Fallacy of Asthma Guideline: Discrepancy
between Science and Practice
Gary Wong
Department of Paediatrics and School of Public Health
Chinese University of Hong Kong
Guidelines from around the world
GINA Asthma Treatment Strategy

GINA Science Committee




10 respirologists and 3 paediatricians
Meet twice a year to review all published trials
Make recommendations of changes for the
Executives to make the final recommendations
Executive Board


8 respirologists, 3 paediatricians,
1 General practitioner
Revision of GINA documents
Minor revision every 12 months
 Major revision every 4-6 yrs

2013 : Major revision
PubMed: RCT, asthma, child :4224
Real-life or pragmatic trials,
asthma, child: 33
Asher et al Lancet 2006;368(9537):733-43.
Asthma in Reality in Asia-Pacific (AIRIAP) 2:Study sites
 4805 patients with diagnosed asthma
either with active symptoms or taking
anti-asthma drugs in the past 12 months
• 3815 (79.4%) adults, i.e. >16 y
• 57.5% female
• questionnaire survey conducted 9-12/2006
South Korea
China
Areas for both 1 & 2
Areas for 2 only
India
Taiwan
Hong Kong
Vietnam
Thailand
Sri Lanka
Malaysia
Singapore
Lai CK et al. Respirology 2011;16, 688–697.
Wong GW et al. Allergy 2012 (In Press).
Indonesia
The Philippines
AIRIAP 2: Pediatric data (n=988)
*
Use of urgent care
Use of medications
* Between group comparisons :P<0.005
Wong GW wt al. Allergy (In press)
Emerging classification of asthma

Proposed by expert panel from
EAACI/AAAAI


Lotvall et al. Asthma endotypes: A new approach to
classification of disease entities within the asthma syndrome.
JACI 2011;127:355-60.
Asthma endotypes: defined by their
phenotypes and putative pathophysiology
Pediatric Asthma ICON
Allergy 2012; DOI: 10.1111/j.1398-9995.2012.02865.x (epub June 15, 2012)
The many “faces” of pediatric asthma
Major problems with asthma clinical trials

Design of the trial: test the average response
of patient:

Compare mean responses in two arms

Most published asthma trials: adults or
adolescents

Do not consider individual variations of
response to each treatment
Variability of Response to ICS:
3 large studies in Children and Adults With Asthma
40
Adult Study
CAMP
35
ACRN
Patients, %
30
25
20
15
10
5
0
< -20
-20 to -10 -10 to 0
0 to 10
10 to 20
20 to 30
% Change in FEV1 From Baseline
Tantisira KG, et al. Hum Molec Genetics. 2004;13:1353–1359.
30 to 40
>40
BADGER study. Lemanske et al (CARE network)
NEJM 2010;362:975-85.
161/165 patients showed a differential response
Top 3 priorities for REG

Identification/Establishment of database for real-life
studies in paediatric asthma

Establishment of evaluation tools for pragmatic studies
similar to those for evaluating RCT

Influence (political/personal/professional) of guideline
bodies to include pragmatic studies and discuss
limitations of RCT in real world settings