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

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) recommends that all patients with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, with treatment adjusted based on symptom control and exacerbation risk using a stepwise approach. 1

Asthma Control Assessment

GINA has evolved from classifying asthma by severity (intermittent, mild-persistent, moderate-persistent, severe-persistent) to focusing on the level of control:

• Control Classification:

  • Controlled: Minimal daytime symptoms, no activity limitations, no nighttime symptoms, minimal reliever use, normal lung function, no exacerbations
  • Partly Controlled: Some limitations in these domains
  • Uncontrolled: Significant symptoms, limitations, and/or exacerbations 2, 3

• Assessment Tools:

  • Validated questionnaires like Asthma Control Test (ACT)
  • Score of 20 or higher on ACT generally indicates well-controlled asthma 4

Treatment Approach

Key Treatment Principles

1. No SABA-only Treatment: GINA recommends against treating asthma with short-acting β2-agonists (SABA) alone due to risks of SABA overuse 5

2. Two-Track Treatment Approach for Adults/Adolescents: 5

   • Track 1 (Preferred): ICS-formoterol as reliever across all steps
     • Steps 1-2 (mild asthma): As-needed only
     • Steps 3-5: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART)
   • Track 2 (Alternative): As-needed SABA across all steps plus:
     • Step 2: Regular ICS
     • Steps 3-5: Regular ICS-LABA

3. Stepwise Approach:

   • Step up treatment if asthma is not controlled
   • Step down if control is maintained for at least 3 months 6

Treatment by Age Group

Adults and Adolescents:

• Mild Asthma: Low-dose ICS-formoterol as needed (preferred) or daily low-dose ICS plus as-needed SABA
• Moderate Asthma: Low-dose ICS-formoterol as maintenance and reliever or medium-dose ICS plus as-needed SABA
• Severe Asthma: High-dose ICS-LABA with consideration of add-on therapies 6, 5

Children 5-11 Years:

• Well-controlled: ≤2 days/week symptoms, ≤1 nighttime awakening/month, no activity limitation, ≤2 days/week SABA use, >80% predicted lung function
• Treatment: Low-dose ICS is preferred for persistent asthma with additional options at Steps 3-4 4, 6

Children 0-4 Years:

• Well-controlled: ≤2 days/week symptoms, ≤1 nighttime awakening/month, no activity limitation, ≤2 days/week SABA use
• Treatment: Adjust based on control level with ICS as cornerstone therapy 4, 6

Exacerbation Management

For acute exacerbations, GINA recommends:

• Immediate Treatment:

  • High-dose inhaled β-agonists (salbutamol 5 mg or terbutaline 10 mg)
  • Systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg)
  • Oxygen therapy to maintain saturation 93-95% 4, 6

• For Life-Threatening Features:

  • Add nebulized ipratropium (0.5 mg)
  • Consider IV aminophylline (250 mg over 20 min) or IV salbutamol/terbutaline (250 μg over 10 min) 4

• Monitoring:

  • Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment
  • Continue oxygen therapy
  • Continue high-dose steroids
  • Adjust nebulized β-agonist frequency based on response 4

Criteria for Hospital Referral

Immediate referral to hospital for:

• Any life-threatening features
• Persistent severe attack features after initial treatment
• PEF <33% of predicted or best value 15-30 minutes after treatment 4

Lower threshold for admission in patients:

• Seen later in the day
• With recent nocturnal symptoms
• With history of severe attacks
• With concerning social circumstances 4

Monitoring and Follow-up

• Assess asthma control at every visit
• Monitor lung function with spirometry or peak flow
• Step up treatment if control is inadequate
• Step down if asthma is well-controlled for at least 3 months 6

Common Pitfalls to Avoid

• Underestimating Severity: Severity is often underestimated by patients and healthcare providers - always use objective measurements 4
• SABA Monotherapy: Never use LABA without ICS due to increased risk of asthma-related deaths 6
• Inadequate ICS Dosing: Standard daily dose of ICS (200-250 μg fluticasone equivalent) achieves 80-90% of maximum benefit 6
• Poor Inhaler Technique: Always check and correct technique
• Ignoring Comorbidities: Address allergies, rhinosinusitis, GERD, and obesity that can worsen asthma control 6

GINA guidelines emphasize that asthma management requires regular assessment, adjustment of treatment, and patient education to achieve optimal outcomes and reduce the risk of exacerbations and mortality.