What are the GINA (Global Initiative for Asthma) guidelines for asthma management?

GINA Guidelines for Asthma: Comprehensive Overview

Core Philosophy and Treatment Paradigm

GINA recommends that asthma management should focus on achieving overall asthma control rather than merely classifying disease severity, with inhaled corticosteroid (ICS)-containing therapy as the foundation for all patients to reduce severe exacerbations and mortality risk. 1, 2, 3

Key Shift from Severity to Control-Based Management

• GINA moved away from severity-based classification (intermittent, mild-persistent, moderate-persistent, severe-persistent) to a control-based approach because severity changes over time and includes both underlying disease and treatment responsiveness 4, 5
• Asthma control is assessed across two critical domains: current symptom control (day-to-day) and future risk (exacerbations, lung function decline, medication side effects) 5, 2
• Control levels are classified as "controlled," "partly controlled," and "uncontrolled" based on daytime symptoms, activity restrictions, nocturnal symptoms/awakening, need for reliever medication, lung function (PEF or FEV₁), and exacerbation frequency 4, 5

The Revolutionary Change: No More SABA-Only Treatment

GINA explicitly recommends against treating asthma in adults and adolescents with short-acting β2-agonist (SABA) alone due to increased risks of severe exacerbations and SABA overuse, mandating ICS-containing therapy even for mild asthma. 2, 3, 6

Evidence Supporting This Paradigm Shift

• Large trials demonstrate that as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone 2
• This approach achieves similar exacerbation, symptom, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA 2
• Even patients with mild disease benefit from ICS-containing therapy in terms of symptoms and outcomes 6

GINA 2021+ Treatment Tracks for Adults and Adolescents

Track 1 (Preferred): ICS-Formoterol Throughout

Track 1 uses low-dose ICS-formoterol as the reliever medication at all treatment steps, representing the preferred GINA approach. 1, 2

Step-by-Step Breakdown:

• Steps 1-2 (Mild Asthma): As-needed ICS-formoterol only, no daily maintenance therapy required 1, 2
• Steps 3-5 (Moderate-Severe Asthma): Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol (MART - Maintenance-And-Reliever Therapy) 1, 2, 3
• Formoterol's rapid onset makes it uniquely suitable for both maintenance and reliever therapy 1

Track 2 (Alternative): Traditional SABA-Based Approach

• As-needed SABA across all steps (though not recommended as monotherapy) 2
• Step 2: Regular low-dose ICS plus as-needed SABA 1, 2
• Steps 3-5: ICS-long-acting β2-agonist (LABA) combinations plus as-needed SABA 2

Critical Safety Warning

Long-acting beta2 agonists (LABAs) must NEVER be used as monotherapy for asthma, as this increases the risk of asthma-related death; they are only effective and safe when combined with ICS. 1

Five-Step Treatment Algorithm

Step 1: Mild Intermittent Asthma

• Preferred: As-needed low-dose ICS-formoterol 2
• Alternative: As-needed SABA (though ICS-containing therapy is strongly preferred) 5, 2

Step 2: Mild Persistent Asthma

• Preferred: As-needed low-dose ICS-formoterol 1, 2
• Alternative: Daily low-dose ICS plus as-needed SABA 1, 5

Step 3: Moderate Asthma

• Preferred: Low-dose maintenance ICS-formoterol plus as-needed ICS-formoterol (MART) 1, 2
• Alternative: Medium-dose ICS or low-dose ICS-LABA plus as-needed SABA 2

Step 4: Moderate-Severe Asthma

• Preferred: Medium-dose maintenance ICS-formoterol plus as-needed ICS-formoterol (MART) 1, 2
• Alternative: Medium/high-dose ICS-LABA plus as-needed SABA 2

Step 5: Severe Asthma

• Preferred: High-dose maintenance ICS-formoterol plus as-needed ICS-formoterol (MART) 1, 2
• Add-on therapies (in order): Long-acting muscarinic antagonists (LAMA), azithromycin, phenotype-specific biologic therapies 1, 2
• Oral corticosteroids as last resort 5, 2

Stepping Up and Stepping Down Treatment

When to Step Up

• Asthma is uncontrolled or partly controlled on current regimen 4, 5
• Increase to next treatment step 4, 5
• Ensure proper inhaler technique and adherence before escalating 7

When to Step Down

• Asthma has been well-controlled for at least 3 months 1
• Gradually reduce to lowest dose necessary to maintain control 4, 5
• Critical caveat: Symptom control does not equal elimination of exacerbation risk, especially in severe asthma 1

Pediatric Asthma Management (Ages 6-11 Years)

Diagnostic Indicators

• Family history of asthma or atopy, recurrent wheezing, persistent cough, nocturnal symptoms 8
• Symptoms triggered by viral infections, exercise, excitement, allergens (feathers, pets, pollens, dust, cigarette smoke) 7, 8

Assessment Criteria for Children

• Well-controlled asthma: nighttime awakenings ≤1 time/month 1
• Monitor days off school, daytime/nighttime cough, frequency of relief medication, activity limitation 7, 8
• Document height and weight velocities (asthma itself can delay growth, but catch-up occurs) 7, 8

Treatment Modifications for Children 6-11

• New treatment options added at Steps 3-4 in recent GINA updates 2
• Inhaler device selection critical: MDI with spacer for most children, as most cannot properly use unmodified MDIs 7, 8
• Large volume spacers enhance medication deposition and should be used with all ICS from MDIs 7, 8

Very Young Children (0-2 Years): Special Considerations

Diagnostic Challenges

• Diagnosis relies almost entirely on symptoms rather than objective lung function tests 7, 8
• Recurrent wheeze often associated with viral respiratory infections, frequently without family history of asthma or atopy 7, 8
• Bronchodilator response is variable in first year of life, but bronchodilators should still be tried 7

Differential Diagnosis

• Consider gastro-oesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 7

Diagnostic Work-Up (Ages 5-16 Years)

Spirometry: The Gold Standard

Spirometry is strongly recommended as part of the diagnostic work-up for children aged 5-16 years with suspected asthma. 7

Interpretation Criteria:

• FEV₁/FVC below lower limit of normal (LLN) or <80% supports asthma diagnosis 7
• FEV₁ < LLN or <80% predicted supports asthma diagnosis 7
• Critical pitfall: Not all children can perform sufficient FVC maneuver, resulting in false normal FEV₁/FVC ratio 7
• Normal spirometry does NOT exclude asthma 7

Bronchodilator Response (BDR) Testing

• Perform if initial spirometry shows abnormality 7
• Repeat spirometry and BDR testing after 4-8 weeks if initial tests negative but symptoms persist 7

Trial of Preventer Medication

A trial of ICS treatment can be considered only in symptomatic children with abnormal spirometry and negative bronchodilator response, but diagnosis should be based on significant improvement in lung function AND symptoms after 4-8 weeks, not symptoms alone. 7

• This differs from traditional practice of diagnosing based on symptom improvement alone 7
• Objective tests (spirometry, FeNO) must be repeated after treatment trial 7
• GINA 2020 supports supervised stepping down of preventer medication with lung function tests to confirm or refute active asthma 7

Acute Severe Asthma Management

Recognition of Severity

Immediate treatment is required when patients present with inability to complete sentences in one breath, respiratory rate >25 breaths/min, heart rate >110 beats/min, or PEF <50% of predicted/best. 7, 9

Life-Threatening Features:

• PEF <33% of predicted/best 7
• Silent chest, cyanosis, or feeble respiratory effort 7
• Bradycardia or hypotension 7
• Exhaustion, confusion, or coma 7

Arterial Blood Gas Markers of Very Severe Attack:

• Normal (5-6 kPa) or high PaCO₂ in breathless asthmatic patient 7
• Severe hypoxia: PaO₂ <8 kPa irrespective of oxygen treatment 7
• Low pH value (or high H⁺) 7

Immediate Management Protocol

• High-dose inhaled β-agonists: Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen 7
• Oral systemic corticosteroids for moderate to severe exacerbations 1
• For children: 1-2 mg/kg for 1-5 days with no tapering needed 8

Critical Pitfall

Beta-blocker use can mask tachycardia, eliminating this warning sign of severe exacerbation; other objective measures like peak flow and arterial blood gases become critical in these patients. 9

Self-Management and Patient Education

Essential Components

All patients must receive written asthma action plans, training on proper inhaler technique, and clear understanding of "relievers" versus "preventers" to enable self-adjustment of medications. 7, 1, 8

Three Elements of Self-Management Plan:

1. Monitoring: Symptoms, peak flow, drug usage 7
2. Prearranged action: Based on written guidance 7
3. Key actions include:
   • Initiation or increase in inhaled steroid 7
   • Self-administration of steroid tablets when peak flow falls below agreed level or <60% of normal 7
   • Urgent medical attention when treatment not working 7

Patient Education Priorities

• Difference between bronchodilators ("relievers") and anti-inflammatory treatment ("preventers") 7
• Recognition of worsening asthma, especially nocturnal symptoms 7, 1
• Proper inhaler technique and peak flow monitoring (where appropriate) 7, 8

Environmental Control and Trigger Management

• Identification and reduction of allergen/irritant exposure that triggers symptoms 1
• Maternal smoking is one of the most important modifiable triggers 7
• Allergy identification via specific IgE measurements and skin prick tests 7
• Acaricides have shown little clinical benefit 7

Specialist Referral Criteria

Adults Requiring Respiratory Physician Referral:

• Diagnostic uncertainty (elderly, smokers with wheeze) 7
• Possible occupational asthma 7
• Catastrophic, sudden, severe (brittle) asthma 7
• Continuing symptoms despite high-dose inhaled steroids 7
• Consideration for long-term nebulized bronchodilators 7
• Pregnant women with worsening asthma 7, 8
• Asthma interfering with lifestyle despite treatment changes 7
• Recent hospital discharge 7

Medication Delivery Devices

Children's Device Selection

• 0-4 years: MDI with spacer and mask 8
• 5+ years: MDI with spacer or dry powder inhaler 8
• Some children under 5 can use powdered drugs with Turbohaler or Diskhaler 7
• Nebulizers are overused and can often be replaced by large volume spacer devices 7, 8

Proper Spacer Technique

• Actuate MDI, breathe in one puff, repeat actuation, breathe in second puff 7
• Continue until appropriate number of puffs inhaled 7
• Every child given inhaled steroids from MDI should use large volume spacer 7

Growth Monitoring in Children on ICS

• Short-term reductions in tibial growth rate occur at doses >400 µg/day 7, 1
• These short-term reductions cannot be extrapolated to long-term effects 7
• Asthma itself can delay growth and puberty, but catch-up growth typically occurs 7, 8
• Use lowest dose providing acceptable control 1

Treatment Goals Across All Ages

Optimal Asthma Control Defined:

• Minimal (ideally no) chronic symptoms, including nocturnal symptoms 7
• Minimal (infrequent) exacerbations 7
• Minimal need for relieving bronchodilators 7
• No limitations on activities, including exercise 7
• Circadian variation in PEF <20% 7
• PEF ≥80% of predicted or best 7
• Minimal (or no) adverse effects from medicine 7

For Children Specifically:

• No missed playgroup, nursery, or school 7
• Full participation in activities 7
• No waking at night 7

Treatments NOT Recommended

• Hyposensitization (immunotherapy) is not indicated in asthma management 7
• Antihistamines (including ketotifen) have proved disappointing 7
• Antibiotics have no place in uncomplicated asthma management 7
• Immunosuppressive drugs (cyclosporin, methotrexate) have no clear place in routine treatment 7
• Complementary treatments (ionizers, acupuncture, homeopathy) lack evidence from controlled trials; conventional treatment must be continued if tried 7