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

GINA Asthma Management Guidelines

The Global Initiative for Asthma (GINA) recommends that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing therapy—never SABA alone—using a stepwise approach with low-dose ICS-formoterol as the preferred reliever medication at all treatment steps. 1, 2, 3, 4

Core Treatment Philosophy

The fundamental goal is achieving overall asthma control using the lowest effective medication dose while preventing exacerbations and minimizing side effects. 2, 5 GINA defines control across two domains: current symptom control (daytime symptoms, nighttime awakenings, need for reliever medication, activity limitation) and future risk reduction (preventing exacerbations, lung function decline, and medication side effects). 1, 6

Diagnosis Requirements

Asthma diagnosis requires compatible clinical history PLUS objective confirmation of variable expiratory airflow limitation on lung function testing. 2 GINA recommends five methods for objective confirmation: 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

Stepwise Treatment Approach: Two Tracks

GINA 2021 introduced a two-track system for adults and adolescents, with Track 1 as the preferred approach: 4

Track 1 (Preferred):

• Step 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol only, which reduces severe exacerbations by ≥60% compared with SABA alone 1, 2, 4
• Step 3-5 (Moderate-Severe Asthma): Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol (SMART/MART therapy) 1, 4

Track 2 (Alternative):

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

Critical Safety Warning: LABAs should NEVER be used as monotherapy for asthma, as this increases risk of asthma-related death. 1, 2

Treatment Steps by Severity

• Step 1: As-needed ICS-formoterol (preferred) or as-needed SABA (alternative, though not recommended as sole therapy) 6, 4
• Step 2: Low-dose ICS as controller medication 6, 4
• Step 3-4: Medium-to-high dose ICS-LABA combinations 6, 4
• Step 5: High-dose ICS-LABA plus add-on therapies (LAMA, azithromycin, or biologic therapies for severe asthma) 4

Add-on long-acting muscarinic antagonists (LAMA) should be considered before initiating phenotype-specific biologics in severe asthma. 1

Acute Exacerbation Management

Severity Assessment:

Life-threatening features: 2, 5

• PEF <33% of predicted/best
• Silent chest, cyanosis, poor respiratory effort
• Bradycardia, hypotension
• Confusion, exhaustion, or coma

Severe features: 2, 5

• Cannot complete sentences in one breath
• Respiratory rate >25/min
• Pulse >110/min
• PEF <50% of predicted/best

Immediate Treatment Protocol:

1. High-flow oxygen 40-60% in all cases 2, 5
2. Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2, 5
3. Systemic corticosteroids: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 2, 5
4. Add ipratropium bromide 0.5 mg nebulized for life-threatening features 2

Hospital Admission Criteria: 2, 5

• Any life-threatening features present
• Severe features persisting after initial treatment
• PEF <33% of predicted/best after treatment
• Lower threshold if attack occurs afternoon/evening, recent nocturnal symptoms, previous severe attacks, or social concerns

Essential Self-Management Components

All patients must receive: 1, 2, 5

• Written asthma action plan with clear instructions for medication adjustment
• Training on proper inhaler technique (verify and document)
• Understanding of "relievers" (bronchodilators) versus "preventers" (anti-inflammatory medications)
• Own PEF meter for monitoring (children >5 years can typically use) 5

Monitoring and Treatment Adjustment

Step down treatment when asthma is well-controlled for at least 3 months. 1 Step up treatment if asthma is uncontrolled or partially controlled. 6, 7 Regular review should assess inhaler technique, adherence, symptom control, and potential medication side effects. 5

Follow-up timing: 8, 5

• Within 24-48 hours after acute exacerbations
• Within 1 week after hospital discharge
• Clinic follow-up within 4 weeks post-discharge

Special Populations

Children 6-11 years: New treatment options added at Steps 3-4 in GINA 2021; use lowest ICS dose providing acceptable control (short-term reductions in tibial growth rate occur at doses >400 µg/day). 1, 4

Children 0-2 years: Diagnosis relies on symptoms rather than objective testing; bronchodilator response is variable. 1

Pregnant women: Refer for specialist consultation if asthma worsens. 1, 5

Modifiable Risk Factors to Address

Common factors increasing exacerbation risk include: 2

• Allergen exposure and environmental tobacco smoke
• Air pollution
• Poor medication adherence and incorrect inhaler technique
• Obesity and comorbidities

Annual influenza vaccination is recommended for all patients with persistent asthma. 2

Common Pitfalls to Avoid

• Underestimating severity by failing to use objective measurements (PEF, spirometry) 5
• Delayed administration of systemic corticosteroids during severe exacerbations 5
• Overreliance on bronchodilators without adequate anti-inflammatory treatment 5
• Using LABA monotherapy 1, 2