Latest GINA Classification for Asthma
The current GINA classification system focuses on assessing asthma control rather than severity, categorizing patients as "controlled," "partly controlled," or "uncontrolled" based on symptom burden and future risk, with treatment organized into 5 stepwise treatment tracks. 1, 2, 3
Core Classification Framework
GINA has fundamentally shifted away from rigid severity-based classification to a control-based assessment system that evaluates two distinct domains 1, 4, 3:
Domain 1: Symptom Control Assessment
The classification evaluates current impairment using specific criteria 1, 4:
- Daytime symptoms (frequency per week)
- Nighttime awakenings (frequency per month/week)
- Need for reliever/rescue medication (days per week)
- Activity limitation due to asthma
- Lung function (PEF or FEV₁ measurements)
Domain 2: Future Risk Assessment
Risk evaluation includes 1, 2:
- Exacerbation history (particularly those requiring oral corticosteroids)
- Risk factors for fixed airflow limitation (including lack of ICS treatment, tobacco smoke exposure, chronic mucus hypersecretion)
- Risk factors for medication side effects (frequent oral corticosteroids, high-dose ICS)
- Independent major risk factors such as history of intubation/ICU admission for asthma or ≥1 severe exacerbation in the past 12 months
Three-Level Control Classification
Patients are categorized into one of three control levels 4, 3:
- Controlled asthma: All control parameters met
- Partly controlled asthma: 1-2 control parameters not met
- Uncontrolled asthma: ≥3 control parameters not met, or any exacerbation in the assessment period
Five-Step Treatment Framework
GINA organizes treatment into 5 steps of increasing intensity, with two distinct treatment tracks introduced in 2021 3, 5:
Track 1 (Preferred)
Uses low-dose ICS-formoterol as reliever at all steps 2, 3:
- Steps 1-2: As-needed ICS-formoterol only (for mild asthma)
- Steps 3-5: Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART therapy)
Track 2 (Alternative)
Uses as-needed SABA across all steps 3:
- Step 2: Regular ICS plus as-needed SABA
- Steps 3-5: ICS-LABA combination plus as-needed SABA
Step 5 additions for severe asthma include long-acting muscarinic antagonists, azithromycin, and phenotype-specific biologic therapies 6, 3.
Severity Classification (For Treatment Initiation Only)
When assessing untreated patients to determine initial therapy, GINA recognizes four severity categories 1, 4:
- Intermittent
- Persistent-mild
- Persistent-moderate
- Persistent-severe
Critical caveat: Severity classification is emphasized only for initiating therapy, while control assessment is emphasized for monitoring and adjusting therapy 1. The term "mild-intermittent" has been eliminated from current classifications 1.
Key Operational Principles
Treatment adjustment is bidirectional 4, 5:
- Step up when asthma is uncontrolled or partly controlled
- Step down when asthma has been well-controlled for ≥3 months, to find the lowest effective dose
GINA functions as a strategy rather than rigid protocol, requiring adaptation to local healthcare systems and medication availability 2, 3.
Pediatric Modifications
For children aged 6-11 years, GINA 2021 added new treatment options at Steps 3-4, with adjusted control criteria (e.g., well-controlled defined as nighttime awakenings ≤1 time/month) 6, 3.
For children aged 0-2 years, diagnosis relies on symptoms rather than objective testing, as bronchodilator response is variable 6.