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

GINA Guidelines: Concise Overview

Core Philosophy

The fundamental shift in modern asthma management is that NO patient should be treated with SABA alone—all patients need inhaled corticosteroids (ICS) because SABA-only treatment increases mortality risk. 1, 2, 3, 4

The Two-Track System (GINA 2021-2024)

GINA divides treatment into two tracks, with Track 1 as the preferred approach 3, 4:

Track 1 (Preferred)

• Use low-dose ICS-formoterol as the reliever at ALL steps 1, 2, 3
• Steps 1-2 (mild asthma): As-needed ICS-formoterol only 1, 3
• Steps 3-5: Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol (SMART therapy) 1, 3
• This approach reduces severe exacerbations by ≥60% compared to SABA alone 2, 3

Track 2 (Alternative)

• As-needed SABA as reliever across all steps 3, 4
• Step 2: Regular ICS 3
• Steps 3-5: ICS-LABA combination 3

Assessment Framework: Control Over Severity

Assess asthma by CONTROL status, not just severity, using two domains: 1, 2, 5

Current Symptom Control

• Daytime symptoms 1, 5
• Nighttime awakenings 1, 5
• Need for reliever medication 1, 5
• Activity limitation 1, 5
• Lung function (PEF or FEV₁) 1, 5

Future Risk

• Frequency of exacerbations 1, 5
• Lung function decline 6
• Medication side effects 6

Classify as: Controlled, Partly Controlled, or Uncontrolled 5

The 5-Step Treatment Algorithm

Step up if uncontrolled, step down if well-controlled for ≥3 months 1, 5, 6

• Step 1: As-needed low-dose ICS-formoterol (Track 1) or SABA (Track 2) 6, 3
• Step 2: Daily low-dose ICS or as-needed ICS-formoterol 1, 6, 3
• Step 3: Low-dose ICS-LABA maintenance 6, 3
• Step 4: Medium/high-dose ICS-LABA 6, 3
• Step 5: High-dose ICS-LABA + add-ons (LAMA, biologics, azithromycin, or oral corticosteroids) 1, 3

Critical Safety Rules

• NEVER use LABA as monotherapy—it increases asthma-related death 1, 2
• Formoterol has rapid onset, making it suitable for both maintenance and reliever therapy 1
• ICS are the most effective anti-inflammatory medication for persistent asthma 1

Essential Patient Management Components

Every patient must receive: 1, 2

• Written asthma action plan 1, 2, 4
• Training on proper inhaler technique 1, 2
• Clear understanding of "relievers" versus "preventers" 1, 2

Diagnosis Requirements

Diagnosis requires compatible clinical history PLUS objective confirmation of variable expiratory airflow limitation 2

GINA recommends five objective confirmation methods 2:

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

Acute Exacerbation Management

Immediate treatment includes: 2

• High-dose inhaled β2-agonists 2
• Systemic corticosteroids 1, 2
• Oxygen therapy 2
• Add ipratropium bromide for life-threatening features 2

Hospital admission criteria: 2

• Any life-threatening features 2
• Severe features persisting after initial treatment 2
• PEF <33% predicted after treatment 2

Special Populations

• Children 6-11 years: New treatment options added at Steps 3-4; use lowest ICS dose providing control (growth concerns at >400 µg/day) 1, 3
• Children 0-2 years: Diagnosis relies on symptoms; bronchodilator response is variable 1
• Pregnant women: Refer for specialist consultation if worsening 1, 2

Key Modifiable Risk Factors

Address these to reduce exacerbations 2:

• Allergen exposure and environmental tobacco smoke 2
• Poor medication adherence and inhaler technique 2
• Obesity and comorbidities 2
• Lack of annual influenza vaccination 2