What are the 2024 Global Initiative for Asthma (GINA) guidelines for managing asthma?

2024 GINA Guidelines for Asthma Management

The 2024 Global Initiative for Asthma (GINA) guidelines strongly recommend that 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

Key Treatment Recommendations

Two-Track Treatment Approach

The 2024 GINA strategy divides treatment into two distinct tracks:

1. Track 1 (Preferred):

   • Uses as-needed low-dose ICS-formoterol as the reliever across all steps
   • For mild asthma (Steps 1-2): As-needed ICS-formoterol only
   • For moderate-severe asthma (Steps 3-5): Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (maintenance-and-reliever therapy, "MART") 1, 2

2. Track 2 (Alternative):

   • Uses as-needed SABA as the reliever across all steps
   • Step 2: Regular daily low-dose ICS plus as-needed SABA
   • Steps 3-5: Regular ICS-long-acting β2-agonist (LABA) plus as-needed SABA 2

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 eligible patients [3]

Assessment and Monitoring

Asthma Control Classification

GINA classifies asthma control (rather than severity) as:

• Controlled
• Partly controlled
• Uncontrolled

This classification is based on:

• Daytime symptoms
• Activity limitations
• Nocturnal symptoms/awakening
• Reliever medication use
• Lung function (PEF or FEV1)
• Frequency of exacerbations 2, 4

Diagnostic Criteria

The 2024 GINA report recommends confirming asthma diagnosis through:

1. Compatible clinical history
2. Objective confirmation of variable expiratory airflow limitation by one of these methods:
   • Positive bronchodilator reversibility test with spirometry
   • Excessive variability in twice-daily peak expiratory flow (PEF) over 2 weeks
   • Improvement in lung function after 4 weeks of ICS treatment
   • Positive bronchial challenge test
   • Excessive variation in lung function between visits 5

Patient Education and Self-Management

The 2024 GINA guidelines emphasize:

• All patients should have a written asthma action plan 1
• Asthma management should be tailored to individual needs
• Regular assessment, adjustment, and review of treatment
• Education on proper inhaler technique
• Recognition of worsening symptoms, especially nocturnal symptoms 3

Special Considerations

Acute Asthma Management

For acute severe asthma:

• Administer oxygen (40-60%)
• Nebulized salbutamol 5-10 mg or terbutaline 5-10 mg
• Systemic corticosteroids (prednisolone 30-60 mg)
• Consider adding ipratropium bromide 0.5 mg nebulized 3

Severe Asthma

For patients with severe asthma (Step 5):

• Add-on long-acting muscarinic antagonists
• Consider azithromycin
• Biologic therapies for eligible patients 2

Common Pitfalls to Avoid

1. Treating with SABA alone: GINA 2024 explicitly recommends against SABA monotherapy due to associated risks and inferior outcomes compared to ICS-containing regimens 6

2. Underuse of inhaled corticosteroids: ICS are the foundation of persistent asthma management 3

3. Failure to address comorbidities: Conditions like GERD, rhinosinusitis, obesity, and sleep apnea can worsen asthma control 3

4. Inadequate monitoring: Regular assessment of control and adjustment of treatment is essential 2

5. Poor inhaler technique: Proper technique should be regularly checked and reinforced 3

The 2024 GINA guidelines represent a significant shift from severity-based classification to control-based management, with a strong emphasis on ICS-containing therapy for all patients and the elimination of SABA-only treatment approaches.