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

Latest GINA Guidelines for Asthma Management (2023)

The 2023 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 exacerbation risk, with ICS-formoterol as the preferred reliever medication rather than short-acting beta-agonists (SABA) alone. 1

Key Changes in Recent GINA Guidelines

Treatment Approach

• Two-track treatment approach for adults and adolescents 2:

  • Track 1 (Preferred): 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 (maintenance-and-reliever therapy, "MART")
  • Track 2 (Alternative): As-needed SABA across all steps, plus:
    • Step 2: Regular ICS
    • Steps 3-5: ICS-LABA

• GINA no longer recommends SABA-only treatment for adults and adolescents with asthma due to risks of SABA overuse and evidence showing ICS benefits 3

Medication Recommendations

• Mild Asthma: As-needed low-dose ICS-formoterol reduces severe exacerbations by ≥60% compared to SABA alone 2
• Moderate-to-Severe Asthma: Step 5 recommendations include:
  • Add-on long-acting muscarinic antagonists (LAMA)
  • Azithromycin (in appropriate patients)
  • Biologic therapies for severe asthma 2
• Children 6-11 years: New treatment options added at Steps 3-4 2

Stepwise Management Approach

Step 1: Mild Asthma

• Preferred: As-needed low-dose ICS-formoterol
• Alternative: Low-dose ICS taken whenever SABA is taken 1, 3

Step 2: Mild Persistent Asthma

• Preferred: As-needed low-dose ICS-formoterol
• Alternative: Daily low-dose ICS plus as-needed SABA 1

Step 3: Moderate Asthma

• Preferred: Low-dose ICS-formoterol as maintenance and reliever therapy
• Alternative: Medium-dose ICS plus as-needed SABA 4

Step 4: Moderate-to-Severe Asthma

• Preferred: Medium-dose ICS-formoterol as maintenance and reliever therapy
• Alternative: Medium/high-dose ICS-LABA plus as-needed SABA 4, 2

Step 5: Severe Asthma

• Continue high-dose ICS-LABA
• Add-on options:
  • LAMA (tiotropium)
  • Azithromycin (in appropriate patients)
  • Biologic therapies based on phenotyping (anti-IgE, anti-IL5/5R, anti-IL4R) 2

Assessment and Monitoring

• Regular personalized assessment of symptom control and risk factors
• Validated questionnaires like Asthma Control Test (ACT) for symptom assessment
• Spirometry or peak flow monitoring for objective assessment 4, 1

Important Clinical Considerations

Severe Asthma Management

• Many patients with difficult-to-treat or severe asthma are not referred early for specialist review
• Primary care providers should optimize treatment, assess adherence, and refer appropriately 1

Asthma Action Plans

• All patients should receive a written asthma action plan for managing worsening symptoms 4
• Plans should document when to seek medical help for worsening symptoms

Common Pitfalls to Avoid

1. Undertreatment: Failing to prescribe ICS-containing therapy for all severity levels
2. SABA overreliance: Associated with poor outcomes including exacerbations and mortality
3. Poor adherence: Particularly to controller medications in mild asthma
4. Ignoring comorbidities: Can lead to worsening outcomes 4

Implementation Challenges

• Access to inhaled medications remains poor in many low- and middle-income countries 1
• Patient education is essential for successful implementation of maintenance-and-reliever therapy 5
• Treatment should be individualized based on symptom control, risk factors, patient preferences, and practical issues 2, 1

The GINA 2023 guidelines represent a significant shift from decades of clinical practice, particularly in mild asthma management, with strong evidence supporting the use of ICS-containing therapy for all patients with asthma.