GINA Guidelines for Asthma Management
The Global Initiative for Asthma (GINA) recommends that all adults, adolescents, and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, with treatment tailored to achieve overall asthma control. 1
Core Principles of Asthma Management
- The goal of asthma management is to achieve control with the least amount of medication, minimizing side effects while reducing the risk of exacerbations 2
- Asthma control consists of two domains: achieving day-to-day symptom control and minimizing future risks (exacerbations, lung function decline, medication side effects) 3
- Successful management should result in minimal daytime symptoms, no nighttime waking, full participation in activities/sports, and infrequent need for relief medications 4
Stepwise Treatment Approach
GINA recommends a 5-step treatment paradigm:
- Step 1: No longer recommends SABA alone - now prefers as-needed low-dose ICS-formoterol combination (Track 1) or regular low-dose ICS with as-needed SABA (Track 2) 5
- Step 2: Low-dose ICS as controller with as-needed SABA, or as-needed ICS-formoterol 3, 1
- Step 3: Low-dose ICS-LABA combination, preferably as maintenance-and-reliever therapy (MART) with ICS-formoterol 1
- Step 4: Medium-dose ICS-LABA combination 3, 6
- Step 5: High-dose ICS-LABA plus additional controllers (e.g., oral corticosteroids) 3
Important Dosing Considerations
- The dose that achieves 80-90% of maximum therapeutic benefit (200-250 μg of fluticasone propionate or equivalent) is considered a "standard daily dose" 6
- Treatment should be stepped up if asthma is uncontrolled and stepped down once control has been maintained for 3 months 3, 2
Acute Exacerbation Management
- Life-threatening features include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion 2
- Severe features include inability to complete sentences, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted 2
- Immediate management requires:
- Hospital admission criteria include any life-threatening features, persistent severe features after initial treatment, or PEF <33% of predicted after treatment 4, 2
Self-Management Education
- Patients should be enabled to manage their treatment rather than requiring consultation before making changes 4
- Every patient should have a written asthma action plan with clear instructions for:
- Monitoring symptoms and peak flow 4
- Recognizing worsening asthma (especially nocturnal symptoms) 4
- Initiating or increasing inhaled steroids when needed 4
- Self-administering oral steroids when peak flow falls below agreed level (typically <60% of normal) 4
- Seeking urgent medical attention when treatment is not working 4
Monitoring and Follow-Up
- Regular review should include assessment of:
- Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 4
- Consider stepping down treatment when asthma has been well-controlled for 3 months 2
Special Populations
Children (0-2 years)
- Diagnosis relies almost entirely on symptoms, which may be highly variable 4
- Recurrent wheeze and cough are often associated with viral respiratory infections 4
- Consider alternative diagnoses such as gastro-esophageal reflux, cystic fibrosis, and chronic lung disease of prematurity 4
Pregnant Women
- Require special attention and may need more aggressive management during pregnancy 4
- Should be included in self-management programs 4
Common Pitfalls to Avoid
- Overreliance on bronchodilators without anti-inflammatory treatment 2
- Underestimating severity of exacerbations 2
- Using sedation in acute asthma (contraindicated) 4, 7
- Delaying administration of systemic corticosteroids during severe exacerbations 2
- Prescribing antibiotics unless bacterial infection is clearly present 4, 7
- Using excessive doses of ICS beyond the standard dose that achieves 80-90% of maximum benefit 6