What are the treatment recommendations for asthma according to GINA (Global Initiative for Asthma) guidelines, including medication options and potential side effects?

Asthma Treatment According to GINA Guidelines

Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment, with ICS-LABA combinations recommended as the preferred therapy for most patients with persistent asthma to reduce morbidity, mortality, and improve quality of life. 1

Stepwise Treatment Approach

Step 1: Mild Intermittent Asthma

• Preferred controller: As-needed low-dose ICS-formoterol or low-dose ICS taken whenever SABA is used 1
• Alternative: Short-acting beta-agonist (SABA) as needed for symptom relief

Step 2: Mild Persistent Asthma

• Preferred controller: Daily low-dose ICS 1
• Alternative: Leukotriene receptor antagonist (less effective than ICS)

Step 3: Moderate Persistent Asthma

• Preferred controller: Low-dose ICS-LABA combination 1
• Alternative: Medium-dose ICS or low-dose ICS plus leukotriene modifier

Step 4: Severe Persistent Asthma

• Preferred controller: Medium-dose ICS-LABA combination 1
• Alternative: High-dose ICS plus additional controller (LABA, leukotriene modifier)

Step 5: Very Severe Persistent Asthma

• Preferred controller: Higher-level care and add-on therapies 1
• Consider referral to specialist for biological therapies

Medication Options and Mechanisms

Inhaled Corticosteroids (ICS)

• Mechanism: Suppress inflammation by switching off multiple activated inflammatory genes through histone deacetylation 2
• Options and dosing:
  • Fluticasone propionate: 88-264 mcg (low), >264-440 mcg (medium), >440 mcg (high) 1
  • Beclomethasone HFA: 80-240 mcg (low), >240-480 mcg (medium), >480 mcg (high) 1
  • Budesonide DPI: 180-600 mcg (low), >600-1200 mcg (medium), >1200 mcg (high) 1
  • Mometasone DPI: 200 mcg (low), 400 mcg (medium), >400 mcg (high) 1

Long-Acting Beta-Agonists (LABAs)

• Mechanism: Bronchodilation through beta-2 receptor stimulation
• Options:
  • Formoterol: Rapid onset (1-3 minutes), 12-hour duration 1
  • Salmeterol: Slower onset (15-20 minutes), 12-hour duration 1
• Warning: LABAs should never be used alone for asthma due to increased risk of asthma-related death 3

ICS-LABA Combinations

• Options:
  • Fluticasone/salmeterol (Wixela Inhub®) 3
  • Budesonide/formoterol
  • Mometasone/formoterol
• Dosing for asthma: 1 inhalation twice daily, with starting dose based on asthma severity 3

Side Effects and Complications

ICS Side Effects

• Local effects:

  • Oral candidiasis (thrush) - preventable by rinsing mouth after use 1
  • Dysphonia (hoarseness)

• Systemic effects (more common with high doses):

  • Potential adrenal suppression
  • Decreased bone mineral density
  • Cataracts and glaucoma with long-term use 1
  • Growth suppression in children (monitor growth) 1

LABA Side Effects

• Tremor
• Tachycardia
• Headache
• Muscle cramps
• Black box warning: Increased risk of asthma-related death when used without ICS 3

Monitoring and Follow-up

1. Assessment of control: Evaluate symptom control within 2-6 weeks after initiating therapy 1

2. Goals of therapy:

   • Symptoms ≤2 days/week
   • Nighttime awakenings ≤2 times/month
   • SABA use ≤2 days/week
   • No interference with normal activity 1

3. If goals not met:

   • Check inhaler technique
   • Assess adherence
   • Consider stepping up therapy 1

4. Referral to specialist if:

   • Symptoms remain uncontrolled despite Step 3 therapy
   • ≥2 exacerbations requiring oral corticosteroids in past year
   • Patient requires Step 4 care or higher 1

Acute Exacerbation Management

For severe asthma exacerbations:

1. High-dose inhaled beta-agonists: Salbutamol 5 mg or terbutaline 10 mg via nebulizer or multiple MDI actuations with spacer 4
2. Systemic corticosteroids: Prednisolone 30-60 mg or IV hydrocortisone 200 mg 4
3. For life-threatening features:
   • Add ipratropium 0.5 mg nebulized
   • Consider IV aminophylline (250 mg over 20 minutes) or IV salbutamol/terbutaline 4

Common Pitfalls and Caveats

1. Underestimation of severity: Asthma severity is often underestimated by patients and clinicians, leading to inadequate treatment 4

2. Improper inhaler technique: Ensure proper inhaler technique for optimal medication delivery 4

   • MDI: Slow deep inhalation with 10-second breath hold
   • DPI: Rapid deep inhalation (not suitable for children <4 years)
   • Use spacers/VHCs for patients with poor MDI technique

3. Alternative medicine: Complementary and alternative treatments (acupuncture, homeopathy, herbal medicine) should not replace conventional asthma therapy due to insufficient evidence 4

4. LABA monotherapy: Never use LABAs alone for asthma treatment due to increased mortality risk 3

5. Overreliance on SABA: Excessive SABA use indicates poor control and need for controller medication adjustment 1

6. Overlooking comorbidities: Identify and address conditions that may worsen asthma control (GERD, rhinosinusitis, etc.) 1