How to track the Global Initiative for Asthma (GINA) guideline for asthma management?

Tracking GINA Guidelines for Asthma Management

To track asthma according to GINA guidelines, assess control level at every visit using the two-domain framework: symptom control (daytime symptoms, activity limitation, nocturnal symptoms, rescue medication use) and future risk (exacerbations, lung function decline, medication side effects), then classify patients as controlled, partly controlled, or uncontrolled to guide treatment adjustments. 1, 2

Assessment Framework

GINA uses a control-based approach rather than severity classification for ongoing management, evaluating two distinct domains at each clinical encounter 2, 3:

Domain 1: Symptom Control Assessment

Evaluate the following parameters over the previous 4 weeks 4, 1:

• Daytime symptoms: Frequency per week (≤2 days/week = controlled; >2 days/week = not controlled) 4
• Activity limitation: Any restriction of normal activities due to asthma 4, 2
• Nocturnal symptoms/awakening: Frequency per month (≤1 time/month for ages 5-11; <2 times/month for ≥12 years = controlled) 4
• Rescue medication use: Short-acting β2-agonist use for symptom relief (≤2 days/week = controlled; >2 days/week = not controlled) 4, 1
• Lung function: FEV₁ or peak flow (>80% predicted/personal best = controlled for ages ≥12 years) 4

Domain 2: Future Risk Assessment

Evaluate risk factors that predict adverse outcomes 2:

• Exacerbation history: Number requiring oral corticosteroids in past year (0-1/year = low risk; ≥2/year = high risk) 4
• Fixed airflow limitation risk: Lack of ICS treatment, tobacco smoke exposure, chronic mucus hypersecretion 2
• Medication side effects: Systemic corticosteroid exposure, high-dose ICS use 4

Three-Level Control Classification

Assign patients to one of three control levels based on the most severe impairment in either domain 4, 2:

• Controlled asthma: All symptom control parameters met AND low future risk 2, 3
• Partly controlled asthma: 1-2 symptom control parameters not met in any week 3
• Uncontrolled asthma: ≥3 symptom control parameters not met in any week OR any exacerbation requiring oral corticosteroids indicates uncontrolled asthma regardless of symptom control 4

Validated Questionnaire Tools

Use standardized instruments to supplement clinical assessment 4:

• Asthma Control Test (ACT): 5-question patient-scored tool (1-5 scale each); score ≥20 indicates well-controlled asthma 4
• Asthma Control Questionnaire (ACQ): ACQ score <0.5 = controlled; ≥1.0 = uncontrolled in real-world practice 5
• Asthma Impairment and Risk Questionnaire: Alternative validated tool 4

Critical caveat: ACQ and ACT classify more patients as uncontrolled compared to GINA criteria alone, with ACQ ≥1.50 and ACT ≤19 showing high sensitivity (88% and 94% respectively) for detecting GINA-defined uncontrolled asthma 6.

Treatment Adjustment Algorithm

Based on control level, adjust treatment bidirectionally through GINA's 5-step framework 1, 2:

• If uncontrolled or partly controlled: Step up treatment by 1-2 steps, reassess in 2-6 weeks 4, 1
• If well-controlled for ≥3 months: Consider stepping down to find lowest effective dose 4, 2
• Before stepping up: Verify medication adherence, inhaler technique, environmental control, and comorbidities 4

Monitoring Frequency

• Initial assessment: Every 1-3 months until control achieved 1
• Maintenance monitoring: Every 3-12 months once controlled 1
• After exacerbation: Within 1 week, then at 1-2 months 1

Common Pitfalls to Avoid

Do not rely on symptoms alone—lung function testing (FEV₁ or peak flow) is essential for complete assessment in patients ≥5 years old 4. The 2023 GINA update removed lung function from control criteria, which artificially increased the percentage of "controlled" patients by 24.3% compared to previous definitions 7.

Do not use severity classification for ongoing management—severity is only relevant for initiating therapy in treatment-naïve patients; control assessment drives all subsequent treatment decisions 2, 3.

Recognize that control is not static—asthma control varies over time, requiring regular reassessment rather than assuming stable disease 3.