GINA Guidelines for Asthma Management
The Global Initiative for Asthma (GINA) recommends a two-track treatment approach for asthma management, with Track 1 (preferred) using ICS-formoterol as reliever across all steps, and Track 2 (alternative) using as-needed SABA plus regular ICS or ICS-LABA, with treatment adjusted based on the level of asthma control rather than severity. 1
Asthma Control Assessment
GINA classifies asthma control into three categories:
- Controlled: Minimal daytime symptoms, no activity limitations, no nighttime symptoms, minimal reliever use, normal lung function, no exacerbations
- Partly Controlled: Some limitations in these areas
- Uncontrolled: Significant symptoms and limitations 1, 2
Assessment tools:
- Validated questionnaires like the Asthma Control Test (ACT) - score ≥20 indicates well-controlled asthma 1
- Regular monitoring of lung function with spirometry or peak flow measurements 1
Treatment Approach
Two-Track Treatment Strategy
Track 1 (Preferred):
- Uses ICS-formoterol as reliever across all treatment steps
- Step 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol
- Steps 3-5: Maintenance ICS-formoterol plus as-needed ICS-formoterol (MART - Maintenance and Reliever Therapy) 1, 3
Track 2 (Alternative):
- Uses as-needed SABA across all steps
- Step 1: No longer recommended to use SABA alone
- Step 2: Daily low-dose ICS plus as-needed SABA
- Steps 3-5: Regular ICS-LABA plus as-needed SABA 1, 3
Treatment by Asthma Severity
Mild Asthma:
Moderate Asthma:
- Preferred: Low-dose ICS-formoterol as maintenance and reliever
- Alternative: Medium-dose ICS or low-dose ICS-LABA plus as-needed SABA 1
Severe Asthma:
Managing Acute Exacerbations
For acute exacerbations, GINA recommends:
- Immediate treatment with 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% 1
Discharge Criteria:
- On discharge medication for 24 hours
- Inhaler technique checked and recorded
- PEF >75% of predicted or best and PEF diurnal variability <25%
- Treatment plan including oral corticosteroids to complete course and maintenance therapy 1
Key Changes in Recent GINA Updates
No more SABA-only treatment: GINA no longer recommends treating asthma with short-acting β2-agonists (SABA) alone due to risks of SABA overuse and evidence for benefit of inhaled corticosteroids (ICS) 4, 3
Focus on exacerbation prevention: Recent updates emphasize preventing exacerbations as a critical goal of asthma management, alongside symptom control 5
As-needed ICS-formoterol for mild asthma: Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared to SABA alone 3
Special Considerations
Pregnant women: Maintain optimal disease control to ensure adequate fetal oxygenation 1
Children under 5 years: PEFR measurements may not be reliable; clinical assessment becomes more important 1
Comorbidities: Identify and treat comorbid conditions that can worsen asthma control 1
Common Pitfalls to Avoid
Using LABA without ICS: Long-acting beta-agonists should never be used as monotherapy due to increased risk of asthma-related deaths 1
Overreliance on SABA: Excessive SABA use (≥3 canisters/year) is associated with increased risk of exacerbations 3
Ignoring poor symptom control: While exacerbation prevention is crucial, persistent poor symptom control remains a major risk factor for exacerbations 5
Failure to step down treatment: Treatment should be stepped down if asthma is well-controlled for at least 3 months 1
Inadequate patient education: Proper inhaler technique, medication adherence, and self-management are essential for effective asthma control 1