GINA Guidelines for Asthma Management
According to the 2024 Global Initiative for Asthma (GINA) update, all adults and adolescents with asthma should receive inhaled corticosteroid (ICS)-containing medication and should not be treated with short-acting beta agonist (SABA) alone. 1
Diagnosis and Assessment
Asthma diagnosis focuses on two domains:
- Impairment: frequency and intensity of symptoms, functional limitations
- Risk: likelihood of exacerbations, decline in lung function, medication side effects 2
Key symptoms include:
- Wheezing
- Coughing (particularly at night or early morning)
- Chest tightness
- Shortness of breath
- Sleep disturbance due to symptoms 2
Severity indicators:
- Ability to speak in sentences
- Respiratory rate (>25/min indicates severe asthma)
- Heart rate (>110/min indicates severe asthma)
- Oxygen saturation
- Peak expiratory flow (PEF) <50% predicted indicates severe asthma 2
Use validated questionnaires like the Asthma Control Test (ACT) to assess control (score ≥20 indicates well-controlled asthma) 2
Treatment Approach
GINA 2024 Treatment Tracks
GINA divides treatment into two tracks 1, 3:
Track 1 (Preferred):
- Uses as-needed low-dose ICS-formoterol as the 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):
- Uses as-needed SABA across all steps
- Plus regular ICS (Step 2) or ICS-long-acting β2-agonist (Steps 3-5)
Treatment Based on Asthma Severity
| Asthma Severity | Preferred Treatment | Alternative Treatment |
|---|---|---|
| Mild | Low-dose ICS-formoterol as needed | Daily low-dose ICS plus as-needed SABA |
| Moderate | Low-dose ICS-formoterol as maintenance and reliever | Medium-dose ICS plus as-needed SABA |
| Severe | High-dose ICS plus LABA | Consider adding biologics for allergic asthma [2] |
Asthma Control Classification
GINA 2006 and later updates classify asthma by level of control rather than severity alone 4:
- Controlled: Minimal or no symptoms, no activity limitation, normal lung function
- Partly Controlled: Some symptoms, some activity limitation, occasional exacerbations
- Uncontrolled: Frequent symptoms, limited activities, frequent exacerbations 4
Medication Dosing Considerations
- Standard daily dose of ICS is defined as 200-250 μg of fluticasone propionate or equivalent, which achieves 80-90% of maximum therapeutic benefit 5
- For exacerbations, recommended medications include:
- Oxygen (40-60%)
- Nebulized salbutamol 5-10 mg or terbutaline 5 mg
- Systemic corticosteroids (prednisolone 30-60 mg)
- Consider adding ipratropium bromide 0.5 mg nebulized 2
Special Considerations
- Pregnancy: Most asthma medications are safe; uncontrolled asthma poses greater risk than medications 2
- Exercise-induced asthma: Pre-treatment with SABA 15 minutes before exercise, regular controller therapy for persistent symptoms 2
- Work-related asthma: Exposure elimination is the strongest preventive approach 2
Common Pitfalls and Patient Education
- Underuse of ICS: This is a common pitfall as ICS are the foundation of persistent asthma management 2
- Failure to address comorbidities: GERD, rhinosinusitis, obesity, and sleep apnea can worsen asthma control 2
- Written asthma action plan: Essential for all patients, should include:
Monitoring and Follow-up
- Regular monitoring and adjustment is essential to maintain asthma control
- If asthma is not or only partially controlled, step-up treatment is recommended
- If disease is controlled, consider gradual stepping-down to the lowest possible dose of medication needed to maintain control 4