What are the recommended treatment guidelines for asthma management according to the GINA (Global Initiative for Asthma) guidelines?

GINA Guidelines for Asthma Management (2025)

The 2025 Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to asthma management with inhaled corticosteroid (ICS)-containing medication for all adults and adolescents with asthma, divided into two treatment tracks: Track 1 using as-needed low-dose ICS-formoterol as the preferred reliever, and Track 2 using SABA as reliever with separate ICS maintenance therapy. 1

Core Principles of Asthma Management

• The primary goal of asthma management is to achieve control with the least amount of medication, minimizing side effects while reducing the risk of exacerbations and enabling normal functioning 2
• Asthma control assessment includes both impairment (symptom frequency, pulmonary function) and risk (exacerbation frequency and severity) components 3
• All adults and adolescents with asthma should receive ICS-containing medication and should not be treated with short-acting beta agonist (SABA) alone 1

Stepwise Treatment Approach

Track 1 (Preferred Approach)

• Step 1: As-needed low-dose ICS-formoterol for patients with limited occasional symptoms (<2 times/month), no nocturnal symptoms, no exacerbation risk, and FEV1>80% predicted 4
• Step 2: As-needed low-dose ICS-formoterol, which significantly reduces moderate-to-severe exacerbations compared to SABA monotherapy 4
• Step 3: Low-dose ICS-LABA (Long-Acting Beta Agonist) maintenance therapy 4
• Step 4: Medium-to-high dose ICS-LABA maintenance therapy 4
• Step 5: Refer to specialist for consideration of add-on biologics or other advanced therapies 4

Track 2 (Alternative Approach)

• Uses SABA as reliever with separate ICS maintenance therapy across all steps 1
• Daily low-dose ICS with as-needed SABA for mild persistent asthma 2
• Increasing ICS dose or adding additional controllers as needed based on control assessment 2

Assessment of Asthma Control

• Evaluate symptom frequency, nighttime awakenings, interference with normal activity, and rescue medication use 3
• Measure peak expiratory flow (PEF) or FEV1 to objectively assess airflow limitation 2
• Severe asthma features include inability to complete sentences in one breath, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted 5
• Life-threatening features include PEF <33% predicted, silent chest, cyanosis, weak respiratory effort, confusion, or exhaustion 5

Management of Acute Exacerbations

• Administer high-dose inhaled beta-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized) with oxygen 5
• Provide systemic corticosteroids immediately (prednisolone 30-60 mg or IV hydrocortisone 200 mg) 5
• Consider adding ipratropium bromide for additional bronchodilation if response to initial therapy is limited 5
• Hospital admission criteria include any life-threatening features, severe features persisting after initial treatment, PEF <33% after treatment, and evening presentations or recent nocturnal symptoms 2

Self-Management Education

• Every patient should have a written asthma action plan with clear instructions for medication adjustment 1
• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 2
• Regular monitoring of symptoms and peak flow should be incorporated into self-management plans 2
• For mild-moderate exacerbations using budesonide-formoterol as reliever, 1-2 additional inhalations may be taken, not exceeding 8 inhalations daily 4

Special Considerations

• Severe asthma is defined as uncontrolled asthma despite 3+ months of standardized medium/high-dose ICS-LABA with treated comorbidities 4
• For severe type 2 asthma, biologic therapies may be considered, with priority to reduce or stop oral corticosteroids while maintaining ICS-LABA therapy 4
• Triple therapy (adding LAMA like tiotropium) can improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium/high-dose ICS-LABA 4
• Low-dose azithromycin (250-500 mg three times weekly for 26-48 weeks) may be considered for persistent symptomatic asthma despite step 5 treatment 4

Common Pitfalls to Avoid

• Overreliance on bronchodilators without anti-inflammatory treatment 2
• Underestimating severity of exacerbations, which can lead to inadequate treatment 2
• Using sedatives in asthma patients, which can worsen respiratory depression 5
• Delaying administration of systemic corticosteroids during severe exacerbations 2
• Treating with antibiotics unless bacterial infection is clearly present 5

Monitoring and Follow-up

• Schedule follow-up visits every 2-4 weeks after initial therapy, then every 1-3 months if responding well 4
• Regularly assess and train patients in correct inhaler technique 4
• Consider step-down of therapy after 3 months of stable control, but maintain ICS therapy 2
• Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 2