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

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) recommends that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing medication as the cornerstone of therapy, with ICS-formoterol combination as the preferred reliever therapy rather than short-acting beta-agonists (SABA) alone. 1, 2

Core Management Principles

GINA has fundamentally shifted from severity-based classification to a control-based approach for ongoing asthma management, recognizing that severity changes over time and control is more clinically relevant. 3, 4 Asthma control is assessed across two domains:

Assessment of Control

• Well-controlled: No daytime symptoms, no nighttime awakenings, no need for reliever medication, no activity limitation, normal lung function 1
• Partly controlled: 1-2 of the above features present
• Uncontrolled: 3-4 of the above features present 1

Critical caveat: Symptom control does not equal elimination of exacerbation risk, especially in severe asthma. 1

Stepwise Treatment Approach

GINA uses a 5-step treatment ladder where therapy is adjusted based on control status rather than fixed severity categories. 3, 5

Track 1 (Preferred Approach)

• Reliever: As-needed low-dose ICS-formoterol for all patients 2
• Maintenance: Daily ICS-formoterol for persistent symptoms 1
• SMART therapy: For moderate-severe asthma, use daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol as reliever 1

Track 2 (Alternative)

• Reliever: SABA as needed 2
• Maintenance: Separate daily ICS inhaler 2

Key principle: Formoterol's rapid onset makes it uniquely suitable for both maintenance and reliever therapy, unlike other LABAs. 1

Treatment by Persistence Level

Mild intermittent asthma:

• As-needed ICS-formoterol (Track 1 preferred) 1, 2
• Alternative: As-needed SABA only if symptoms are truly infrequent 6

Mild persistent asthma:

• Daily low-dose ICS plus as-needed ICS-formoterol 1
• Alternative: Daily low-dose ICS plus as-needed SABA 1

Moderate persistent asthma:

• Low-dose ICS-LABA combination daily 6
• As-needed ICS-formoterol for relief 1

Severe persistent asthma:

• High-dose ICS-LABA combination 6
• Consider add-on treatments (leukotriene modifiers, long-acting muscarinic antagonists) before biologics 6
• Phenotype-specific biologics for refractory cases 6

Critical Safety Warnings

Never use LABA monotherapy - this increases the risk of asthma-related death. LABAs must always be combined with ICS. 1

Avoid SABA-only treatment for persistent asthma - GINA 2024 explicitly advises against treating adults and adolescents with SABA alone. 2

Stepping Up and Down

Step up when asthma is partly controlled or uncontrolled despite good inhaler technique and adherence. 7

Step down after asthma is well-controlled for at least 3 months, reducing to the lowest dose that maintains control. 1, 6

Acute Severe Asthma Management

Recognition of Severity

Severe asthma features (immediate treatment required):

• Too breathless to complete sentences in one breath 8, 7
• Respiratory rate >25 breaths/min 8, 7
• Heart rate >110 beats/min 8, 7
• Peak expiratory flow (PEF) <50% of predicted or personal best 8, 7

Life-threatening features (call for senior help immediately):

• PEF <33% of predicted or personal best 8, 7
• Silent chest, cyanosis, or feeble respiratory effort 8, 7
• Bradycardia or hypotension 8, 7
• Exhaustion, confusion, or coma 8, 7
• Normal or high PaCO2 (5-6 kPa or higher) in a breathless patient 8
• Severe hypoxia: PaO2 <8 kPa despite oxygen 8

Immediate Treatment

For all severe exacerbations (start AT ONCE):

• High-dose inhaled β-agonist: salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen 8, 6
• Alternative: 20-40 puffs of MDI with large-volume spacer 8
• High-dose systemic corticosteroids: prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 8, 6
• High-flow oxygen 6, 7

For life-threatening features (add immediately):

• Ipratropium 0.5 mg nebulized with the β-agonist 8, 6
• IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes 8, 6
• Do not give bolus aminophylline to patients already taking oral theophyllines 8

Absolute contraindications:

• Sedation is absolutely contraindicated in acute asthma 6
• Do not attempt intubation until the most expert available doctor (ideally an anaesthetist) is present 8

Hospital Admission Criteria

Admit immediately if:

• Any life-threatening features present 8
• Features of severe attack persist after initial treatment 8
• PEF remains <33% of predicted 15-30 minutes after nebulization 8

Discharge Criteria

Do not discharge until:

• PEF >75% of predicted or personal best 6
• Diurnal PEF variability <25% 6
• Nocturnal symptoms resolved 6

All discharged patients must receive:

• Prednisolone course 6
• Inhaled corticosteroids 6
• Peak flow meter with written self-management plan 6
• Follow-up within 24-48 hours 7

Essential Patient Education

Every patient must have:

• Written asthma action plan with specific PEF thresholds for stepping up treatment 1, 7, 2
• Peak flow meter for home monitoring 6, 7
• Training on proper inhaler technique 1
• Understanding of "relievers" (bronchodilators) vs "preventers" (ICS) 7

Action plan should specify:

• When to increase inhaled steroids (e.g., PEF drops below 80% of personal best) 7
• When to self-administer oral steroids 7
• When to seek emergency care 7

Specialist Referral Indications

Refer to respiratory physician for:

• Diagnostic uncertainty (especially elderly smokers with wheeze) 8, 7
• Possible occupational asthma 8, 7
• Continuing symptoms despite high-dose inhaled steroids 7
• Patients requiring or likely to require systemic corticosteroids 7
• Unexplained systemic symptoms suggesting vasculitis or eosinophilia 8

Special Populations

Pregnancy

• Budesonide is the preferred ICS with the most reassuring safety data 6
• Other ICS may be continued if providing good control 6
• Albuterol is the preferred SABA with extensive pregnancy safety data 6

Children 0-2 years

• Diagnose based on symptoms rather than objective testing 7
• Trial bronchodilator response 7

Children 3-4 years

• Use large-volume spacer devices 7
• Use nebulizers judiciously 7

Children ≥5 years

• Can typically use peak flow meters 7
• Should carry and be responsible for their own inhalers at school 8, 7
• For children 5-11, well-controlled asthma defined as nighttime awakenings ≤1 time/month 1

Environmental Control

Identify and reduce exposure to allergens and irritants that trigger symptoms. 1 This includes tobacco smoke, with specific emphasis on discouraging smoking in pregnancy due to asthma risk. 8