What are the recommendations for managing asthma according to the Global Initiative for Asthma (GINA) 2025 guidelines?

GINA 2025 Asthma Management Recommendations

Core Treatment Principle

All adults and adolescents with asthma must receive inhaled corticosteroid (ICS)-containing medication and should never be treated with short-acting beta-agonist (SABA) alone. 1

Diagnostic Confirmation

• Asthma diagnosis requires compatible clinical history plus objective confirmation of variable expiratory airflow limitation on spirometry or peak expiratory flow (PEF) testing 2
• Five methods confirm excessive lung function variability: positive bronchodilator reversibility test, excessive variability in twice-daily PEF over 2 weeks, increased lung function after 4 weeks of ICS treatment, positive bronchial challenge test, or excessive variation between visits 2
• Failure to use objective measurements (spirometry or PEF) to assess severity is a common factor in preventable asthma deaths 3

Stepwise Treatment Algorithm: Two-Track System

GINA 2024 divides treatment into two tracks, with Track 1 as the preferred approach 1:

Track 1 (Preferred):

• Reliever at all steps: As-needed low-dose ICS-formoterol 1, 4
• Step 1-2 (Mild asthma): As-needed ICS-formoterol only 4
• Step 3-5 (Moderate-severe asthma): Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART regimen) 4
• This approach reduces severe exacerbations by ≥60% compared with SABA alone in mild asthma 4

Track 2 (Alternative):

• Reliever: As-needed SABA across all steps 1
• Step 2: Regular low-dose ICS plus as-needed SABA 5
• Step 3-5: ICS-long-acting β2-agonist (LABA) combination plus as-needed SABA 5

Step 5 Add-On Therapies:

• Long-acting muscarinic antagonists for uncontrolled moderate-severe asthma 4, 6
• Biologic therapies for severe asthma with allergic component 4
• Consider azithromycin as add-on therapy 4

Acute Exacerbation Management

Severity Assessment:

• Life-threatening features: PEF <33% predicted/best, silent chest, cyanosis, poor respiratory effort, bradycardia, hypotension, confusion, exhaustion, or coma 3, 7
• Severe features: Cannot complete sentences in one breath, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted/best 3, 5

Immediate Treatment Protocol:

• High-flow oxygen: 40-60% in all cases 3, 7
• High-dose inhaled β-agonist: Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 3, 5, 7
• Systemic corticosteroids immediately: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV (or both) 3, 7
• For life-threatening features, add: Ipratropium 0.5 mg nebulized with β-agonist 2

Maintenance During Exacerbation:

• Measure PEF 15-30 minutes after initial treatment 7
• Continue hydrocortisone 200 mg IV every 6 hours if seriously ill or vomiting 7
• If improving: nebulized β-agonist every 4 hours 7
• If not improving after 15-30 minutes: increase β-agonist frequency (up to every 15 minutes) and consider IV aminophylline or parenteral β-agonist 2, 7

Hospital Admission Criteria:

• Any life-threatening features present 3
• Severe features persisting after initial treatment 3
• PEF <33% predicted/best after treatment 3
• Lower threshold for afternoon/evening presentations, recent nocturnal symptoms, previous severe attacks, or concerns about patient assessment or social circumstances 2

ICU Transfer Indications:

• Deteriorating PEF, worsening/persisting hypoxia (PaO₂ <8 kPa) despite 60% oxygen, or hypercapnia (PaCO₂ >6 kPa) 7
• Exhaustion, feeble respiration, confusion, drowsiness, coma, or respiratory arrest 7

Self-Management Requirements

• Written asthma action plan mandatory for all patients with clear medication adjustment instructions 3, 1
• Patients must understand "relievers" (bronchodilators) versus "preventers" (anti-inflammatory medications) 3, 5
• Regular monitoring using either symptoms or peak flow measurements 3

Discharge and Follow-Up

Discharge Criteria:

• PEF >75% predicted/personal best 3
• Diurnal variability <25% 3
• No nocturnal symptoms 3

Discharge Medications:

• Prednisolone 30+ mg daily for 1-3 weeks 7
• ICS at higher dose than pre-admission 7
• As-needed β-agonist 7
• Personal PEF meter with written self-management plan 7

Follow-Up Schedule:

• Primary care visit within 1 week 7
• Respiratory clinic follow-up within 4 weeks 7
• Review within 24-48 hours after acute exacerbations 5

Critical Pitfalls to Avoid

• Never underestimate severity by failing to obtain objective PEF or spirometry measurements 3
• Never use SABA monotherapy as controller medication—all patients need ICS-containing therapy 1, 4
• Never delay systemic corticosteroids during severe exacerbations—effects take 6-12 hours to manifest 7
• Never use sedation in acute asthma 2
• Never give bolus aminophylline to patients already taking oral theophyllines 2
• Antibiotics only if bacterial infection confirmed 2
• Percussive physiotherapy unnecessary 2

Monitoring and Treatment Adjustment

• Regular review of inhaler technique, adherence, and symptom control at every visit 5
• Consider stepping down treatment when stable for ≥3 months 3, 5
• Monitor for ICS side effects, particularly at higher doses 3