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

GINA Guidelines for Asthma Management

Core Treatment Philosophy

The Global Initiative for Asthma (GINA) recommends that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing therapy using a stepwise approach, with low-dose ICS-formoterol as the preferred reliever medication at all treatment steps to achieve overall asthma control while preventing exacerbations. 1

GINA defines control across two domains: current symptom control (day-to-day symptoms) and future risk reduction (preventing exacerbations, lung function decline, and medication side effects). 1, 2 The goal is achieving control using the lowest effective medication dose. 1

Diagnosis Requirements

Before initiating treatment, asthma diagnosis requires compatible clinical history PLUS objective confirmation of variable expiratory airflow limitation on lung function testing, preferably using spirometry or peak expiratory flow measurements. 1, 3

Stepwise Treatment Approach

GINA organizes treatment into 5 steps, with two treatment tracks for adults and adolescents:

Track 1 (Preferred Approach)

• Step 1 (Mild Intermittent): As-needed low-dose ICS-formoterol only, which reduces severe exacerbations by ≥60% compared with SABA alone. 1, 4

• Step 2 (Mild Persistent): As-needed low-dose ICS-formoterol remains the preferred option. 5, 1

• Steps 3-5 (Moderate to Severe): Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol (SMART/MART therapy), which provides superior exacerbation reduction compared to fixed-dose ICS-LABA plus SABA. 5, 1, 6

Track 2 (Alternative Approach)

• Uses as-needed SABA across all steps plus regular ICS at Step 2, or ICS-LABA combinations at Steps 3-5. 4

• Critical Safety Warning: LABAs should NEVER be used as monotherapy for asthma, as this increases risk of asthma-related death. 5, 1

Step 5 Add-On Therapies

For severe asthma not controlled on high-dose ICS-LABA, add-on options include:

• Long-acting muscarinic antagonists (LAMA) before initiating phenotype-specific biologics. 5, 4
• Azithromycin for select patients. 4
• Biologic therapies for severe asthma. 4

Key Medication Principles

• Formoterol is the only LABA suitable for as-needed use due to its rapid onset, making it appropriate for both maintenance and reliever therapy. 5, 3

• Salmeterol should never be used for SMART therapy due to slower onset. 3

• ICS are the most effective anti-inflammatory medication for persistent asthma, reducing airway inflammation and improving symptoms, lung function, and quality of life. 5

• GINA no longer recommends doubling ICS dose for home management of exacerbations, as this strategy is ineffective. 3

Assessment of Asthma Control

Well-controlled asthma requires ALL of the following over the past 4 weeks: 5, 1

• Daytime symptoms ≤2 days/week
• No nighttime awakenings due to asthma
• Reliever use ≤2 days/week
• No activity limitation due to asthma

Asthma is classified as:

• Controlled: Meets all criteria above
• Partly controlled: Meets 1-2 symptom criteria
• Uncontrolled: Meets 3-4 symptom criteria 5

Treatment Adjustment Strategy

• Step up treatment when asthma is partly controlled or uncontrolled, or when a patient has had two or more exacerbations requiring oral corticosteroids in the past year. 5, 1

• Step down treatment when asthma is well-controlled for at least 3 months. 5, 1

• Before stepping up, verify proper inhaler technique, medication adherence, and environmental trigger control. 7, 1

Acute Exacerbation Management

Severity Classification

Life-threatening features: 1

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

Severe features: 1

• Inability to complete sentences in one breath
• Respiratory rate >25/min
• Pulse >110/min
• PEF <50% of predicted/best

Immediate Treatment Protocol

• High-flow oxygen 40-60% 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
• Systemic corticosteroids (oral or IV) 5
• Add ipratropium bromide 0.5 mg for life-threatening features 1

Essential Patient Self-Management

Every patient must receive: 5, 1

• Written asthma action plan with specific PEF or symptom thresholds for medication adjustment
• Training on proper inhaler technique (checked and recorded at each visit) 7
• Clear understanding of "relievers" versus "preventers"
• Own PEF meter for home monitoring

Special Population Considerations

Children 6-11 Years

• GINA does NOT recommend SMART therapy for this age group. 3
• Use lowest ICS dose providing acceptable control. 1
• ICS doses >400 mcg/day cause short-term reductions in tibial growth rate. 1, 3
• New treatment options added at Steps 3-4 in recent updates. 1, 4

Children 0-5 Years

• Diagnosis relies on symptoms rather than objective testing, as bronchodilator response is variable. 5
• GINA does not recommend ICS-formoterol as reliever therapy in this age group. 3

Pregnant Women

• Refer for specialist consultation if asthma worsens. 5, 1

Modifiable Risk Factors to Address

Common factors increasing exacerbation risk that should be identified and reduced: 1

• 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. 1

Monitoring and Follow-Up

• Regular assessment of symptom control, lung function, and exacerbation risk should be performed at each visit. 7
• Inhaler technique should be checked and recorded at each visit. 7
• Follow-up within 1-4 weeks after treatment changes is recommended to adjust therapy as needed. 7
• Peak expiratory flow monitoring can help assess variability and response to treatment. 7

Specialist Referral Indications

Refer patients to an asthma specialist when: 5

• Difficulty achieving or maintaining control
• Two or more bursts of oral corticosteroids in a year
• Exacerbation requiring hospitalization

Critical Safety Considerations

• Underuse of corticosteroids is a major factor in poor asthma outcomes. 7
• ICS doses >500 mcg/day carry significant systemic adverse effects, including adrenal suppression equivalent to 5 mg oral prednisone daily. 1
• Symptom control does not equal elimination of exacerbation risk, especially in severe asthma. 5
• GINA no longer recommends SABA-only treatment due to safety concerns regarding excessive SABA use and increased risk of serious exacerbations and asthma-related deaths. 4, 8