L'approche par paliers

A tiered approach has been used in asthma for a long time, thanks to the GINA recommendations. This approach needs to be applied in several compulsory stages including an evaluation (diagnosis, control, compliance, addressing risk factors and search for symptoms) adjustment of treatment and re-evaluation. A therapeutic escalade is proposed beginning with the simple addition of a short acting bronchodilatator in stage 1 and progressing to more specific treatments like thermoplasty or monoclonal antibodies in stage 5. This is an interesting approach allowing a better understanding of the chronicity of the disease and of its spontaneous fluctuations. Because of the characteristic variability of asthma it is necessary to use stages, particularly “step up” in case of poor control while “step down” is not so easy to apply in practice. However this technique is in direct opposition to personalized medicine as each similar patient is put into the same box. Maybe this is also why 50% of asthma patients are still uncontrolled.