Bronchial Asthma

- Annexes

The following annexes are reproduced from the Egyptian MoH Asthma Management Protocol for Adolescents and Adults (2023), except Annexes 13 and 14, which are retained to operationalize the Protocol’s dosing and written-action-plan recommendations.

Annex 1. Treatment Summary Chart — Steps 1–5 (initiation by ACT score)

Initiate therapy by ACT score: ACT ≥20 → Step 1; ACT 16–19 → Step 2; ACT <16 → Step 3 (escalate to Steps 4–5 if still uncontrolled). Reliever at Steps 2–5: as-needed low-dose ICS-formoterol or ICS-SABA. Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 2. Asthma Control Test (ACT) — Arabic patient version

Scoring: total 20–25 = well controlled; 16–19 = partly controlled; <16 = uncontrolled. Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 3. Checklists — comorbidities/aggravating factors and environmental triggers

Checklist for comorbidities / aggravating factors	Yes	No	Checklist for triggers	Yes	No
Allergic rhinitis	☐	☐	Indoor — Animal dander	☐	☐
Gastroesophageal reflux disease (GERD)	☐	☐	Indoor — House dust mite	☐	☐
Obesity	☐	☐	Outdoor — Occupational	☐	☐
Psychiatric disease	☐	☐	Outdoor — Non-occupational	☐	☐
Obstructive sleep apnea (OSA)	☐	☐

Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 4. Step-Down Table — options for stepping down by current step

Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 5. Definition of severe asthma and its qualifying criteria

Severe asthma is asthma that requires treatment with high-dose ICS and LABA (± antileukotriene / theophylline) ± systemic corticosteroids for ≥50% of the previous year to prevent it from becoming uncontrolled, OR that remains uncontrolled despite this therapy — together with any one of the following:

· Poor symptom control: ACQ >1.5, ACT <20 (or “not well controlled” by NAEPP/GINA).

· Frequent severe exacerbations: ≥2 bursts of systemic corticosteroids (>3 days each) in the previous year.

· Serious exacerbations: ≥1 hospitalization, ICU stay or mechanical ventilation in the previous year.

· Airflow limitation: FEV₁ <80% predicted after appropriate bronchodilator withholding; FEV₁/FVC below the lower limit of normal.

· Controlled asthma that worsens on tapering of treatment.

Source: Chung KF et al. (reference 36); adopted by the Egyptian MoH Asthma Management Protocol (2023).

Annex 6. Difficult-to-treat versus severe asthma

Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 7. Panel of Type 2 biomarkers

Class	Name	Age	Asthma indication	Other indications
Anti-IgE	Omalizumab	≥6 years	Severe allergic asthma	Chronic spontaneous urticaria
Anti-IL-5Rα	Benralizumab	≥12 years	Severe eosinophilic / Type 2 asthma	—
Anti-IL-4Rα	Dupilumab	≥6 years	Severe eosinophilic / Type 2 asthma, or maintenance OCS	Atopic dermatitis, CRSwNP

Clinically allergen-driven disease = specific IgE or positive skin-prick test for relevant allergens. Source: GINA 2023, adopted by the Egyptian MoH Protocol (2023).

Annex 8. Biologics in severe asthma in Egypt

Class	Name	Age	Asthma indication	Other indications
Anti-IgE	Omalizumab	≥6 years	Severe allergic asthma	Chronic spontaneous urticaria
Anti-IL-5Rα	Benralizumab	≥12 years	Severe eosinophilic / Type 2 asthma	—
Anti-IL-4Rα	Dupilumab	≥6 years	Severe eosinophilic / Type 2 asthma, or maintenance OCS	Atopic dermatitis, CRSwNP

Check local eligibility criteria for specific biologic therapies. Source: Egyptian MoH Asthma Management Protocol (2023).

Annex 9. Selection of biologics for severe uncontrolled asthma (by blood-eosinophil stratum)

Source: Buhl R et al. (reference 42); adopted by the Egyptian MoH Protocol (2023).

Annex 10. Risk factors for asthma-related death

Source: GINA 2023 and ESSB 2019, adopted by the Egyptian MoH Protocol (2023).

Annex 11. Classification of asthma exacerbation severity

Patients with features of more than one severity level should be classified to the higher level and managed accordingly. Source: GINA 2023 and ESSB 2019.

Annex 12. Treatment of exacerbations by severity and time interval (ER / ICU)

Source: GINA 2023 and ESSB 2019, adopted by the Egyptian MoH Protocol (2023).

Annex 13. Low, medium and high daily metered doses of inhaled corticosteroids

This is not a table of equivalence, but suggested total daily doses for “low”, “medium” and “high” dose ICS options for adults and adolescents (12 years and older), based on product information.
The table does NOT imply potency equivalence. For example, if you switch treatment from a “medium” dose of one ICS to a “medium” dose of another ICS, this may represent a decrease (or an increase) in potency, and the patient’s asthma may become unstable (or they may be at increased risk of adverse effects).
A patient’s asthma should be monitored for stability after any change of treatment or inhaler device. Doses and potency may also differ by country, depending on local products, inhaler devices, regulatory labelling and clinical guidelines or, for one product, with addition of a LAMA to an ICS-LABA. Low-dose ICS provides most of the clinical benefit of ICS for most patients with asthma. However, ICS responsiveness varies between patients, so some patients may need medium-dose ICS if their asthma is uncontrolled, or they have ongoing exacerbations, despite good adherence and correct technique with low-dose ICS (with or without LABA). High-dose ICS (in combination with LABA or separately) is needed by very few patients, and its long-term use is associated with an increased risk of local and systemic side-effects, which must be balanced against the potential benefits. The timing of medication use also affects outcomes, particularly for exacerbations, as seen with an anti-inflammatory reliever (see Section 4). Daily doses in this table are shown as metered doses. See product information for delivered doses.
Inhaled corticosteroid (alone or in combination with LABA)	Total daily ICS dose (mcg) – see notes above
	Low	Medium	High
Adults and adolescents (12 years and older)
Beclometasone dipropionate (pMDI, standard particle, HFA)	200–500	>500–1000	>1000
Beclometasone dipropionate (DPI or pMDI, extrafine particle, HFA)	100–200	>200–400	>400
Budesonide (DPI, or pMDI, standard particle, HFA)	200–400	>400–800	>800
Ciclesonide (pMDI, extrafine particle, HFA)	80–160	>160–320	>320
Fluticasone furoate (DPI)	100	—	200
Fluticasone propionate (DPI)	100–250	>250–500	>500
Fluticasone propionate (pMDI, standard particle, HFA)	100–250	>250–500	>500
Mometasone furoate (DPI)	Depends on DPI device – see product information
Mometasone furoate (pMDI, standard particle, HFA)	200–400	—	>400

Retained to operationalize the Protocol’s “low/medium/high-dose ICS” prescribing.

Annex 14. Written Asthma Action Plan

Retained; required by recommendations 4.13.3 and Section 8 (written action plan).