What are the Global Initiative for Asthma (Gina) guidelines for managing asthma?

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) 2021-2025 guidelines fundamentally changed asthma management by recommending that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing therapy—either as regular maintenance or as-needed ICS-formoterol—and explicitly state that short-acting beta-agonist (SABA) monotherapy should never be used due to increased risk of severe exacerbations and asthma-related death. 1, 2, 3

Core Diagnostic Approach

Asthma diagnosis requires two essential components 2:

• Compatible clinical history PLUS objective confirmation of variable expiratory airflow limitation on lung function testing
• GINA specifies five methods to confirm excessive variability: positive bronchodilator responsiveness test with spirometry, excessive variability in twice-daily PEF measurements, increase in lung function after 4 weeks of ICS treatment, positive bronchial challenge test, and excessive variation in lung function between visits 2

Assessment Framework: Control-Based Classification

GINA shifted from severity-based to control-based classification with three categories 1, 2:

Well-Controlled Asthma (all of the following):

• Daytime symptoms ≤2 times/week 1
• No nighttime awakenings (or ≤1 time/month for children 5-11 years) 1
• Need for reliever medication ≤2 times/week 1
• No activity limitation 1
• Normal lung function 1

Partly Controlled: 1-2 of above criteria present 1

Uncontrolled: 3-4 of above criteria present 1

Stepwise Treatment Algorithm

Track 1 (Preferred): ICS-Formoterol as Reliever at All Steps

This track reduces severe exacerbations by ≥60% compared with SABA alone 2, 3:

Step 1 (Mild Intermittent):

• As-needed low-dose ICS-formoterol only 1, 3
• This replaces the outdated SABA-only approach 3

Step 2 (Mild Persistent):

• As-needed low-dose ICS-formoterol 1, 3
• Alternative: Daily low-dose ICS plus as-needed SABA 1

Step 3 (Moderate):

• Daily maintenance low-dose ICS-formoterol PLUS as-needed ICS-formoterol (SMART therapy) 1, 3
• Alternative: Medium-dose ICS or low-dose ICS-LABA 3

Step 4 (Moderate-Severe):

• Daily maintenance medium-dose ICS-formoterol PLUS as-needed ICS-formoterol 1, 3
• Consider adding long-acting muscarinic antagonist (LAMA) before biologics 1, 3

Step 5 (Severe):

• Daily high-dose ICS-formoterol PLUS as-needed ICS-formoterol 1, 3
• Add LAMA (tiotropium) 3
• Consider add-on azithromycin for frequent exacerbations 3
• Phenotype-specific biologics for severe uncontrolled asthma 1, 3
• Oral corticosteroids as last resort 1

Track 2 (Alternative): SABA as Reliever

Uses as-needed SABA across all steps plus regular ICS (Step 2) or ICS-LABA (Steps 3-5), but this is less preferred due to higher exacerbation risk 2, 3

Critical Safety Warnings

Never use LABA monotherapy—this increases risk of asthma-related death 1, 2

Never use SABA-only treatment—even in mild asthma, this significantly increases severe exacerbation risk 2, 3, 4

Treatment Adjustment Algorithm

Step-Up Criteria (increase treatment by 1-2 steps if):

• Uncontrolled symptoms despite 2-3 months of current therapy 2
• Any exacerbation requiring systemic corticosteroids 2
• Poor inhaler technique or medication non-adherence has been addressed 2

Step-Down Criteria (reduce treatment if):

• Asthma well-controlled for at least 3 months 1
• Low risk of exacerbations 1
• Use lowest effective dose to minimize side effects 2

Important caveat: Symptom control does not equal elimination of exacerbation risk, especially in severe asthma 1

Acute Exacerbation Management

Immediate treatment for severe exacerbation 2, 5:

• High-dose inhaled β2-agonists (salbutamol 5 mg nebulized or via MDI with spacer) 5
• Systemic corticosteroids (prednisolone 30-60 mg orally immediately) 2, 5
• Oxygen therapy to maintain saturation >92% 5
• Add ipratropium bromide for life-threatening features 2

Hospital admission criteria 2, 5:

• PEF <33% of predicted after initial treatment 2
• Respiratory rate >25 breaths/min 5
• Heart rate >110 beats/min 5
• Inability to complete sentences in one breath 5
• Oxygen saturation <92% on room air 5
• Any life-threatening features 2

Absolutely avoid sedatives—any sedation is contraindicated in acute asthma 5

Essential Self-Management Components

All patients must receive 1, 2:

• Written asthma action plan with clear instructions for recognizing worsening symptoms and adjusting medications 1, 2
• Training on proper inhaler technique (poor technique is a major modifiable risk factor) 1, 2
• Clear understanding of "relievers" versus "preventers" to enable self-adjustment 1, 2

Modifiable Risk Factors for Exacerbations

Address these systematically 2:

• Allergen exposure and environmental tobacco smoke 2
• Air pollution 2
• Poor medication adherence 2
• Poor inhaler technique 2
• Obesity 2
• Comorbidities (rhinosinusitis, GERD) 2

Special Population Considerations

Children 6-11 years:

• New treatment options added at Steps 3-4 in GINA 2021 2, 3
• For inhaled steroid concerns, use lowest dose providing acceptable control; short-term reductions in tibial growth rate occur at doses >400 µg/day 1

Children 0-2 years:

• Diagnosis relies on symptoms rather than objective testing 1
• Bronchodilator response is variable 1

Pregnant women:

• Refer for specialist consultation if asthma worsens 1, 2

Additional Preventive Measures

• Annual influenza vaccination for all patients with persistent asthma 2
• Identification and reduction of exposure to allergens and irritants 1

Implementation Philosophy

GINA now functions as an asthma strategy rather than rigid guideline, emphasizing evidence-based approach with customization for individual patient care and adaptation to local healthcare systems 2

The fundamental principle is using the lowest effective dose of medication to maintain control while minimizing side effects 2