Mild persistent asthma (Step 2), 2019 GINA

Mild persistent asthma (Step 2) 환자들에서 low-dose inhaled glucocorticoid를 포함한 regimen 사용을 권고합니다. Low-dose inhaled glucocorticoid 또는 glucocorticoid-LABA inhaler의 규칙적 (매일) 사용을 제안합니다. 그 이유는 흡입 스테로이드의 규칙적 사용이 증상의 빈도를 줄이고 (증상 완화를 위한 SABAs 필요성을 줄이고) 삶의 질을 개선하며 중증 악화 위험을 줄이기 때문입니다. 2015 한국 천식 진료지침에서는 low-dose inhaled glucocorticoid를, 2019 GINA에서는 다음 4가지 선택을 제안했습니다.

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㉮ As-needed use of a combination inhaler that contains low-dose glucocorticoid and the fast-acting LABA, formoterol (preferred, but off-label)

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㉯ Low dose inhaled glucocorticoid taken whenever SABA reliever used (separate or combination inhalers, off-label)

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㉰ Regular (daily) treatment with low dose inhaled glucocorticoid-LABA (not fast-acting) combination, with as-needed SABA

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㉱ Maintenance and reliever therapy with inhaled glucocorticoid-formoterol

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Leukotriene modifiers는 흡입 스테로이드를 원하지 않을 때 대안으로 사용되며 효능은 일반적으로 떨어집니다. GINA는 2단계에서 regular (daily), low-dose inhaled glucocorticoid를 사용하고 대안으로 LTRA를 선택하는 전통적 전략을 유지합니다.

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LABA에는 formoterol, salmeterol, vilanterol이 있습니다. Formoterol이 포함된 제품은 아스트라제네카의 심비코트 (터부헬러, 라피헬러)이며, vilanterol이 포함된 제품은 글락소스미스클라인의 렐바 (엘립타), salmeterol이 포함된 제품은 글락소스미스클라인의 세레타이드 (디스커스, 에보할러)입니다. 2019 GINA에서 언급되는 fast-acting LABA는 formoterol이며, non-fasting LABA는 salmeterol, vilanterol입니다.

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Usual doses of combination inhaled glucocorticoids and long-acting beta-agonists for the treatment of asthma in adolescents age 12 and older and adults

Medication	Low dose	Medium dose	High dose
Budesonide-formoterol HFA (Brand name: Symbicort) * (우리나라 상품명) 심비코트 라피헬러는 MDI, 심비코트 터부헬러는 DPI [아스트라제네카]
80 mcg-4.5 mcg	2 puffs twice a day
160 mcg-4.5 mcg		2 puffs twice a day
Fluticasone furoate-vilanterol DPI (Brand name: Breo Ellipta)* * (우리나라 상품명) 렐바 엘립타 (Relvar Ellipta) [글락소스미스클라인]
NOTE: Inhaled fluticasone furoate has a greater anti-inflammatory potency per microgram than fluticasone propionate inhalers. Thus, fluticasone furoate is administered at a lower daily dose and used only once daily.
100 mcg-25 mcg		1 inhalation once daily
200 mcg-25 mcg			1 inhalation once daily
Fluticasone propionate-salmeterol DPI (Brand name: Advair Diskus) * (우리나라 상품명) 세레타이드 디스커스 [글락소스미스클라인]
100 mcg-50 mcg	1 inhalation twice a day
250 mcg-50 mcg		1 inhalation twice a day
500 mcg-50 mcg			1 inhalation twice a day
Fluticasone propionate-salmeterol HFA (Brand name: Advair HFA) * (우리나라 상품명) 세레타이드 에보할러 [글락소스미스클라인]
45 mcg-21 mcg	2 puffs twice a day
115 mcg-21 mcg		2 puffs twice a day
230 mcg-21 mcg			2 puffs twice a day
Fluticasone propionate-salmeterol DPI (Brand name: AirDuo RespiClick)¶
55 mcg-14 mcg	1 inhalation twice a day
113 mcg-14 mcg	1 inhalation twice a day	1 inhalation twice a day
232 mcg-14 mcg			1 inhalation twice a day
Mometasone-formoterol HFA (Brand name: Dulera)
100 mcg-5 mcg		2 puffs twice a day
200 mcg-5 mcg			2 puffs twice a day

Do not exceed the maximum number of inhalations/puffs per day listed in the table due to the risk of toxicity from an excess dose of long acting beta-agonist (ie, salmeterol, formoterol, or vilanterol). Brand names and dose per puff or per inhalation of commercially available fixed dose combinations are according to United States licensed product information. Consult local product information before use.

HFA: metered dose inhaler with hydrofluoroalkane propellant; DPI: dry powder inhaler.

* Not approved for use in patients <18 years old.

¶ In AirDuo inhalers the daily dose of salmeterol is approximately one-fourth of the dose in Advair, and the daily dose of fluticasone is approximately one-half that of the comparable low, medium, and high dose strengths of Advair. AirDuo contains lactose.

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REF. UpToDate 2020.05.24