GINA Asthma Management Recommendations
The Global Initiative for Asthma (GINA) recommends a stepwise approach centered on inhaled corticosteroid (ICS)-containing therapy for all patients, with ICS-formoterol combination as both maintenance and reliever therapy (SMART/MART approach) as the preferred strategy for most patients with asthma. 1, 2
Core Treatment Principles
ICS-containing therapy is now recommended for all asthma patients—the use of short-acting beta-2 agonists (SABA) alone is no longer recommended due to safety concerns and increased risk of asthma-related death. 1, 2, 3 This represents a fundamental shift from older guidelines that allowed SABA monotherapy for mild intermittent asthma.
The primary goals of asthma management according to GINA are:
- Achieve day-to-day symptom control (minimal daytime symptoms, no nighttime awakenings, minimal need for reliever medication, no activity limitation) 1, 4
- Minimize future risks including exacerbations, accelerated lung function decline, and medication side effects 4, 2
Stepwise Treatment Algorithm
GINA uses a 5-step treatment approach where therapy is adjusted based on control: 4, 2
Step 1 (Mild Intermittent):
- Preferred: As-needed low-dose ICS-formoterol 1, 2
- Alternative: Low-dose ICS taken whenever SABA is used 1
- SABA alone is no longer recommended 2, 3
Step 2 (Mild Persistent):
- Preferred: Daily low-dose ICS plus as-needed ICS-formoterol 1, 2
- Alternative: Daily low-dose ICS plus as-needed SABA 1
Steps 3-4 (Moderate to Severe):
- Preferred: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART/SMART therapy) 1, 2
- This approach has demonstrated superior outcomes compared to fixed-dose therapy 5
- Long-acting beta-agonists (LABAs) should never be used as monotherapy due to increased mortality risk 1
Step 5 (Severe Asthma):
- High-dose ICS-LABA combinations 4
- Add-on treatments (long-acting muscarinic antagonists/LAMA) before initiating phenotype-specific biologics 6, 5
- Consider oral corticosteroids if needed, though minimize use 4
- Biologic agents for appropriate phenotypes 5
Critical Implementation Points
Formoterol is specifically recommended because of its rapid onset of action, making it suitable for both maintenance and reliever therapy—this is why ICS-formoterol combinations are preferred over other ICS-LABA combinations for the MART approach. 1
Treatment should be stepped down when asthma is well-controlled for at least 3 months to use the lowest effective dose and minimize side effects. 1 Conversely, step up immediately if control is lost. 4
Acute Exacerbation Management
For moderate to severe exacerbations: 1, 7
- Adults: Prednisolone 40-60 mg daily until PEF reaches 70% of predicted 7
- Children: Prednisolone 1-2 mg/kg/day (maximum 60 mg/day) until PEF is 70% of predicted 7
- Total course typically 3-10 days 7
- Administer systemic corticosteroids immediately—delayed administration worsens outcomes 7
Life-threatening features requiring immediate hospital admission include silent chest, cyanosis, poor respiratory effort, confusion, exhaustion, or PEF <33% predicted after treatment. 7
Essential Patient Education Components
All patients must receive: 6, 7
- Written asthma action plan with specific PEF thresholds for medication adjustment 1, 7
- Training on proper inhaler technique 1
- Clear understanding of "relievers" versus "preventers" 6, 7
- Recognition of worsening symptoms, especially nocturnal symptoms 6, 7
- Empowerment to self-adjust medications according to their action plan without requiring physician consultation for every change 6, 7
Common Pitfalls to Avoid
Do not overrely on bronchodilators without anti-inflammatory treatment—this is the most dangerous error in asthma management. 7 Symptom control does not equal elimination of exacerbation risk, particularly in severe asthma. 1
Do not underestimate exacerbation severity—patients with severe features (inability to complete sentences, respiratory rate >25/min, pulse >110/min, PEF <50% predicted) require aggressive treatment and close monitoring. 7
Never use sedation in acute asthma—this can be fatal. 7
Special Populations
Children 0-2 years: Diagnosis relies on symptoms rather than objective testing; bronchodilator response is variable but should still be tried; consider alternative diagnoses like gastroesophageal reflux, cystic fibrosis, or chronic lung disease of prematurity. 6
Pregnant women with worsening asthma should be referred for specialist consultation. 6
Patients with inhaled steroid concerns: Use the lowest dose providing acceptable control; short-term reductions in tibial growth rate occur at doses >400 µg/day in children, but long-term effects are unclear and asthma itself delays growth with eventual catch-up. 6