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This Guidelines summary is taken from the GINA 2021 pocket guide for asthma management and prevention. It outlines recommendations for the management of asthma in adults, adolescents, and children aged 6–11.

Download the full global strategy for asthma management and prevention:

Global strategy for asthma management and prevention

2021 Pocket guide for asthma management and prevention

This summary is adapted from the GINA pocket guide, which itself is a summary of the GINA 2021 report for primary healthcare providers. It does not contain all of the information required for managing asthma, for example about the safety of treatments, and it should be used in conjunction with the full GINA 2021 report. When assessing and treating patients, healthcare professionals are strongly advised to use their own professional judgement and to take into account local and national regulations and guidelines.

View the full group of Guidelines GINA asthma strategy summaries at guidelines.co.uk/ginaasthma.

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

Population-level recommendations about ‘preferred’ asthma treatments represent the best treatment for most patients in a particular population. In steps one to five, there are population-level recommendations for different age groups. In step five, there are also different population-level recommendations depending on the inflammatory phenotype—type 2 or non-type 2.

Patient-level treatment decisions should take into account any individual characteristics, risk factors, co-morbidities, or phenotype that predict how likely the patient’s symptoms and exacerbation risk are to be reduced by a particular treatment, together with their personal goals, and practical issues such as inhaler technique, adherence, and affordability.

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

The asthma management cycle of shared decision making

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available from www.ginasthma.org

  • 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 co-morbidities 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 inhaled corticosteroid (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 for as-needed use, either low dose ICS-formoterol or short-acting beta2 agonist (SABA)
    • treating modifiable risk factors and co-morbidities (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 treatment of asthma in adults and adolescents with SABA alone, without ICS. There is strong evidence that SABA-only treatment, although providing short-term relief of asthma symptoms, does not protect patients from severe exacerbations, and that regular or frequent use of SABA increases the risk of exacerbations 
  • GINA now 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
  • For adults and adolescents, the treatment options for mild asthma are:
    • as-needed low-dose ICS-formoterol (preferred) or
    • regular low-dose ICS, plus as-needed SABA.

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 hospitalisations 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 is associated with 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 two with either as-needed low-dose ICS-formoterol (preferred), or regular daily low-dose ICS with as-needed SABA. 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 9 in the pocket guide report
  • Consider starting at step three (for example maintenance and reliever therapy [MART] with low-dose ICS-formoterol) 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 four (or example medium-dose ICS-formoterol MART); a short course of oral corticosteroids may also be needed
  • Consider stepping down after asthma has been well-controlled for 3 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 2–3 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 3 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.

Asthma treatment tracks for adults and adolescents

  • The options for ongoing treatment for adults and adolescents have been clarified in Algorithm 3 by showing two treatment ‘tracks’. The key difference between the tracks is the medication that is used for symptom relief: as-needed low-dose ICS-formoterol in track one (preferred), and as-needed SABA in track two.

Track one

  • The reliver is as-needed low-dose ICS-formoterol
  • This is the preferred approach recommended by GINA for adult and adolescents
  • Using low-dose ICS-formoterol as reliever reduced the risk of severe exacerbations compared with regimens with SABA as reliever, with similar symptom control. With this approach:
    • when a patient at any treatment step has asthma symptoms, they use low-dose ICS-formoterol in a single inhaler for symptom relief
    • in steps three to five, patients also take ICS-formoterol as their regular daily treatment. This is called maintenance and reliever therapy (MART)
  • ICS formoterol should not be used as the reliever by patients taking any other ICS-LABA

Track two

  • The reliever is as-needed SABA
  • This is an alternative approach when track one is not possible or is not preferred by a patient who has no exacerbations on their current therapy
  • In step one, the patient takes a SABA and a low-dose ICS together for symptom relief when symptoms occur, either in a combination inhaler, or with the ICS taken right after the SABA
  • In steps two to five, a SABA (alone) is used for symptom relief, and the patient takes ICS-containing controller therapy, as otherwise they will be at higher risk of exacerbations
  • During ongoing treatment, treatment can be stepped up or down along one track, using the same reliever at each step, or it can be switched between tracks according to the individual patient’s needs 
  • Before stepping up, check for common problems such as incorrect inhaler technique, poor adherence, and environmental exposures, and confirm that the symptoms are due to asthma (see Box 5 in the full pocket guide).

Stepwise approach for adjusting treatment for individual patient needs

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

Algorithm 2

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available from www.ginasthma.org

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

Algorithm 3

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available from www.ginasthma.org

Algorithm 4: The GINA asthma treatment strategy—children 6–11 years

Algorithm 4

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available from www.ginasthma.org

Algorithm 5: Initial treatment—children 6–11 years with a diagnosis of asthma

Algorithm 5

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available from www.ginasthma.org

  • For clarity, treatment options for adults and adolescents in Algorithm 2 are shown as two tracks, based on the choice of reliever
  • In track one, the reliever is low-dose ICS-formoterol. This is the preferred approach recommended by GINA, because it reduces the risk of severe exacerbations compared with using a SABA reliever (options shown in track two)
  • Once asthma treatment has been started (see Algorithms 3 and 5), 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). Treatment can be stepped up or down along one track using the same reliever at each step, or it can be switched between tracks, according to the individual patient’s needs
  • 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 6–11 years. For more details, including for children aged 5 years and younger, see the full report.

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 2–3 months): if symptoms and/or exacerbations persist despite 2–3 months of controller treatment, assess the following common issues before considering a step-up:
      • incorrect inhaler technique
      • poor adherence
      • modifiable risk factors, for example smoking
      • are symptoms due to co-morbid conditions, for example allergic rhinitis
    • short-term step-up (for 1–2 weeks) by clinician or by patient with written asthma action plan, for example during viral infection or allergen exposure
    • day-to-day adjustment by patient with as-needed low-dose ICS formoterol for mild asthma, or ICS-formoterol maintenance and reliever therapy. This is particularly effective in reducing severe exacerbations.

Stepping down treatment when asthma is well-controlled

  • Consider stepping down treatment once good asthma control has been achieved and maintained for 3 months, to find the lowest treatment that controls both symptoms and exacerbations, and minimises 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 2–3-month intervals (see Box 3-9 in full report for details of how to step down different controller treatments)
    • if asthma is well-controlled on low dose ICS or leukotriene receptor antagonist therapy, as-needed low-dose ICS-formoterol is a step-down option based on three large studies in mild asthma. 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 peak expiratory flow, 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. MART with ICS-formoterol reduces the risk of severe exacerbations compared with if the reliever is SABA
    • avoidance of exposure to tobacco smoke
    • confirmed food allergy: appropriate food avoidance; ensure availability of injectable adrenaline 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; it may have a small benefit for asthma control and lung function. 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 sensitisers as soon as possible. Refer patients for expert advice, if available
    • identify aspirin-exacerbated respiratory disease, and before prescribing non-steroidal anti-inflammatory drugs including aspirin, always ask about previous reactions
  • Although allergens may contribute to asthma symptoms in sensitised 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 (for example exercise, laughter) should not be avoided, and others (for example viral respiratory infections, stress) are difficult to avoid and should be managed when they occur
  • During 2020, many countries saw a reduction in asthma exacerbations and influenza-related illness, possibly due to handwashing, masks, and social/physical distancing because of COVID-19 that also reduced the incidence of other respiratory infections, including influenza.

For information on treatment in specific populations or contexts, such as pregnancy, rhinitis and sinusitis, obesity, the elderly, gastro-oesophageal reflux disease, anxiety and depression, aspirin-exacerbated respiratory disease, food allergy and anaphylaxis, and surgery, see the pocket guide.

 

Full guideline:

Global Initiative for Asthma. 2021 Pocket guide for asthma management and prevention. April 2021. Available at: www.ginaasthma.org.

Published date: 1995.

Last updated: April 2021.