What are the recommendations for managing asthma according to the Global Initiative for Asthma (Gina) guidelines?

Global Initiative for Asthma (GINA) Guidelines: Recommendations for Managing Asthma

The Global Initiative for Asthma (GINA) recommends a stepwise approach for asthma management with inhaled corticosteroids (ICS) as the cornerstone of treatment, and ICS-formoterol combination as the preferred treatment for mild to severe asthma. 1

Core Principles of Asthma Management

• GINA aims to achieve overall asthma control through two domains: day-to-day symptom control and minimizing future risk (preventing exacerbations, preventing lung function decline, and avoiding medication side effects) 2
• The goal is to achieve control with the least amount of medication to minimize side effects while enabling normal activities and growth in children 3
• GINA no longer recommends SABA alone as treatment for asthma due to safety concerns 4

Stepwise Approach to Treatment

GINA recommends a 5-step treatment approach:

Step 1 (Mild Intermittent Asthma)

• Preferred option: As-needed low-dose ICS-formoterol (replacing the previous recommendation of SABA alone) 1, 4
• Alternative: Low-dose ICS taken whenever SABA is taken 1

Step 2 (Mild Persistent Asthma)

• Preferred option: Daily low-dose ICS plus as-needed ICS-formoterol OR as-needed ICS-formoterol alone 1
• Alternative: Daily low-dose ICS plus as-needed SABA 1, 5

Step 3 (Moderate Persistent Asthma)

• Preferred option: Low-dose ICS-LABA maintenance plus as-needed ICS-formoterol (SMART therapy) 1
• Alternative: Medium-dose ICS plus as-needed SABA 2

Step 4 (Severe Persistent Asthma)

• Preferred option: Medium-dose ICS-LABA maintenance plus as-needed ICS-formoterol 1
• Alternative: High-dose ICS plus as-needed SABA 2

Step 5 (Very Severe Persistent Asthma)

• High-dose ICS-LABA plus add-on treatments (LAMA, biologic agents) 6
• Consider referral for phenotype-specific treatments 6
• Oral corticosteroids may be required but should be used at lowest effective dose 2

Medication Classes in Asthma Management

• Inhaled Corticosteroids (ICS): Most effective anti-inflammatory medication for persistent asthma, improving symptoms, lung function, and quality of life 1, 5
• Long-Acting Beta2-Agonists (LABAs): Should never be used as monotherapy (increases risk of asthma-related death) and are most effective when combined with ICS 1
• Formoterol: Has rapid onset, making it suitable for both maintenance and reliever therapy 1
• Short-Acting Beta2-Agonists (SABA): No longer recommended as standalone therapy 4

Acute Exacerbation Management

• Life-threatening features include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion 3
• Severe features include inability to complete sentences, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted 3
• Treatment includes high-dose inhaled beta2-agonists, systemic corticosteroids, and oxygen therapy 3
• Hospital admission criteria include any life-threatening features, severe features persisting after initial treatment, PEF <33% of predicted after treatment 3

Self-Management Education

• Patients should understand the difference between "relievers" and "preventers" 3
• Self-management plans should include:
  • Regular monitoring of symptoms and peak flow 3
  • Pre-arranged action steps based on symptoms/peak flow 3
  • Written guidance for medication adjustments 3
  • Clear instructions for when to seek urgent medical attention 3

Monitoring and Follow-Up

• Regular assessment of symptom control, exacerbation risk, and lung function 1
• Consider stepping down treatment if asthma is well-controlled for at least 3 months 1
• Review inhaler technique and adherence at every visit 3
• Consider initiating ICS before discharge from emergency department for patients with persistent asthma 7

Common Pitfalls to Avoid

• Overreliance on bronchodilators without anti-inflammatory treatment 3
• Underestimating severity of exacerbations 3
• Using LABA monotherapy 1
• Delaying administration of systemic corticosteroids during severe exacerbations 3
• Failure to initiate ICS therapy in patients with persistent asthma after emergency department visits 7