What are the recommendations of the Global Initiative for Asthma (GINA) guideline for managing asthma?

GINA Asthma Management Guidelines Summary

Core Philosophy and Goals

GINA recommends achieving overall asthma control as the primary goal of therapy, consisting of two domains: current day-to-day symptom control and minimizing future risk (exacerbations, lung function decline, medication side effects). 1, 2

• Asthma control is classified as "controlled," "partly controlled," or "uncontrolled" based on daytime symptoms, activity restrictions, nocturnal symptoms/awakening, need for reliever medication, lung function (PEF or FEV1), and exacerbation frequency 3
• The fundamental principle is using the lowest effective dose of medication to maintain control while minimizing side effects 4

Critical Paradigm Shift: No SABA-Only Treatment

GINA 2021 made a landmark change: asthma in adults and adolescents should NOT be treated with short-acting β2-agonist (SABA) alone, due to risks of SABA-only treatment and SABA overuse. 2, 5

• All adults, adolescents, and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce severe exacerbations 5
• This applies even to mild intermittent asthma, representing a major departure from older guidelines 2, 6

Stepwise Treatment Approach: Two Tracks

Track 1 (Preferred): ICS-Formoterol as Reliever

GINA 2021 introduced a preferred treatment track using low-dose ICS-formoterol as the reliever medication at all steps: 2

• Steps 1-2 (Mild Asthma): As-needed ICS-formoterol only, which reduces severe exacerbations by ≥60% compared with SABA alone 2
• Steps 3-5 (Moderate-Severe Asthma): Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol (MART - Maintenance-And-Reliever Therapy) 7, 2
• Formoterol's rapid onset makes it suitable for both maintenance and reliever therapy 7

Track 2 (Alternative): Traditional SABA Reliever

• As-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting β2-agonist (Steps 3-5) 2
• Critical warning: Long-acting beta2 agonists (LABAs) should NEVER be used as monotherapy for asthma, as this increases risk of asthma-related death 7, 8

The Five Treatment Steps

Step 1 (Intermittent Asthma):

• Preferred: As-needed low-dose ICS-formoterol 2
• Alternative: As-needed SABA only (no longer recommended as first-line) 8, 2

Step 2 (Mild Persistent Asthma):

• Preferred: As-needed low-dose ICS-formoterol 2
• Alternative: Daily low-dose ICS plus as-needed SABA, or alternatives including leukotriene receptor antagonist 7, 8

Step 3 (Moderate Persistent Asthma):

• Preferred: Low-dose ICS-formoterol as MART 2
• Alternative: Low-dose ICS plus LABA, or medium-dose ICS alone 8

Step 4 (Severe Persistent Asthma):

• Preferred: Medium-dose ICS-formoterol as MART 2
• Alternative: Medium/high-dose ICS plus LABA 8

Step 5 (Severe Uncontrolled Asthma):

• High-dose ICS-formoterol as MART 2
• Add-on options: Long-acting muscarinic antagonists (LAMA), azithromycin, or phenotype-specific biologic therapies 7, 2
• Consider oral corticosteroids at lowest effective dose 8, 1

Diagnosis: Objective Testing is Mandatory

Asthma diagnosis requires compatible clinical history PLUS objective confirmation of variable expiratory airflow limitation on lung function testing. 9, 8

GINA recommends five methods to objectively confirm excessive variability in lung function: 9

1. Positive bronchodilator responsiveness test with spirometry
2. Excessive variability in twice-daily PEF measurements over 2 weeks
3. Increase in lung function after 4 weeks of ICS treatment
4. Positive bronchial challenge test
5. Excessive variation in lung function between visits

• For patients already on ICS-containing medication, repeat objective testing and trial step-down of ICS treatment to confirm diagnosis 9
• Common pitfall: Relying on symptoms alone without objective testing leads to misdiagnosis 8

Stepping Up and Down Treatment

Treatment should be adjusted based on current asthma control rather than remaining static. 8, 2

Before stepping up treatment, verify: 8

• Medication adherence
• Proper inhaler technique
• Environmental trigger control
• Evaluation for comorbidities

Step down treatment when: 8, 4

• Asthma is well-controlled for at least 3 months
• Use the lowest effective dose providing acceptable control

Acute Exacerbation Management

Life-threatening features requiring immediate intensive care: 4

• Silent chest, cyanosis, poor respiratory effort
• Confusion, exhaustion, or altered consciousness
• PEF <33% of predicted after treatment

Severe features: 4

• Inability to complete sentences
• Respiratory rate >25/min, pulse >110/min
• PEF <50% predicted

Immediate treatment for acute severe asthma: 4

• High-dose inhaled β2-agonists (nebulized)
• Systemic corticosteroids immediately (prednisolone 40-60 mg daily for adults, 1-2 mg/kg/day for children, maximum 60 mg/day) 4
• Oxygen therapy to maintain saturation 92-95% 9
• Add ipratropium bromide (0.5 mg) nebulized to β-agonist for life-threatening features 9

Hospital admission criteria: 4

• Any life-threatening features
• Severe features persisting after initial treatment
• PEF <33% of predicted after treatment
• Lower threshold for evening presentations, recent nocturnal symptoms, or previous severe attacks

Duration: Total course of systemic corticosteroids typically lasts 3-10 days, with no advantage for higher doses in severe exacerbations 4

Essential Self-Management Components

All patients must receive: 7, 4

• Written asthma action plan with clear instructions for medication adjustment
• Training on proper inhaler technique
• Understanding of "relievers" (bronchodilators) versus "preventers" (anti-inflammatory medications)
• Recognition of worsening symptoms and nocturnal symptoms

Monitoring and Follow-Up

Regular assessment should include: 4, 2

• Review of inhaler technique and adherence at every visit
• Symptom control and lung function monitoring
• Treatment adjustment based on control level
• Consideration of step-down when stable for 3 months

Discharge criteria from hospital: 4

• PEF >75% of predicted/personal best
• Symptoms stabilized
• Follow-up within 24-48 hours after acute exacerbations

Special Populations

Children aged 0-2 years: 7

• Diagnosis relies on symptoms rather than objective testing
• Bronchodilator response is variable

Children aged 6-11 years: 2

• New treatment options added at Steps 3-4 in GINA 2021
• For inhaled steroid concerns, use lowest dose providing acceptable control (short-term reductions in tibial growth rate occur at doses >400 µg/day) 7

Pregnant women: 7

• Those with worsening asthma should be referred for specialist consultation

Severe asthma (5-10% of patients): 9

• Accounts for disproportionate 50% of asthma-related healthcare costs
• Requires referral to asthma specialists and assessment for biologic therapies including phenotyping using biomarkers 9

Critical Pitfalls to Avoid

• Never use LABA monotherapy - increases risk of asthma-related death 7, 8
• Never rely on symptoms alone - symptom control does not equal elimination of exacerbation risk 7
• Never underestimate exacerbation severity - leads to inadequate treatment 4
• Never use sedation in acute asthma - contraindicated 9, 4
• Never delay systemic corticosteroids during severe exacerbations 4
• Never overrely on bronchodilators without anti-inflammatory treatment 4
• Never assess severity during acute exacerbations - wait until stable 8

Risk Factors for Exacerbations

Common modifiable risk factors: 9

• Allergen exposure and environmental tobacco smoke
• Air pollution
• Poor asthma control and medication non-adherence
• Poor inhaler technique
• Obesity
• Comorbidities

High-risk indicators: 9

• Hospitalization or ED visits for asthma in the last year
• Extreme inhaled bronchodilator use
• Previous severe attacks, especially with rapid onset
• Sputum or blood eosinophilia

Implementation Considerations

GINA now functions as an asthma strategy rather than rigid guideline, emphasizing: 9, 5

• Evidence-based approach with customization for patient care
• Adaptation to local healthcare systems, practices, and resource availability
• Country-specific guidelines should use GINA framework while addressing local medication access and environmental issues

Annual influenza vaccination is recommended for all patients with persistent asthma. 8