What are the GINA guidelines for managing asthma?

GINA Guidelines for Asthma Management

The Global Initiative for Asthma (GINA) 2021-2022 strategy fundamentally changed asthma management by recommending that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing therapy rather than short-acting β2-agonist (SABA) alone, with as-needed ICS-formoterol as the preferred reliever across all severity levels to reduce severe exacerbations and prevent SABA overuse. 1, 2

Core Treatment Philosophy

GINA divides adult and adolescent treatment into two tracks, with Track 1 (preferred) using low-dose ICS-formoterol as the reliever at all steps 1:

• Track 1 (Preferred): As-needed ICS-formoterol only for Steps 1-2 (mild asthma), escalating to daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART - maintenance-and-reliever therapy) for Steps 3-5 1, 2
• Track 2 (Alternative): As-needed SABA across all steps, plus regular ICS at Step 2, or ICS-long-acting β2-agonist (LABA) at Steps 3-5 1

The rationale for this shift is compelling: as-needed combination ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, while achieving similar symptom control, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA 1.

Diagnosis Confirmation

Before initiating treatment, confirm asthma diagnosis using objective measurements 2:

• Spirometry showing variable expiratory airflow limitation, or
• Peak expiratory flow (PEF) measurements demonstrating variability 2

Stepwise Treatment Algorithm for Adults and Adolescents

Step 1 (Mild Intermittent Asthma)

• Preferred: As-needed low-dose ICS-formoterol only 1, 2
• Alternative: As-needed SABA (though this carries higher exacerbation risk) 1

Step 2 (Mild Persistent Asthma)

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

Research supports that ICS monotherapy achieves asthma control in 65-71% of steroid-naive patients with mild to moderate asthma within 4-8 weeks 3.

Step 3 (Moderate Asthma)

• Preferred: Low-dose ICS-formoterol as MART (daily maintenance plus as-needed) 1, 2
• Alternative: Low-dose ICS-LABA daily plus as-needed SABA 1
• Additional option for children 6-11 years: Medium-dose ICS or low-dose ICS-LABA 1

Step 4 (Moderate-Severe Asthma)

• Preferred: Medium-dose ICS-formoterol as MART 1, 2
• Alternative: Medium-dose ICS-LABA daily plus as-needed SABA 1

Step 5 (Severe Asthma)

• Preferred: High-dose ICS-formoterol as MART 1, 2
• Add-on therapies: Long-acting muscarinic antagonists (LAMA), azithromycin, or biologic therapies for severe asthma 1

Critical caveat: High starting doses of ICS show no additional clinical benefit in most efficacy parameters compared with low or moderate doses but carry potential safety concerns 4. Start with appropriate doses and escalate only if control is not achieved.

Acute Severe Asthma Management

Assessment of Severity

Acute severe asthma features 5, 6:

• Cannot complete sentences in one breath
• Pulse >110 beats/min
• Respirations >25 breaths/min
• PEF <50% predicted or best

Life-threatening features 5, 6:

• PEF <33% predicted
• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia, hypotension, confusion, exhaustion, or coma

Immediate Treatment

For all acute severe asthma 5, 7:

• High-flow oxygen 40-60% immediately to maintain oxygen saturation 5, 7
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 5, 6
• Systemic corticosteroids: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV (if vomiting or unable to take oral medications) 5, 7

Monitor response 15-30 minutes after nebulizer 5:

• Measure PEF before and after treatment 7, 8
• If not improving: increase nebulized β-agonist frequency up to every 15-30 minutes 5, 7
• Add ipratropium 0.5 mg to nebulizer and repeat 6-hourly until improvement 5

Hospital Admission Criteria

Admit immediately if 5:

• Any life-threatening features present
• PEF <33% predicted after initial treatment
• Features of acute severe asthma persist after initial treatment

Lower threshold for admission if 5, 7:

• Attack occurs in afternoon or evening
• Recent nocturnal symptoms
• Recent hospital admission or previous severe attacks
• Patient vomiting during exacerbation 7

Critical Contraindications

Never administer sedatives to asthmatic patients—they are absolutely contraindicated and can worsen respiratory depression 7, 6, 8.

Do not prescribe antibiotics unless bacterial infection is clearly documented 7, 6, 8.

Discharge and Follow-Up Requirements

Before hospital discharge, ensure 5:

• Patient on discharge medication for 24 hours with verified inhaler technique
• PEF >75% predicted or best with diurnal variability <25%
• Prescribed prednisolone for 1-3 weeks, increased inhaled corticosteroids, and as-needed β-agonists 7
• Patient has own PEF meter and written self-management action plan 7
• GP follow-up arranged within 1 week and specialist clinic within 4 weeks 5

Special Populations

Children 6-11 Years

• ICS-containing therapy recommended for most children with asthma 2
• New treatment options at Steps 3-4 include medium-dose ICS or low-dose ICS-LABA 1

Patients with Vomiting During Exacerbation

• Administer IV hydrocortisone 200 mg every 6 hours instead of oral corticosteroids 7
• Vomiting indicates severe attack or intolerance to oral medications, lowering threshold for admission 7
• Check plasma electrolytes and urea concentrations 7, 8
• Obtain chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 7, 8

Ongoing Management Principles

Regular assessment must include 1, 2:

• Symptom frequency and severity
• PEF measurements and monitoring 5, 6
• Frequency of rescue medication use
• Treatment of modifiable risk factors
• Self-management education and skills training

Adjust treatment based on control achieved, stepping up if control is inadequate after 4-8 weeks, or stepping down once good control is maintained for 3 months 3, 1.