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

Latest GINA Guidelines for Management of Asthma

The 2024 GINA guidelines recommend that all adults and adolescents with asthma should receive inhaled corticosteroid (ICS)-containing medication and should not be treated with short-acting beta agonists (SABA) alone, with treatment divided into two tracks: Track 1 (preferred) using as-needed low-dose ICS-formoterol as reliever, and Track 2 using SABA as reliever with separate ICS controller therapy. 1

Key Changes in Recent GINA Guidelines

Treatment Approach

• GINA has shifted from classifying asthma by severity to classifying by level of control as "controlled," "partly controlled," and "uncontrolled" 2
• Assessment of control is based on:
  • Daytime symptoms
  • Restrictions of physical activity
  • Nocturnal symptoms/awakening
  • Need for reliever medication
  • Lung function (PEF or FEV1)
  • Frequency of exacerbations 2

Two-Track Treatment Strategy

1. Track 1 (Preferred):

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

2. Track 2 (Alternative):

   • Uses as-needed SABA across all steps
   • Plus regular ICS (Step 2) or ICS-LABA (Steps 3-5) 3

Evidence for Treatment Changes

• Large trials show as-needed ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared to SABA alone
• Similar outcomes for exacerbations, symptoms, lung function, and inflammatory markers compared to daily ICS plus as-needed SABA 3

Stepwise Management Approach

Step 1-2 (Mild Asthma)

• Track 1: As-needed low-dose ICS-formoterol
• Track 2: Daily low-dose ICS plus as-needed SABA 3

Step 3 (Moderate Asthma)

• Track 1: Low-dose ICS-formoterol as maintenance and reliever
• Track 2: Medium-dose ICS plus as-needed SABA or low-dose ICS-LABA plus as-needed SABA 4

Step 4-5 (Severe Asthma)

• Track 1: Medium to high-dose ICS-formoterol as maintenance and reliever
• Track 2: High-dose ICS-LABA plus as-needed SABA
• Step 5 Add-ons: Long-acting muscarinic antagonists (LAMA), azithromycin, and biologic therapies for severe asthma 3

Assessing Asthma Control

Domains of Control Assessment

1. Impairment Domain:

   • Day-to-day symptoms and limitations
   • Validated questionnaires like Asthma Control Test (ACT) are useful 5
   • ACT score ≥20 indicates well-controlled asthma 5

2. Risk Domain:

   • Probability of future exacerbations
   • Progressive loss of lung function
   • Medication side effects 5

Classification of Control

• Well-controlled: Minimal symptoms (≤2 days/week), no nighttime awakenings, no activity limitations, minimal rescue medication use, normal lung function
• Not well-controlled: Symptoms >2 days/week, some nighttime awakenings, some activity limitations, rescue medication use >2 days/week
• Very poorly controlled: Symptoms throughout the day, frequent nighttime awakenings, extreme activity limitations, rescue medication needed several times daily 5

Patient Education and Self-Management

• Every patient should be able to recognize symptoms indicating inadequate asthma control 5
• All patients should receive a written asthma action plan for managing worsening symptoms 4
• Action plans should include:
  • Daily treatment instructions
  • How to recognize and handle worsening asthma
  • When to seek medical help 5, 4
• Education should extend beyond physician's office to settings like pharmacies, schools, and community centers 5

Treatment of Exacerbations

• Short-term oral corticosteroids (3-10 days) are indicated for acute exacerbations 4
• For children with exacerbations: high-flow oxygen, nebulized salbutamol (5 mg), and oral prednisolone 1-2 mg/kg (max 40 mg) 4
• Consider hospital admission if:
  • Severe symptoms persist after initial treatment
  • Peak expiratory flow <33% of predicted/best after treatment 4

Common Pitfalls in Asthma Management

• Undertreatment: Failing to prescribe ICS for persistent asthma
• Overreliance on SABAs: GINA explicitly recommends against SABA-only treatment due to risks
• Ignoring comorbidities: Conditions like allergic rhinitis, GERD, and obesity can worsen asthma control
• Inadequate follow-up: Regular monitoring and adjustment of therapy is essential 4
• Poor inhaler technique: Proper education on inhaler use is critical 4

Special Considerations

• Work-related asthma: Exposure elimination is the strongest preventive approach; if not possible, reduction is the second-best option 5
• Children 6-11 years: Special treatment options are available at Steps 3-4 3
• Severe asthma: Consider add-on biologic therapies after optimizing standard treatments 3

The GINA guidelines emphasize that asthma management should be tailored to the individual patient, with regular reassessment and adjustment of therapy to maintain optimal control while using the lowest effective medication doses.