What are the GINA (Global Initiative for Asthma) guidelines for managing asthma?

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to asthma management with inhaled corticosteroids (ICS) as the cornerstone of treatment for all patients, moving away from SABA-only treatment due to increased mortality risk. 1, 2

Assessment and Classification of Asthma

GINA has shifted from classifying asthma by severity to classifying by level of control:

• Controlled: No daytime symptoms, no activity limitations, no nocturnal symptoms, no need for rescue medication, normal lung function, no exacerbations
• Partly controlled: Some limitations in these areas
• Uncontrolled: Three or more features of partly controlled asthma present in a week 3, 4

Assessment should include:

• Symptom frequency and severity
• Limitations in daily activities
• Nocturnal symptoms/awakenings
• Need for reliever medication
• Lung function (PEF or FEV₁)
• Exacerbation frequency and severity 5

Treatment Approach

Stepwise Treatment Model

GINA 2021 divides treatment into two tracks for adults and adolescents 1:

Track 1 (Preferred):

• Step 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol
• Steps 3-5: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART approach)

Track 2 (Alternative):

• Step 1: As-needed SABA (not recommended as sole therapy)
• Step 2: Daily low-dose ICS plus as-needed SABA
• Steps 3-5: Daily ICS-LABA plus as-needed SABA

Key Medication Recommendations

1. All patients should receive ICS-containing therapy to reduce exacerbation risk 2
2. No patient should be treated with SABA alone due to increased mortality risk 1
3. Maintenance and reliever therapy (MART) with ICS-formoterol is preferred for moderate-severe asthma 2
4. Step 5 add-on options for severe asthma include long-acting muscarinic antagonists, azithromycin, and biologic therapies 1

Monitoring and Adjusting Treatment

• Regular monitoring of symptoms, lung function, and exacerbations is essential
• Step up treatment if asthma is uncontrolled or exacerbations occur
• Step down cautiously when control is maintained for 3 months to find minimum effective dose 4
• PEF monitoring should be used to assess response to treatment, with measurements taken 15-30 minutes after starting treatment during exacerbations 5

Acute Exacerbation Management

For acute exacerbations, GINA recommends:

• Oxygen therapy to maintain saturation 93-95%
• Frequent SABA (salbutamol 5mg) via nebulizer or MDI with spacer
• Early systemic corticosteroids (prednisolone 30-60mg daily)
• Consider ipratropium bromide (0.5mg nebulized) for severe exacerbations
• Reassessment after 15-30 minutes to determine response 5

Life-threatening features requiring immediate intervention include:

• PEF <33% predicted
• Silent chest, cyanosis, poor respiratory effort
• Exhaustion, confusion, or decreased consciousness 5

Self-Management Education

GINA emphasizes patient education including:

• Written asthma action plan
• Regular medication review
• Proper inhaler technique training
• Recognition of worsening symptoms
• When and how to seek medical attention 6

Common Pitfalls to Avoid

• Underestimating asthma severity
• Inadequate corticosteroid dosing during acute attacks
• Failure to monitor response to treatment
• Discharging patients too early without adequate follow-up
• Not addressing adherence issues or incorrect inhaler technique 5

Special Considerations

• Children 6-11 years: Additional treatment options at Steps 3-4 1
• Pregnant women: Maintain controller medications; uncontrolled asthma poses greater risk than medications 6
• Work-related asthma: Exposure elimination is the strongest preventive approach 6

Remember that asthma management requires regular reassessment and adjustment of treatment to maintain optimal control and reduce future risk of exacerbations and lung function decline.