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

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to asthma management with inhaled corticosteroids (ICS) as the cornerstone of treatment, focusing on achieving and maintaining asthma control rather than classifying by severity. 1, 2

Core Principles of GINA Guidelines

• GINA was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention, and management worldwide 3
• GINA provides annually updated, evidence-based resources for clinicians that are adopted or adapted by many national guidelines 3
• The guidelines have shifted from classifying asthma by severity to focusing on the level of asthma control as "controlled," "partly controlled," or "uncontrolled" 4
• GINA recommends that all adults, adolescents, and most children with asthma should receive ICS-containing therapy to reduce exacerbation risk 3

Assessment of Asthma Control

GINA defines asthma control across two domains:

Current Symptom Control (Impairment)

• Daytime symptoms (≤2 days/week for well-controlled) 5
• Nighttime awakenings (≤2 times/month for adults for well-controlled) 5
• Need for reliever medication (≤2 days/week for well-controlled) 5
• Activity limitation (none for well-controlled) 5
• Lung function (FEV1 or PEF >80% predicted/personal best for well-controlled) 5

Future Risk Assessment

• Risk of exacerbations 6
• Risk of fixed airflow limitation 6
• Risk of medication side effects 6

Treatment Approach

GINA 2021 divides treatment for adults and adolescents into two tracks:

Track 1 (Preferred)

• Step 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol 2
• Step 3-5 (Moderate-Severe): Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (SMART therapy) 1, 2

Track 2 (Alternative)

• Step 1: As-needed SABA (not recommended as sole therapy) 2
• Step 2: Regular low-dose ICS plus as-needed SABA 1
• Step 3-5: Regular ICS-LABA plus as-needed SABA 2

For Children 6-11 Years

• Treatment options are modified with age-appropriate dosing and delivery devices 2
• Assessment criteria are adjusted for age (e.g., ≤1 time/month nighttime awakenings for well-controlled in ages 5-11) 5

Special Considerations

• Diagnosis Confirmation: GINA recommends confirming asthma diagnosis with spirometry or peak flow measurements before starting long-term therapy 3
• Comorbidities: Assessment should include identification of conditions that can mimic or worsen asthma, such as COPD, vocal cord dysfunction, or cardiac conditions 7
• Environmental Control: Identification and reduction of exposure to allergens and irritants that trigger symptoms 5
• Self-Management Education: Patients should receive written asthma action plans and training on proper inhaler technique 5

Step-Up and Step-Down Approach

• Step-Up: If asthma is uncontrolled with current treatment, consider stepping up after checking inhaler technique, adherence, and environmental triggers 4
• Step-Down: If asthma is well-controlled for at least 3 months, consider gradually stepping down to the lowest effective dose 1

Severe Asthma Management

• Step 5 Add-on Options: For adults with severe asthma, GINA recommends considering:
  • Long-acting muscarinic antagonists (LAMA) 2
  • Azithromycin (in those with persistent symptoms despite high-dose ICS-LABA) 2
  • Biologic therapies for appropriate phenotypes 2

Common Pitfalls to Avoid

• SABA Overreliance: GINA no longer recommends SABA-only treatment due to risks of overuse and associated morbidity/mortality 2
• Underuse of ICS: Even in mild asthma, ICS therapy (either regular or as-needed with formoterol) reduces severe exacerbation risk 3
• LABA Monotherapy: LABAs should never be used as monotherapy for asthma due to increased risk of asthma-related death 1
• Inadequate Follow-up: Regular monitoring and adjustment of therapy is essential for maintaining control 4
• Overlooking Comorbidities: Conditions like GERD, rhinosinusitis, or vocal cord dysfunction can mimic or worsen asthma symptoms 7

GINA guidelines emphasize that asthma management is not "one size fits all" and requires individualized assessment, adjustment, and review of treatment to optimize outcomes 3.