. Studies of as-needed ICS–formoterol are still needed in children, where reliance on SABA is currently established and maintained. The work of GINA has cumulated in significant changes to asthma prevention and management protocols. Levy reports personal fees for consultancy from Clement Clarke International, personal fees for lecturing from Teva and Soar Beyond, personal fees for advisory board work from AstraZeneca, Orion Pharmaceuticals, GlaxoSmithKline and Trudel Pharmaceuticals, non-financial (travel) support from and is a board member of GINA, personal fees for data monitoring committee work and travel support from Chiesi, grants from Conzorcio Futuro In Ricerca, support for meeting attendance from Napp Pharmaceuticals, personal fees for consultancy from National Services for Health Improvement, a company providing services for practices (Nurse asthma reviews), personal fees for lecturing and advisory board work from Novartis Pharmaceuticals, and support from Whole Systems Integrated Care (WSIC) for whom M.L. Print 2020 Feb. Muneswarao J, Hassali MA, Ibrahim B, Saini B, Ali IAH, Verma AK. Vol. ‘GINA 2019: a fundamental change in asthma management’, is the title of a short, free editorial in Eur Respir J that summarises the key recommendations, provides evidence and outlines the rationale for … Print 2019 Nov. View This Abstract Online; GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Epub 2016 Oct 5. Eur Respir J. Conflict of interest: G. Brusselle reports personal fees for lecturing and advisory board work from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis and Teva, personal fees for advisory board work from Sanofi, outside the submitted work. Lee SC, Son KJ, Han CH, Jung JY, Park SC. Conflict of interest: A. Sheikh reports support for meeting attendance from GSK, grants from Asthma UK, and other support from the Scottish Allergy and Respiratory Academy (a not-for-profit training initiative for health care professionals supported by a consortium of industry funders), outside the submitted work. Eur Respir J. Epub 2008 Apr 18. 2020 Dec;43(6):220-224. doi: 10.18773/austprescr.2020.076. In making this recommendation, high importance was given to the weight of evidence that ICS reduces asthma-related deaths [6], and that it reduces exacerbations even in so-called “intermittent” asthma [26]. Conflict of interest: F.W. GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. 2019 Nov 21;54(5):1901860. doi: 10.1183/13993003.01860-2019. 2019 Jun … 2020 Feb 6;55(2):1902043. doi: 10.1183/13993003.02043-2019. Levy is lead on asthma and joint lead for COPD in developing dashboards for clinical care for general practitioners in London, outside the submitted work. In addition, there was a paucity of evidence for feasible alternatives. 2019 Aug 14;20(1):183. doi: 10.1186/s12931-019-1159-y. Last April, the Global Initiative for Asthma (GINA 2019) recommended that short-acting bronchodilators (SABA) not be used alone for mild asthma. A survey of two Cochrane reviews]. Would you like email updates of new search results? Conflict of interest: R. Buhl reports personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Novartis, Roche, and Teva, outside the submitted work, as well as grants to Mainz University from Boehringer Ingelheim, GlaxoSmithKline, Novartis, and Roche, also outside the submitted work. Levy reports personal fees for consultancy from Clement Clarke International, personal fees for lecturing from Teva and Soar Beyond, personal fees for advisory board work from AstraZeneca, Orion Pharmaceuticals, GlaxoSmithKline and Trudel Pharmaceuticals, non-financial (travel) support from and is a board member of GINA, personal fees for data monitoring committee work and travel support from Chiesi, grants from Conzorcio Futuro In Ricerca, support for meeting attendance from Napp Pharmaceuticals, personal fees for consultancy from National Services for Health Improvement, a company providing services for practices (Nurse asthma reviews), personal fees for lecturing and advisory board work from Novartis Pharmaceuticals, and support from Whole Systems Integrated Care (WSIC) for whom M.L. Reddel … In 2014, GINA recommended that SABA-only treatment should be restricted to patients with symptoms twice a month or less and with no risk factors for exacerbations. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Conflict of interest: J.A. Conflict of interest: A. Yorgancioglu reports grants from MSD, personal fees for advisory board work from GSK, personal fees for advisory board work and lecturing from AstraZeneca, Abdi İbrahim, Chiesi, Novartis and Sandoz, outside the submitted work. T1 - GINA 2019. Global Initiative for Asthma. Conflict of interest: L.B. The GINA strategy has a strong focus on preventing asthma-related deaths and severe exacerbations, as well as on efficacy and effectiveness for symptom control and lung function, and it promotes personalised treatment decisions across the spectrum of asthma severity. Eur Respir J. Conflict of interest: H.K. J. From 2007, based on evidence that exacerbations were significantly reduced by low dose ICS–formoterol maintenance and reliever therapy in moderate–severe asthma [21] and, in a study by Papi et al. The GINA 2019 report and other GINA publications can be purchased, or downloaded free for personal use, from the GINA website (www.ginasthma.org). Krishnan reports research grants from the US National Institutes of Health (current), research contracts from the US Patient Centered Outcomes Research Institute (current), and personal fees from Sanofi to serve on an independent data monitoring committee, outside the submitted work. However, acceptance of daily ICS was slow, partly based on physician concern about the serious side-effects seen with oral corticosteroids [1]. Conflict of interest: J.M. Conflict of interest: L-P. Boulet reports research grants for participation in multicentre studies from AstraZeneca, Boston Scientific, GlaxoSmithKline, Hoffman La Roche, Novartis, Ono Pharma, Sanofi and Takeda; support for research projects from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck and Takeda; fees for consulting and advisory board work from AstraZeneca, Novartis and Methapharm; royalties as co-author of “Up-To-Date” (occupational asthma); nonprofit grants for production of educational materials from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Merck, Frosst and Novartis; conference fees from AstraZeneca, GlaxoSmithKline, Merck and Novartis; support for participation in conferences and meetings from Novartis and Takeda; is past president and member of the Canadian Thoracic Society Respiratory Guidelines Committee; Chair of the Board of Directors of the Global Initiative for Asthma (GINA); Laval University Chair on Knowledge Transfer, Prevention and Education in Respiratory and Cardiovascular Health; member of scientific committees for the American College of Chest Physicians, American Thoracic Society, European Respiratory Society and the World Allergy Organization; 1st Vice-President of the Global Asthma Organization “InterAsma”. T2 - a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. USA.gov. Evaluating the association of osteoporosis with inhaled corticosteroid use in chronic obstructive pulmonary disease in Taiwan. 2019;53(6):1901046. Allergy. GINA 2019: a fundamental change in asthma management: treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. However, unusually among chronic diseases, patients with apparently mild asthma are over-represented in serious outcomes: 30–37% of adults with acute asthma, 16% of patients with near-fatal asthma, and 15–20% of adults dying of asthma had asthma symptoms less than weekly in the previous 3 months [33].  |  2019 Nov 21;54(5):1901583. doi: 10.1183/13993003.01583-2019. FitzGerald reports grants and personal fees for advisory board work and speaker bureau-related presentations from AstraZeneca, GSK and Sanofi Regeneron, grants from Novartis, Boehringer Ingelheim and TEVA, during the conduct of the study; and is a member of the Executive and Science Committees of GINA. However, adherence with ICS is poor in real life, often only 25–35% of the prescribed dose [15], leaving patients exposed to the risks of SABA-only treatment [16]. Reddel reports grants and personal fees for data monitoring committee and advisory board work, and providing independent medical education and consultancy from AstraZeneca, grants, personal fees for data monitoring committee and advisory board work, and providing independent medical education and consultancy, and non-financial support (study medication) from GlaxoSmithKline, personal fees for data monitoring committee work from Merck, grants and personal fees for data monitoring committee and advisory board work, and providing independent medical education from Novartis, personal fees for providing independent medical education from Teva and Mundipharma, personal fees for advisory board work and providing independent medical education from Boehringer Ingelheim, outside the submitted work; and H.K Reddel is Chair of the GINA Scientific Committee. Currently, all of these as-needed strategies are technically “off-label”, as ICS, ICS–formoterol and ICS–SABA are indicated only for regular use in most countries. Conflict of interest: E.D. Leukotriene receptor antagonists are still included as a Step 2 option, but they are not preferred as they are less effective than daily ICS for preventing exacerbations and do not avoid the need for a reliever [31]. The new recommendations follow a decade-long programme of work by GINA, prompted by concerns about the risks and consequences of the long-standing approach of commencing asthma … Conflict of interest: H. Inoue reports grants from Boehringer Ingelheim, Kyorin, MeijiSeikaPharma, Novartis, Ono, Taiho and Teijin-Pharma, personal fees for lecturing and advisory board work from Astellas, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Kyorin, Merck Sharp & Dohme, Novartis, Otsuka and Sanofi, outside the submitted work. A description of GINA methodology is also available on the GINA website. Dimethyl Fumarate Attenuates Lung Inflammation and Oxidative Stress Induced by Chronic Exposure to Diesel Exhaust Particles in Mice. According to GINA 2019, there is a fundamental change to the management of mild asthma. 2008 Jul;102(7):993-8. doi: 10.1016/j.rmed.2008.02.009. Sign In to Email Alerts with your Email Address, GINA 2019: a fundamental change in asthma management, A brief history of inhaled asthma therapy over the last fifty years, A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Respir. 2019… Combination ICS–SABAs are available in a few countries, but with limited safety data. Regular ICS is not recommended for Step 1, because it was considered extremely unlikely that patients with such infrequent symptoms would be prepared to take a daily treatment. Conflict of interest: J.A. Ko has nothing to disclose. Eur Respir J. Conflict of interest: M.L. GINA 2019: a fundamental change in asthma management: treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Reddel reports grants and personal fees for data monitoring committee and advisory board work, and providing independent medical education and consultancy from AstraZeneca, grants, personal fees for data monitoring committee and advisory board work, and providing independent medical education and consultancy, and non-financial support (study medication) from GlaxoSmithKline, personal fees for data monitoring committee work from Merck, grants and personal fees for data monitoring committee and advisory board work, and providing independent medical education from Novartis, personal fees for providing independent medical education from Teva and Mundipharma, personal fees for advisory board work and providing independent medical education from Boehringer Ingelheim, outside the submitted work; and H.K Reddel is Chair of the GINA Scientific Committee. There is only one study to date of as-needed ICS–SABA in children [29], and none with as-needed ICS–formoterol. The new recommendations follow a decade-long programme of work by GINA, prompted by concerns about the risks and consequences of the long-standing approach of commencing asthma … These include two open-label randomised controlled trials, representing the way that patients would use as-needed ICS–formoterol in real life [34, 35]; both of these studies include type 2 biomarkers at baseline and during treatment. GINA recommendations in adults with symptomatic mild asthma and a smoking history. [22]. Regular ICS maintenance treatment has been around for more than 40 years. Mason N, Roberts N, Yard N, Partridge MR. Respir Med. Spiral, Imperial College Digital Repository. Sci Rep. 2021 Jan 12;11(1):724. doi: 10.1038/s41598-020-80815-y. However, it was recognised that this cut-off was arbitrary, and that patients with infrequent symptoms would be unlikely to be adherent with daily ICS, reverting to SABA-only treatment. In April 2019, the Global Initiative for Asthma (GINA) ( box 1) published new recommendations that might be considered the most fundamental change in asthma management in 30 years. As a global initiative, GINA aims to improve asthma care by presenting evidence-based treatment options. Of particular concern to GINA was the paradoxical switch in messaging for patients and clinicians between Step 1, where symptom relief was the priority and SABA use was encouraged, and Step 2, where patients were told that they should reduce what was to them a familiar, effective, low cost treatment, and that to achieve this, they should take a daily treatment even when asymptomatic [19, 20]. The aim of the GINA proposals was to improve management of mild asthma by a strategy that would reduce the risk of severe exacerbations while also being concordant with patient behaviour, beliefs and preferences. The work of GINA is supported only by the sale and licensing of GINA reports and its other publications, and by the voluntary work of GINA committee members. GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. In April 2019, the Global Initiative for Asthma (GINA) ( box 1) published new recommendations that might be considered the most fundamental change in asthma management in 30 years. These are also the countries in which the burden of potentially preventable asthma hospitalisations and deaths are greatest and in which the cost-effectiveness of the new approach might be best seen. The other “preferred controller option” for Step 2 is as-needed low dose ICS-formoterol. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2007 Mar 12;169(11):997-1001. 3 In April 2019, the Global Initiative for Asthma (GINA, see Box) published new recommendations that might be considered the most fundamental change in asthma management in 30 years. FitzGerald reports grants and personal fees for advisory board work and speaker bureau-related presentations from AstraZeneca, GSK and Sanofi Regeneron, grants from Novartis, Boehringer Ingelheim and TEVA, during the conduct of the study; and is a member of the Executive and Science Committees of GINA. Patient reliance on SABA was further reinforced by its prominent use in the trusted environments of emergency department and hospital care. Reddel HK, FitzGerald JM, Bateman ED, et al. GINA 2019: a fundamental change in asthma management: Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. GINA prepares scientific reports on asthma, encourages dissemination and implementation of the recommendations, and promotes international collaboration on asthma research. For Step 2 (for patients with symptoms twice a month or more, or with risk factors for exacerbations), the previous recommendation for daily low dose ICS remains. Print 2019 Nov. JAMA Pediatr. GINA does not accept donations. 2020 Nov 7;18(1):22. doi: 10.1186/s12948-020-00137-2. GINA 2019: a fundamental change in asthma management: treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. http://bit.ly/310LLzE. In parallel, extensive evidence emerged of the protective value of regular ICS, with a dramatic reduction in the risk of asthma-related hospitalisations and death [6, 7]. Instead, they should receive symptom-driven (in mild asthma) or a daily corticosteroid-containing inhaler, to reduce risk of severe exacerbations. Although the public health implications of these major changes in GINA recommendations remain to be studied, their potential is great, both in economically developed countries and in low income countries where access to ICS-containing medications, particularly as maintenance therapy, is limited or non-existent. It is time to change the way we manage mild asthma: an update in GINA 2019. Conflict of interest: A. Becker reports personal fees for continuing medical education from AstraZeneca, personal fees for lecturing from Johnson and Johnson, and MSD, personal fees for advisory board work from Novartis, outside the submitted work. Bacharier reports personal fees for lecturing and consultancy from Aerocrine, GlaxoSmithKline, Genentech/Novartis, Teva, Boehringer Ingelheim and AstraZeneca, personal fees for advisory board work from Merck and Circassia, personal fees for data monitoring committee work from DBV Technologies, personal fees for CME programme development from WebMD/Medscape, personal fees for lecturing and advisory board work from Sanofi/Regeneron, personal fees for consultancy and advisory board work from Vectura, outside the submitted work. NLM Drug Ther Bull. Cattani-Cavalieri I, da Maia Valença H, Moraes JA, Brito-Gitirana L, Romana-Souza B, Schmidt M, Valença SS. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. The need for such studies was supported by the findings of the UK National Review of Asthma Deaths in 2014, that 9% of asthma deaths were in patients being treated with SABA alone (suggesting that their physician had considered they had mild asthma), and 39% were associated with excess prescriptions for SABA [23]. Eur. The Global Initiative for Asthma (GINA) was established by the World Health Organization and the National Heart Lung and Blood Institute in 1993, to increase awareness about asthma among health professionals, public health authorities and the community, and to improve asthma prevention and management through a coordinated worldwide effort. Conflict of interest: L. Fleming reports grants from Asthma UK, and speaker and consutancy fees, all paid direct to her institution, from Boehringer Ingelheim, AstraZeneca, GSK, Sanofi, Respiri and Novartis, outside the submitted work. Here, no direct evidence is available, but the rationale for the “preferred” controller option of as-needed ICS–formoterol, or for taking ICS whenever SABA is taken, is based on indirect evidence from the corresponding Step 2 studies. Aust Prescr. Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews. The authors are members of the GINA Science Committee and/or the GINA Board. The most recent change occurred in 2019 when the use of short acting β2 antagonists in … Ko has nothing to disclose. Pollock M, Sinha IP, Hartling L, Rowe BH, Schreiber S, Fernandes RM. Conflict of interest: H. Inoue reports grants from Boehringer Ingelheim, Kyorin, MeijiSeikaPharma, Novartis, Ono, Taiho and Teijin-Pharma, personal fees for lecturing and advisory board work from Astellas, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Kyorin, Merck Sharp & Dohme, Novartis, Otsuka and Sanofi, outside the submitted work. The 2019 update, published in April, was perhaps the most fundamental change in asthma management in 30 yr. Large long-term studies would be needed to identify patients for whom it would be safe (in terms of risk of severe exacerbations or death) to treat without any ICS. Q1. Here, we provide the background to these recommendations, summarise the evidence and rationale for the changes, and identify research gaps. 2020 GINA Report, Global Strategy for Asthma Management … Please enable it to take advantage of the complete set of features! Reddel HK, FitzGerald JM, Bateman ED, Bacharier LB, Becker A, Brusselle G, et al. Online ISSN: 1399-3003, Copyright © 2021 by the European Respiratory Society. In health administrative database studies, patients with a lower ratio of ICS to SABA were at greater risk of hospitalisation and urgent admission [12], whereas population-based strategies that increased access to ICS were associated with reduced hospitalisations and deaths [13, 14]. Krishnan reports research grants from the US National Institutes of Health (current), research contracts from the US Patient Centered Outcomes Research Institute (current), and personal fees from Sanofi to serve on an independent data monitoring committee, outside the submitted work. Lower importance was given to small non-cumulative differences seen in the SYGMA studies [24, 25] for forced expiratory volume in 1 s (∼30–50 mL), symptom control (difference in Asthma Control Questionnaire (ACQ-5) ∼0.15 versus the minimal clinically important difference of 0.5), and symptom-free days (mean difference 10.6 days per year) compared with regular ICS. Figure 1 www.ginasthma.org ) ):1901860. doi: 10.1183/13993003.00068-2020, Ibrahim B, Schmidt M Valença.: 10.1186/s12931-019-1159-y Attenuates Lung Inflammation and Oxidative Stress Induced by chronic Exposure to Diesel Exhaust Particles in Mice B... 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