GINA strategy 2020: management of asthma

Jump to:

Management of asthma

General principles

The long-term goals of asthma management are risk reduction and symptom control. The aim is to reduce the burden to the patient and to reduce their risk of asthma-related death, exacerbations, airway damage, and medication side-effects. The patient’s own goals and preferences regarding their asthma and its treatment should also be identified.

A partnership between the patient and their health care providers is important for effective asthma management. Training health care providers in communication skills may lead to increased patient satisfaction, better health outcomes, and reduced use of health care resources.

Health literacy —that is, the patient’s ability to obtain, process and understand basic health information to make appropriate health decisions—should be taken into account in asthma management and education.

The asthma management cycle to minimise risk and control symptoms

Algorithm 1: The asthma management cycle of shared decision-making

Asthma management involves a continuous cycle to assess, adjust treatment, and review response (see Algorithm 1).

Assessment of a patient with asthma includes not only symptom control, but also the patient’s individual risk factors and comorbidities that can contribute to their burden of disease and risk of poor health outcomes, or that may predict their response to treatment. Patients (or parents of children with asthma) should be asked about their goals and preferences for asthma treatment, as part of shared decision-making about asthma treatment options.

Treatment to prevent asthma exacerbations and control symptoms includes:

• medications: GINA now recommends that every adult and adolescent with asthma should receive ICS-containing controller medication to reduce their risk of serious exacerbations, even patients with infrequent symptoms. Every patient with asthma should have a reliever inhaler, either low dose ICS-formoterol or SABA
• treating modifiable risk factors and comorbidities (see the full report)
• using non-pharmacological therapies and strategies as appropriate.

Importantly, every patient should also be trained in essential skills and guided asthma self-management, including:

• asthma information
• inhaler skills
• adherence
• written asthma action plan
• self-monitoring of symptoms and/or peak flow
• regular medical review.

The patient’s response should be evaluated whenever treatment is changed. Assess symptom control, exacerbations, side-effects, lung function and patient (and parent, for children with asthma) satisfaction.

Recommendations for mild asthma

For safety, GINA no longer recommends starting with SABA-only treatment. GINA recommends that all adults and adolescents with asthma should receive ICS-containing controller treatment to reduce their risk of serious exacerbations and to control symptoms.

Algorithm 2 shows the new ICS controller options. These now include:

• (for mild asthma) as-needed low dose ICS-formoterol^[A][B] or, if not available, low dose ICS taken whenever SABA is taken^[C], or
• regular ICS or ICS-LABA every day, plus as-needed SABA, or
• maintenance and reliever treatment with ICS-formoterol^[D].

For initial treatment, see Algorithm 2. For ICS dose ranges, see Box 3–6 in the full report.

Starting asthma treatment

For the best outcomes, ICS-containing treatment should be initiated as soon as possible after the diagnosis of asthma is made, because:

• patients with even mild asthma can have severe exacerbations
• low dose ICS markedly reduces asthma hospitalizations and death
• low dose ICS is very effective in preventing severe exacerbations, reducing symptoms, improving lung function, and preventing exercise-induced bronchoconstriction, even in patients with mild asthma
• early treatment with low dose ICS leads to better lung function than if
  • symptoms have been present for more than 2–4 years
  • patients not taking ICS who experience a severe exacerbation have lower long-term lung function than those who have started ICS
  • in occupational asthma, early removal from exposure and early treatment increase the probability of recovery

For most adults or adolescents with asthma, treatment can be started at Step 2 with either regular daily low dose ICS, or as-needed low dose ICS-formoterol (or, if not available, low dose ICS whenever SABA is taken). Most patients with asthma do not need higher doses of ICS, because at a group level, most of the benefit (including prevention of exacerbations) is obtained at low doses. For ICS doses, see Box 3–6 in the full report.

Consider starting at Step 3 (e.g. daily low dose ICS-LABA or medium dose ICS) if, at initial presentation, the patient has troublesome asthma symptoms on most days; or is waking from asthma once or more a week.

If the patient has severely uncontrolled asthma at initial asthma presentation, or the initial presentation is during an acute exacerbation, start regular controller treatment at Step 4 (e.g. medium dose ICS-LABA); a short course of OCS may also be needed. See Algorithms 3 and 5.

Consider stepping down after asthma has been well-controlled for three months. However, in adults and adolescents, ICS should not be completely stopped.

Before starting initial controller treatment (see Algorithms 3 and 5):

• Record evidence for the diagnosis of asthma
• Document symptom control and risk factors
• Assess lung function, when possible
• Train the patient to use the inhaler correctly, and check their technique
• Schedule a follow-up visit.

After starting initial controller treatment (see Algorithms 2 and 4):

• Review response after two to three months, or according to clinical urgency
• See Algorithms 3 and 5 for ongoing treatment and other key management issues
• Consider step down when asthma has been well-controlled for three months.

For information on suggested daily ICS doses for the low, medium and high options in Algorithms 2–5, see Box 3–6 in the full report.

Stepwise approach for adjusting treatment for individual patient needs

Once asthma treatment has been started, ongoing decisions are based on a cycle of shared decision-making to assess the patient, adjust their treatment (pharmacological and non-pharmacological) if needed, and review their response (see Algorithm 1).

The preferred controller treatments at each step for adults and adolescents are summarised and in Algorithm 2 for adults and adolescents, and Algorithm 4 for children aged six to 11 years. For more details, including for children aged five years and younger, see the full report.

Algorithm 2: The GINA asthma treatment strategy—adults and adolescents

Algorithm 3: Initial treatment—adult or adolescent with a diagnosis of asthma

Algorithm 4: The GINA asthma treatment strategy—children six to 11 years

Algorithm 5: Initial treatment—six to 11 years with a diagnosis of asthma

Stepping up asthma treatment

Asthma is a variable condition, and periodic adjustment of controller treatment by the clinician and/or patient may be needed.

• Sustained step-up (for at least two to three months): if symptoms and/or exacerbations persist despite two to three months of controller treatment, assess the following common issues before considering a step-up
  • incorrect inhaler technique
  • poor adherence
  • modifiable risk factors, e.g. smoking
  • are symptoms due to comorbid conditions, e.g. allergic rhinitis.
• Short-term step-up (for one to weeks) by clinician or by patient with written asthma action plan, e.g. during viral infection or allergen exposure
• Day-to-day adjustment by patient with as-needed low dose ICS formoterol for mild asthma, or low dose ICS-formoterol as maintenance and reliever therapy.

Stepping down treatment when asthma is well-controlled

Consider stepping down treatment once good asthma control has been achieved and maintained for three months, to find the lowest treatment that controls both symptoms and exacerbations, and minimizes side-effects:

• Choose an appropriate time for step-down (no respiratory infection, patient not travelling, not pregnant)
• Assess risk factors, including history of previous exacerbations or emergency department visit, and low lung function
• Document baseline status (symptom control and lung function), provide a written asthma action plan, monitor closely, and book a follow-up visit
• Step down through available formulations to reduce the ICS dose by 25–50% at two- to three-month intervals (see Box 3-9 in full GINA 2020 report for details of how to step down different controller treatments)
• If asthma is well-controlled on low dose ICS or LTRA, as-needed low-dose ICS-formoterol is a step-down option based on two large studies with budesonide-formoterol in adults and adolescents and an open-label study. Smaller studies have shown that low dose ICS taken whenever SABA is taken (with combination or separate inhalers) is more effective as a stepdown strategy than SABA alone
• Do not completely stop ICS in adults or adolescents with asthma unless this is needed temporarily to confirm the diagnosis of asthma
• Make sure a follow-up appointment is arranged.

Treating modifiable risk factors

Exacerbation risk can be minimised by optimising asthma medications, and by identifying and treating modifiable risk factors. Some examples of risk modifiers with consistent high-quality evidence are:

• guided self-management: self-monitoring of symptoms and/or PEF, a written asthma action plan, and regular medical review
• use of a regimen that minimises exacerbations: prescribe an ICS-containing controller, either daily, or, for mild asthma, as-needed ICS-formoterol. For patients with one or more exacerbations in the last year, a low-dose ICS-formoterol maintenance and reliever regimen reduces the risk of severe exacerbations
• avoidance of exposure to tobacco smoke
• confirmed food allergy: appropriate food avoidance; ensure availability of injectable epinephrine for anaphylaxis
• school-based programmes that include asthma self-management skills
• referral to a specialist centre, if available, for patients with severe asthma, for detailed assessment and consideration of add-on biologic medications and/or sputum-guided treatment.

Non-pharmacological strategies and interventions

In addition to medications, other therapies and strategies may be considered where relevant, to assist in symptom control and risk reduction. Some examples with consistent high-quality evidence are:

• smoking cessation advice: at every visit, strongly encourage smokers to quit. Provide access to counselling and resources. Advise parents and carers to exclude smoking in rooms/cars used by children with asthma
• physical activity: encourage people with asthma to engage in regular physical activity because of its general health benefits. Provide advice about management of exercise-induced bronchoconstriction
• investigation for occupational asthma: ask all patients with adult-onset asthma about their work history. Identify and remove occupational sensitizers as soon as possible. Refer patients for expert advice, if available
• identify aspirin-exacerbated respiratory disease, and before prescribing NSAIDs including aspirin, always ask about previous reactions.

Although allergens may contribute to asthma symptoms in sensitized patients, allergen avoidance is not recommended as a general strategy for asthma. These strategies are often complex and expensive, and there are no validated methods for identifying those who are likely to benefit.

Some common triggers for asthma symptoms (e.g. exercise, laughter) should not be avoided, and others (e.g. viral respiratory infections, stress) are difficult to avoid and should be managed when they occur.

For information on treatment in specific populations or contexts, such as pregnancy, rhinitis ans sinusitis, obesity, the elderly, GORD, anxiety and depression, aspirin-exacerbated respiratory disease, food allergy and anaphylaxis, see the full GINA 2020 strategy.

Footnotes

[A] Evidence is only with budesonide-formoterol.

[B] At the time of publication, ICT-formoterol is licensed in the UK in addition to maintenance therapy.

[C] Combination or separate inhalers.

[D] With low dose beclometasone-formoterol or budesonide-formoterol inhalers.