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

GINA Guidelines for Managing Asthma

The Global Initiative for Asthma (GINA) guidelines recommend that all adults, adolescents, and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, with a stepwise approach to treatment based on symptom control and risk assessment. 1, 2

Diagnosis and Assessment

• Confirm asthma diagnosis using:

  • Spirometry showing variable airflow limitation
  • Peak expiratory flow (PEF) measurements showing variability
  • Assessment of symptoms and response to treatment 3

• Assess asthma control using validated tools:

  • Symptom frequency and severity
  • Nighttime awakenings
  • Rescue medication use
  • Activity limitations
  • Lung function measurements 1

Treatment Approach

Initial Treatment

GINA divides treatment into two tracks 2, 4:

Track 1 (Preferred):

• Uses as-needed low-dose ICS-formoterol as reliever at all steps
• Steps 1-2 (mild asthma): As-needed ICS-formoterol only
• Steps 3-5: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART approach)

Track 2 (Alternative):

• Uses SABA as reliever across all steps
• Step 1: Low-dose ICS whenever SABA is taken
• Step 2: Regular low-dose ICS plus as-needed SABA
• Steps 3-5: Regular ICS-LABA plus as-needed SABA

Stepwise Management

Step 1 (Mild Intermittent Asthma):

• Track 1: As-needed low-dose ICS-formoterol
• Track 2: As-needed SABA with low-dose ICS taken at the same time

Step 2 (Mild Persistent Asthma):

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

Step 3 (Moderate Asthma):

• Track 1: Low-dose ICS-formoterol maintenance and reliever therapy (MART)
• Track 2: Low-dose ICS-LABA maintenance plus as-needed SABA

Step 4 (Moderate-to-Severe Asthma):

• Track 1: Medium-dose ICS-formoterol maintenance and reliever therapy
• Track 2: Medium-dose ICS-LABA maintenance plus as-needed SABA

Step 5 (Severe Asthma):

• High-dose ICS-LABA
• Consider add-on treatments:
  • Long-acting muscarinic antagonist (LAMA)
  • Azithromycin
  • Biologic therapies for appropriate phenotypes 4

Acute Exacerbation Management

For acute exacerbations, GINA recommends 1:

• Short-acting beta-agonists (e.g., salbutamol 5-10 mg nebulized every 15-30 minutes as needed)
• Systemic corticosteroids (prednisolone 30-60 mg daily)
• Consider adding ipratropium bromide (0.5 mg nebulized)
• High-flow oxygen to maintain SaO2 >92%

Hospital Admission Criteria

• Life-threatening features
• Features of acute severe asthma persisting after initial treatment
• PEF <33% of predicted after treatment 5

Discharge Criteria and Follow-up

When discharging patients from hospital 1:

• Patient should be on discharge medication for 24 hours
• Inhaler technique checked and recorded
• PEF >75% of predicted/best with diurnal variability <25%
• Treatment plan includes:
  • Oral corticosteroids to complete course
  • Inhaled corticosteroids as maintenance therapy
  • Written asthma action plan
• Primary care follow-up within 1 week
• Specialist follow-up within 4 weeks

Long-term Management Considerations

• Medication Dosing: The standard daily dose of ICS (defined as 200-250 μg of fluticasone propionate or equivalent) achieves 80-90% of maximum therapeutic benefit 6
• Self-Management: All patients should have a written asthma action plan 2
• Regular Review: Assess, adjust, and review treatment regularly 3
• Comorbidity Management: Address treatable traits and comorbidities that may contribute to poor control 5

Common Pitfalls to Avoid

1. Treating with SABA alone: GINA explicitly recommends against SABA-only treatment due to risks of overuse and increased exacerbation risk 2, 4

2. Overuse of high-dose ICS: Current evidence suggests that 80-90% of maximum benefit is achieved at standard doses, with higher doses increasing risk of adverse effects 6

3. Failure to address poor adherence and inhaler technique: These should be checked before escalating treatment 5

4. Not providing written action plans: Self-management education is essential for optimal outcomes 2

5. Delayed referral for specialist care: Patients with difficult-to-treat or severe asthma should be referred early for specialist review 3