现在是时候改变我们治疗轻度哮喘的方法了：GINA 2019的最新更新
2020/02/11
摘要
哮喘是一种特异性肺部疾病，常以慢性气道炎症为特征。虽然在大多数国家都有循证治疗，但哮喘控制仍然不够理想，与哮喘相关的死亡仍然是一个持续关注的问题。一般认为，50 ~ 75%的哮喘患者可视为轻度哮喘。
《全球哮喘防治创议》(GINA)的早期版本表明，成人轻度哮喘可以通过缓解性药物(例如单独使用短效β-2受体激动剂(SABA))或联合使用常规低剂量吸入性皮质类固醇(ICS)等控制类药物得到很好的控制。考虑到轻度哮喘症状的低频率或无干扰性，患者对控制性药物的依从性，特别是对吸入性皮质类固醇的依从性通常不令人满意。这类患者往往仅依靠短效β-2受体激动剂来缓解症状，这可能导致短效β-2受体激动剂的过度依赖。过度使用诸如短效β-2受体激动剂的缓解性药物与不良的哮喘结局有关，例如恶化甚至死亡。新的GINA 2019哮喘治疗建议提出了哮喘管理中5步治疗法第1、2步的重大改变。该报告承认出现了新的证据，表明在缺乏伴随控制药物的情况下过度使用短效β-2受体激动剂的非安全性，因此不支持仅在轻度哮喘中使用短效β-2受体激动剂的疗法，并且包括了新的标注外建议，例如症状驱动（按需）低剂量吸入性皮质类固醇-福莫特罗和“每次服用短效β-2受体激动剂都使用低剂量皮质类固醇”。
GINA 2019年的报告强调了轻度哮喘管理方面的重大更新，这些建议明显偏离了数十年来的临床实践——即仅对轻度哮喘患者使用症状驱动的短效β-2受体激动剂治疗。虽然新加入的策略包括症状驱动（按需）低剂量吸入性皮质类固醇-福莫特罗和“每次服用短效β-2受体激动剂都使用低剂量皮质类固醇”等策略都是基于几个关键试验，但在此背景下的数据仍只是新兴数据，相对于维持吸入性皮质类固醇治疗，按需使用吸入性皮质类固醇-福莫特罗联合治疗的明确优势尚未建立有效的端点。然而，当前和正在出现的数据将临床哮喘领域置于一个分水岭时刻，我们管理轻度哮喘的方式可能即将发生改变。
It is time to change the way we manage mild asthma: an update in GINA 2019
Respir Res. 2019 Aug 14;20(1):183
Abstract
Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma.
Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients’ adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and “low dose ICS taken whenever SABA is taken”.
The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and “ICS taken whenever SABA is taken” are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.
哮喘是一种特异性肺部疾病，常以慢性气道炎症为特征。虽然在大多数国家都有循证治疗，但哮喘控制仍然不够理想，与哮喘相关的死亡仍然是一个持续关注的问题。一般认为，50 ~ 75%的哮喘患者可视为轻度哮喘。
《全球哮喘防治创议》(GINA)的早期版本表明，成人轻度哮喘可以通过缓解性药物(例如单独使用短效β-2受体激动剂(SABA))或联合使用常规低剂量吸入性皮质类固醇(ICS)等控制类药物得到很好的控制。考虑到轻度哮喘症状的低频率或无干扰性，患者对控制性药物的依从性，特别是对吸入性皮质类固醇的依从性通常不令人满意。这类患者往往仅依靠短效β-2受体激动剂来缓解症状，这可能导致短效β-2受体激动剂的过度依赖。过度使用诸如短效β-2受体激动剂的缓解性药物与不良的哮喘结局有关，例如恶化甚至死亡。新的GINA 2019哮喘治疗建议提出了哮喘管理中5步治疗法第1、2步的重大改变。该报告承认出现了新的证据，表明在缺乏伴随控制药物的情况下过度使用短效β-2受体激动剂的非安全性，因此不支持仅在轻度哮喘中使用短效β-2受体激动剂的疗法，并且包括了新的标注外建议，例如症状驱动（按需）低剂量吸入性皮质类固醇-福莫特罗和“每次服用短效β-2受体激动剂都使用低剂量皮质类固醇”。
GINA 2019年的报告强调了轻度哮喘管理方面的重大更新，这些建议明显偏离了数十年来的临床实践——即仅对轻度哮喘患者使用症状驱动的短效β-2受体激动剂治疗。虽然新加入的策略包括症状驱动（按需）低剂量吸入性皮质类固醇-福莫特罗和“每次服用短效β-2受体激动剂都使用低剂量皮质类固醇”等策略都是基于几个关键试验，但在此背景下的数据仍只是新兴数据，相对于维持吸入性皮质类固醇治疗，按需使用吸入性皮质类固醇-福莫特罗联合治疗的明确优势尚未建立有效的端点。然而，当前和正在出现的数据将临床哮喘领域置于一个分水岭时刻，我们管理轻度哮喘的方式可能即将发生改变。
（中国医科大学附属第一医院 李文扬 摘译 杨冬 审校）
（Respir Res. 2019 Aug 14;20(1):183）
（Respir Res. 2019 Aug 14;20(1):183）
It is time to change the way we manage mild asthma: an update in GINA 2019
Respir Res. 2019 Aug 14;20(1):183
Abstract
Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma.
Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients’ adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and “low dose ICS taken whenever SABA is taken”.
The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and “ICS taken whenever SABA is taken” are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.
上一篇：
系统评估难治性和严重哮喘独立于单克隆生物制剂，可改善预后、减轻口服皮质类固醇的负担
下一篇：
全球哮喘防治创议(GINA): 25年后（Eur Respir J）
