Prevalence of asthma in children aged 13-14 years GINA 2016 Appendix Box A1-1; figure provided by R Beasley © Global Initiative for Asthma

Éléments de surveillance d’un asthme de l’enfant 1ère Journée SPO-AFMCS de Saïda 27-01-2017

Définition L’asthme est une maladie inflammatoire chronique des voies aériennes qui se caractérise par des symptômes de brève durée spécifique à chaque patient, spontanément réversibles ou sous l’effet d’un traitement, et des exacerbations potentiellement grave

GINA 2014 Maladie hétérogène, habituellement caractérisée par une inflammation chronique des voies aériennes. L’asthme est défini par une histoire de symptômes respiratoires tels que sifflements, essoufflement, oppression thoracique et toux qui varient dans le temps et en intensité et qui sont associés à une limitation variable des débits expiratoires

The GINA program

Objectifs du traitement de l’asthme chez l’enfant  • Activités physiques, sportives, scolaires normales.  • Symptômes diurnes et nocturnes minimaux.  • EFR normales ou normalisées.  • Débits expiratoires de pointe (DEP stables).  • Besoins en b2 adrénergiques de secours minimes.   Ces objectifs doivent être obtenus avec :  des traitements bien tolérés une croissance et un développement harmonieux.

2-rechercher les facteurs de risque objectifs 1-évaluer le contrôle 2-rechercher les facteurs de risque

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GINA resources - 2016 Global Strategy for Asthma Management and Prevention 2016 Full report with many clinical tools/flow-charts, and Online Appendix Fully revised in 2014, updated 2015 and 2016 Diagnosis of asthma-COPD overlap syndrome (ACOS): a project of GINA and GOLD. Published within GINA report and separately Pocket Guides 2016 Asthma Management and Prevention, adults and children >5 years Asthma Management and Prevention, children ≤5 years Dissemination and Implementation Strategies All materials available on the GINA web site www.ginasthma.org can also be ordered in hard copy Use ‘Contact us’ link at bottom of webpage to order materials Additional dissemination and implementation tools will be added to the website during 2016 GINA 2016

GINA Global Strategy for Asthma Management and Prevention Not a guideline, but a practical approach to managing asthma in clinical practice A global strategy, relevant to both low and high resource countries Evidence-based and clinically-oriented Provides clinical tools and measurable outcomes GINA 2016

The control-based asthma management cycle Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference REVIEW RESPONSE ASSESS Symptoms Exacerbations Side-effects Patient satisfaction Lung function ADJUST TREATMENT Asthma medications Non-pharmacological strategies Treat modifiable risk factors GINA 2016, Box 3-2

Assessing asthma severity How? Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations When? Assess asthma severity after patient has been on controller treatment for several months Severity is not static – it may change over months or years, or as different treatments become available Categories of asthma severity Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low dose ICS) Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA) Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment GINA 2016

How to distinguish between uncontrolled and severe asthma Watch patient using their inhaler. Discuss adherence and barriers to use Compare inhaler technique with a device- specific checklist, and correct errors; recheck frequently. Have an empathic discussion about barriers to adherence. If lung function normal during symptoms, consider halving ICS dose and repeating lung function after 2–3 weeks. Confirm the diagnosis of asthma Remove potential risk factors. Assess and manage comorbidities Check for risk factors or inducers such as smoking, beta-blockers, NSAIDs, allergen exposure. Check for comorbidities such as rhinitis, obesity, GERD, depression/anxiety. Consider step up to next treatment level. Use shared decision-making, and balance potential benefits and risks. Consider treatment step-up Refer to a specialist or severe asthma clinic If asthma still uncontrolled after 3–6 months on Step 4 treatment, refer for expert advice. Refer earlier if asthma symptoms severe, or doubts about diagnosis. GINA 2016, Box 2-4 (5/5) © Global Initiative for Asthma

Initial controller treatment for adults, adolescents and children 6–11 years Start controller treatment early For best outcomes, initiate controller treatment as early as possible after making the diagnosis of asthma Indications for regular low-dose ICS - any of: Asthma symptoms more than twice a month Waking due to asthma more than once a month Any asthma symptoms plus any risk factors for exacerbations Consider starting at a higher step if: Troublesome asthma symptoms on most days Waking from asthma once or more a week, especially if any risk factors for exacerbations If initial asthma presentation is with an exacerbation: Give a short course of oral steroids and start regular controller treatment (e.g. high dose ICS or medium dose ICS/LABA, then step down) GINA 2016, Box 3-4 (1/2)

Facteurs de risque d’évolution défavorable chez l’enfant à partir de 6 ans (GINA 2015) Risque d’exacerbations dans les mois à venir Exacerbation sévère dans l’année précédente (≥ 1), antécédent d’intubation Symptômes non contrôlés Consommation excessive de BD (1 AD/mois) Défaut de traitement par les CSI VEMS bas (surtout si <60%) Technique défectueuse, mauvaise compliance Problèmes psychosociaux ou économiques Tabagisme passif ou actif, persistance d’allergènes Comorbidité : obésité, rhinosinusite, allergie alimentaire vraie Risque d’obstruction fixée Défaut de traitement par CSI Exposition au tabac, vapeur chimique nocive VEMS initial bas, asthme hypersécrétant, éosinophilie sanguine ou expectoration Risque d’effets secondaires des médicaments Systémique: cures fréquentes de CSO ou doses élevées de CSI

Initial controller treatment Before starting initial controller treatment Record evidence for diagnosis of asthma, if possible Record symptom control and risk factors, including lung function Consider factors affecting choice of treatment for this patient Ensure that the patient can use the inhaler correctly Schedule an appointment for a follow-up visit After starting initial controller treatment Review response after 2-3 months, or according to clinical urgency Adjust treatment (including non-pharmacological treatments) Consider stepping down when asthma has been well-controlled for 3 months GINA 2016, Box 3-4 (2/2)

Choosing between controller options – individual patient decisions Decisions for individual patients Use shared decision-making with the patient/parent/carer to discuss the following: Preferred treatment for symptom control and for risk reduction Patient characteristics (phenotype) Does the patient have any known predictors of risk or response? (e.g. smoker, history of exacerbations, blood eosinophilia) Patient preference What are the patient’s goals and concerns for their asthma? Practical issues Inhaler technique - can the patient use the device correctly after training? Adherence: how often is the patient likely to take the medication? Cost: can the patient afford the medication? GINA 2016, Box 3-3 (2/2) Provided by H Reddel

Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years) Total daily dose (mcg) Low Medium High Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000 Beclometasone dipropionate (HFA) 100–200 >200–400 >400 Budesonide (DPI) 200–400 >400–800 >800 Ciclesonide (HFA) 80–160 >160–320 >320 Fluticasone furoate (DPI) 100 n.a. 200 Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500 Mometasone furoate 110–220 >220–440 >440 Triamcinolone acetonide 400–1000 >1000–2000 >2000 This is not a table of equivalence, but of estimated clinical comparability Most of the clinical benefit from ICS is seen at low doses High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effects GINA 2016, Box 3-6 (1/2)

Low, medium and high dose inhaled corticosteroids Children 6–11 years Total daily dose (mcg) Low Medium High Beclometasone dipropionate (CFC) 100–200 >200–400 >400 Beclometasone dipropionate (HFA) 50–100 >100–200 >200 Budesonide (DPI) Budesonide (nebules) 250–500 >500–1000 >1000 Ciclesonide (HFA) 80 >80–160 >160 Fluticasone furoate (DPI) n.a. Fluticasone propionate (DPI) Fluticasone propionate (HFA) >200–500 >500 Mometasone furoate 110 ≥220–<440 ≥440 Triamcinolone acetonide 400–800 >800–1200 >1200 This is not a table of equivalence, but of estimated clinical comparability Most of the clinical benefit from ICS is seen at low doses High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effects GINA 2016, Box 3-6 (2/2)

Diagnosis and management of asthma in children 5 years and younger GINA 2016

Control-based asthma management cycle in children ≤5 years Diagnosis Symptom control & risk factors Inhaler technique & adherence Parent preference REVIEW RESPONSE ASSESS Symptoms Exacerbations Side-effects Parent satisfaction ADJUST TREATMENT Asthma medications Non-pharmacological strategies Treat modifiable risk factors GINA 2016, Box 6-5 (1/8)

Check list de la consultation pour l’enfant Concernant les exacerbations Combien d’épisodes depuis la dernière consultation ? Est ce que les infections VAS virale déclenchent/aggravent l’asthme ? Y a -t il eu des consultations aux urgences (médecin/hôpital)? Est ce que les symptômes interfèrent avec l’école, le sport ? Durée des épisodes ? L’enfant a t il un plan d’action ? Concernant la fonction respiratoire Vérifier VEMS et VEMS/CVF Concernant les effets secondaires Vérifier annuellement la taille Comptabiliser dose CSI et CSO Evaluation Technique/ compliance Autres manifestations allergiques : Rhinite, eczéma, allergie alimentaire Si besoin, évaluation symptômes et DEP sur 2 semaines

GINA assessment of asthma control in children ≤5 years A. Symptom control In the past 4 weeks, has the child had: Well-controlled Partly controlled Uncontrolled Daytime asthma symptoms for more than few minutes, more than once/week? Yes No None of these 1-2 of these 3-4 of these Any activity limitation due to asthma? (runs/plays less than other children, tires easily during walks/playing) Yes No Reliever needed* more than once a week? Yes No Any night waking or night coughing due to asthma? Yes No B. Risk factors for poor asthma outcomes ASSESS CHILD’S RISK FOR: Exacerbations within the next few months Fixed airflow limitation Medication side-effects Level of asthma symptom control GINA 2016, Box 6-4A

Evaluation du contrôle de l’asthme avant 6 ans Risque d’exacerbations dans les mois à venir Symptômes d’asthme non contrôlés ≥ 1 exacerbation sévère dans l’année précédente Exposition: tabagisme, pollution intérieure (acariens, blattes, animaux domestiques, moisissures) Problème psycho-sociaux ou socio-économiques importants Mauvaise adhérence, technique d’inhalation défectueuse Risque d’obstruction fixée Asthme sévère avec plusieurs hospitalisations Antécédents de bronchiolite

Risk factors for poor asthma outcomes in children ≤5 years Risk factors for exacerbations in the next few months Uncontrolled asthma symptoms One or more severe exacerbation in previous year The start of the child’s usual ‘flare-up’ season (especially if autumn/fall) Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g. house dust mite, cockroach, pets, mold), especially in combination with viral infection Major psychological or socio-economic problems for child or family Poor adherence with controller medication, or incorrect inhaler technique Risk factors for fixed airflow limitation Severe asthma with several hospitalizations History of bronchiolitis Risk factors for medication side-effects Systemic: Frequent courses of OCS; high-dose and/or potent ICS Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect skin or eyes when using ICS by nebulizer or spacer with face mask GINA 2016, Box 6-4B (3/3)

Stepwise approach to control symptoms and reduce risk (children ≤5 years) Diagnosis Symptom control & risk factors Inhaler technique & adherence Parent preference REVIEW RESPONSE ASSESS ADJUST TREATMENT Symptoms Exacerbations Side-effects Parent satisfaction Asthma medications Non-pharmacological strategies Treat modifiable risk factors STEP 4 STEP 3 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Continue controller & refer for specialist assessment Double ‘low dose’ ICS Daily low dose ICS Other controller options Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS RELIEVER As-needed short-acting beta2-agonist (all children) CONSIDER THIS STEP FOR CHILDREN WITH: Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well- controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures ALL CHILDREN • Assess symptom control, future risk, comorbidities • Self-management: education, inhaler skills, written asthma action plan, adherence • Regular review: assess response, adverse events, establish minimal effective treatment • (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution KEY ISSUES GINA 2016, Box 6-5 (2/8)

Stepwise approach – pharmacotherapy (children ≤5 years) PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Continue controller & refer for specialist assessment Double ‘low dose’ ICS Daily low dose ICS Other controller options Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS RELIEVER As-needed short-acting beta2-agonist (all children) Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS CONSIDER THIS STEP FOR CHILDREN WITH: Not well-controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures GINA 2016, Box 6-5 (3/8)

Stepwise approach – key issues (children ≤5 years) ALL CHILDREN • Assess symptom control, future risk, comorbidities • Self-management: education, inhaler skills, written asthma action plan, adherence • Regular review: assess response, adverse events, establish minimal effective treatment • (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution Assess asthma control Symptom control, future risk, comorbidities Self-management Education, inhaler skills, written asthma action plan, adherence Regular review Assess response, adverse events, establish minimal effective treatment Other (Where relevant): environmental control for smoke, allergens, indoor or outdoor air pollution GINA 2016, Box 6-5 (4/8)

Step 1 (children ≤5 years) – as-needed inhaled SABA PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Continue controller & refer for specialist assessment Double ‘low dose’ ICS Daily low dose ICS Other controller options Leukotriene receptor antagonist (LTRA) Intermittent ICS Low dose ICS + LTRA Add LTRA Inc. ICS frequency Add intermitt ICS As-needed short-acting beta2-agonist (all children) RELIEVER CONSIDER THIS STEP FOR CHILDREN WITH: Infrequent viral wheezing and no or few interval symptoms Symptom pattern consistent with asthma and asthma symptoms not well-controlled, or ≥3 exacerbations per year Symptom pattern not consistent with asthma but wheezing episodes occur frequently, e.g. every 6–8 weeks. Give diagnostic trial for 3 months. Asthma diagnosis, and not well-controlled on low dose ICS Not well-controlled on double ICS First check diagnosis, inhaler skills, adherence, exposures GINA 2016, Box 6-5 (5/8)

‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years Low daily dose (mcg) Beclometasone dipropionate (HFA) 100 Budesonide (pMDI + spacer) 200 Budesonide (nebulizer) 500 Fluticasone propionate (HFA) Ciclesonide 160 Mometasone furoate Not studied below age 4 years Triamcinolone acetonide Not studied in this age group This is not a table of equivalence A low daily dose is defined as the dose that has not been associated with clinically adverse effects in trials that included measures of safety GINA 2016, Box 6-6 GINA 2016, Box 6-6

Choosing an inhaler device for children ≤5 years Age Preferred device Alternate device 0–3 years Pressurized metered dose inhaler plus dedicated spacer with face mask Nebulizer with face mask 4–5 years Pressurized metered dose inhaler plus dedicated spacer with mouthpiece Pressurized metered dose inhaler plus dedicated spacer with face mask, or nebulizer with mouthpiece or face mask GINA 2016, Box 6-6 GINA 2016, Box 6-7

Initial assessment of acute asthma exacerbations in children ≤5 years Symptoms Mild Severe* Altered consciousness No Agitated, confused or drowsy Oximetry on presentation (SaO2)** >95% <92% Speech† Sentences Words Pulse rate <100 beats/min >200 beats/min (0–3 years) >180 beats/min (4–5 years) Central cyanosis Absent Likely to be present Wheeze intensity Variable Chest may be quiet *Any of these features indicates a severe exacerbation **Oximetry before treatment with oxygen or bronchodilator † Take into account the child’s normal developmental capability GINA 2016, Box 6-9

Indications for immediate transfer to hospital for children ≤5 years Transfer immediately to hospital if ANY of the following are present: Features of severe exacerbation at initial or subsequent assessment Child is unable to speak or drink Cyanosis Subcostal retraction Oxygen saturation <92% when breathing room air Silent chest on auscultation Lack of response to initial bronchodilator treatment Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated 3 times) over 1-2 hours Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the child shows other clinical signs of improvement Unable to be managed at home Social environment that impairs delivery of acute treatment Parent/ carer unable to manage child at home *Normal respiratory rates (breaths/minute): 0-2 months: <60; 2-12 months: <50; 1-5 yrs: <40 GINA 2016, Box 6-10

Initial management of asthma exacerbations in children ≤5 years Therapy Dose and administration Supplemental oxygen 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-98% Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first hour, then reassess severity. If symptoms persist or recur, give an additional 2-3 puffs per hour. Admit to hospital if >10 puffs required in 3-4 hours. Systemic corticosteroids Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for children <2 years; 30 mg for 2-5 years) Additional options in the first hour of treatment Ipratropium bromide For moderate/severe exacerbations, give 2 puffs of ipratropium bromide 80mcg (or 250mcg by nebulizer) every 20 minutes for one hour only Magnesium sulfate Consider nebulized isotonic MgSO4 (150mg) 3 doses in first hour for children ≥2 years with severe exacerbation GINA 2016, Box 6-11 (2/2)

Stepwise approach to control asthma symptoms and reduce risk Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference REVIEW RESPONSE ASSESS ADJUST TREATMENT Symptoms Exacerbations Side-effects Patient satisfaction Lung function Asthma medications Non-pharmacological strategies Treat modifiable risk factors STEP 5 STEP 4 Refer for add-on treatment e.g. tiotropium,* omalizumab, mepolizumab* STEP 3 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Med/high ICS/LABA Low dose ICS/LABA** Low dose ICS Other controller options Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* Med/high dose ICS Low dose ICS+LTRA (or + theoph*) Add tiotropium* High dose ICS + LTRA (or + theoph*) Add low dose OCS As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol# RELIEVER • Provide guided self-management education (self-monitoring + written action plan + regular review) • Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety • Advise about non-pharmacological therapies and strategies e.g. physical activity, weight loss, avoidance of sensitizers where appropriate • Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first • Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. REMEMBER TO... GINA 2016, Box 3-5 (1/8) © Global Initiative for Asthma

stratégies du traitement Évaluer le contrôle Traiter pour obtenir le contrôle Surveiller pour maintenir le contrôle 2 approches: Désescalade thérapeutique Escalade thérapeutique

Provide hands-on inhaler skills training Choose Choose an appropriate device before prescribing. Consider medication options, arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer Avoid multiple different inhaler types if possible Check Check technique at every opportunity – “Can you show me how you use your inhaler at present?” Identify errors with a device-specific checklist Correct Give a physical demonstration to show how to use the inhaler correctly Check again (up to 2-3 times) Re-check inhaler technique frequently, as errors often recur within 4-6 weeks Confirm Can you demonstrate correct technique for the inhalers you prescribe? Brief inhaler technique training improves asthma control GINA 2016, Box 3-11 (4/4)

For children at risk of asthma, dampness, visible mold and mold odor in the home are associated with increased risk of developing asthma

GINA 2016 Peak flow meters recommended by WHO as essential tools for Package of Essential Non- communicable Diseases Interventions WHO-PEN recommends inclusion of peak flow meters as essential tools, and oximeters if resources permit Up to 50% asthma undiagnosed, up to 34% over-diagnosed

The role of lung function in asthma Diagnosis Demonstrate variable expiratory airflow limitation Reconsider diagnosis if symptoms and lung function are discordant Frequent symptoms but normal FEV1: cardiac disease; lack of fitness? Few symptoms but low FEV1: poor perception; restriction of lifestyle? Risk assessment Low FEV1 is an independent predictor of exacerbation risk Monitoring progress Measure lung function at diagnosis, 3-6 months after starting treatment (to identify personal best), and then periodically Consider long-term PEF monitoring for patients with severe asthma or impaired perception of airflow limitation Adjusting treatment? Utility of lung function for adjusting treatment is limited by between-visit variability of FEV1 (15% year-to-year) GINA 2016

Place des EFR Les EFR sont un des marqueurs les plus utiles pour prédire le risque futur Documenter la variabilité de l’obstruction Amélioration VEMS >12% et > 200 ml après BD (ou après 4 sem de traitement CSI) Chute VEMS > 12% à l’exercice Chute VEMS ≥ 20% test métacholine Variabilité nycthémérale DEP >13% La discordance entre fonction et symptômes nécessite des investigations Moment des EFR Au moment du diagnostic Après 2-3 mois de mise en route du traitement Puis selon pression thérapeutique (1 à 3 /an)

Typical spirometric tracings Volume Flow Volume Normal Asthma (after BD) Asthma (before BD) FEV1 1 2 3 4 5 Normal Asthma (after BD) Asthma (before BD) Time (seconds) Note: Each FEV1 represents the highest of three reproducible measurements GINA 2016

EFR >1-2 X /an :malade sous CSI à faibles doses 3 -6 mois CSI à fortes doses Non Contrôlé : tous les 3 mois jusqu’au contrôle optimal. Après chaque modification thérapeutique: délai 1-3 mois. Asthme sévère :EFR / 3 mois. Après stabilisation : pour évaluer la fonction en période stable.

Risque d’effets secondaires des médicaments Systémique: cures fréquentes de CSO ou doses élevées de CSI

PRISE EN CHARGE DE LA MALADIE ASTHMATIQUE Les moyens thérapeutiques 1-Éducation. 2- L’éviction. 3 -Traitement pharmacologique. BDCA Les corticostéroïdes inhalés (CSI) BDLA Les antagonistes des récepteurs des leucotriènes Les Anti IgE : Omalizumab

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