What are the recommendations for track 1 and track 2 in the latest Global Initiative for Asthma (GINA) guidelines for asthma management?

GINA Guidelines: Track 1 and Track 2 Approach to Asthma Management

The 2024 GINA guidelines recommend a two-track approach to asthma management with Track 1 (preferred) using as-needed low-dose ICS-formoterol as reliever across all steps, while Track 2 (alternative) uses SABA as reliever with separate ICS-containing controller therapy. 1

Overview of the Two-Track Approach

Track 1 (Preferred)

• Reliever medication: Low-dose ICS-formoterol combination used as-needed across all steps
• Step 1-2 (Mild Asthma): As-needed ICS-formoterol only
• Step 3-5: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (Maintenance and Reliever Therapy, "MART") 2

Track 2 (Alternative)

• Reliever medication: As-needed SABA across all steps
• Step 2: Regular daily ICS plus as-needed SABA
• Step 3-5: Regular ICS-LABA plus as-needed SABA 2

Key Changes and Rationale

The two-track approach represents a significant shift from previous guidelines based on compelling evidence:

• Elimination of SABA-only treatment: GINA no longer recommends SABA alone without ICS due to risks of SABA overuse and evidence supporting ICS benefits 2
• Evidence-based change: Large trials show as-needed ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared to SABA alone 2
• Comparable outcomes: As-needed ICS-formoterol provides similar exacerbation protection, symptom control, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA 2

Step-by-Step Management Approach

Steps 1-2 (Mild Asthma)

• Track 1: As-needed low-dose ICS-formoterol
• Track 2: Daily low-dose ICS plus as-needed SABA

Steps 3-4 (Moderate Asthma)

• Track 1: Low-dose maintenance ICS-formoterol plus as-needed ICS-formoterol (MART)
• Track 2: Regular ICS-LABA plus as-needed SABA
• For children 6-11 years, additional treatment options are available 2

Step 5 (Severe Asthma)

• Both tracks: Consider add-on therapies:
  • Long-acting muscarinic antagonists (LAMA)
  • Azithromycin
  • Biologic therapies for severe asthma 2

Monitoring and Follow-up

Regular monitoring is essential across both tracks:

• Assessment of asthma control using validated tools (ACT or ACQ)
• Regular spirometry to monitor lung function
• Short-term follow-up (1-2 weeks) to assess response to therapy
• Medium-term follow-up (4-6 weeks) to assess control and adjust therapy 3

Discharge Planning

Patients should only be discharged when:

• They have been on discharge medication for 24 hours
• Inhaler technique has been checked and recorded
• PEF >75% of predicted or best
• Treatment plan includes oral steroids and inhaled steroids
• Follow-up with primary care arranged within 1 week
• Follow-up in respiratory clinic within 4 weeks 3

Important Considerations

• Written asthma action plan: All patients should have a personalized written plan
• Risk factor assessment: Consider factors for poor asthma outcomes before selecting a track
• Personalized approach: Treatment should be tailored to individual patient needs, compliance, and expectations 4
• Regular review: Ongoing assessment, treatment adjustment, and skills training remain essential across all severity levels 2

Common Pitfalls to Avoid

• SABA-only treatment: No longer recommended for any asthma patient
• Sedatives in acute asthma: Can cause respiratory depression
• Delaying treatment: Prompt management of exacerbations is critical
• Initiating immunotherapy with uncontrolled asthma: Increases risk of severe reactions 3

The two-track approach represents a significant advancement in asthma management, providing clinicians with clear, evidence-based options that prioritize both symptom control and exacerbation prevention.