Global strategy for asthma management and prevention

Key points

• Asthma is a heterogeneous disease, usually with chronic airway inflammation, defined by variable respiratory symptoms (wheeze, shortness of breath, chest tightness, cough) together with variable expiratory airflow limitation.
• The 2024 diagnostic flowchart accepts different initial lung function tests depending on local resources; peak expiratory flow is less reliable than spirometry but better than symptoms alone.
• In Track 1, as-needed low-dose ICS-formoterol has been the preferred treatment for Steps 1-2 since 2021, and GINA has recommended against SABA-only treatment since 2019.
• All patients with asthma should receive ICS-containing therapy.
• High-dose inhaled corticosteroids are for short-term use only, for example 3-6 months.

Overview

The Global Initiative for Asthma (GINA) strategy is a widely used international report on asthma diagnosis and treatment; this summary covers the key changes in the 2024 update. The main themes are diagnosis where spirometry is not available, treatment choices based on ICS-containing therapy, clearer dosing guidance, and a new framework for asthma remission.

Diagnosis

GINA reviewed but did not adopt the American Thoracic Society and European Respiratory Society proposal to define bronchodilator responsiveness as an increase of more than 10% predicted, keeping the criterion of an increase of at least 12% and 200 mL from baseline for now. Cough variant asthma is described in more detail: spirometry may be normal, variable airflow limitation may appear only on bronchial provocation testing, treatment is the same as for asthma in general, and the cough may return if inhaled corticosteroids (ICS) are stopped.

Assessment and goals

Assessment of symptom control should not be limited to the most recent 4 weeks, although no validated tools cover longer periods. Risk factors for exacerbations, lung function decline and medication adverse effects must also be assessed. The goal of treatment is the best possible long-term outcome for the individual patient, and patient goals should be elicited. A new section outlines clinical and complete remission in children and adults, both off and on treatment.

Treatment

Suggested reasons to start at Step 3 with maintenance-and-reliever therapy (MART) include daily symptoms, current smoking, low lung function, a recent severe or life-threatening exacerbation, impaired perception of bronchoconstriction, severe airway hyperresponsiveness or current seasonal allergen exposure. For patients with infrequent symptoms in Track 2, taking ICS whenever SABA is taken is preferred over daily ICS plus as-needed SABA. The maximum total formoterol dose with ICS is 72 mcg metered dose per day for adults and adolescents (12 inhalations of beclometasone-formoterol 100/6 mcg for MART) and 48 mcg for children 6-11 years using budesonide-formoterol MART. Patients taking montelukast should be advised about possible neuropsychiatric adverse events. In severe asthma responding well to Type 2-targeted therapy, maintenance oral corticosteroids should be reduced and stopped first, and maintenance ICS-formoterol should not be stopped. Allergen immunotherapy may be considered as add-on treatment in severe asthma only once symptoms and exacerbations are controlled.

Frequently asked questions

Can asthma be diagnosed without spirometry?

Yes. The 2024 flowchart allows other initial lung function tests such as peak expiratory flow, which is less reliable than spirometry but better than relying on symptoms alone.

Is a short-acting reliever alone acceptable treatment?

No. GINA has recommended against SABA-only treatment since 2019, and all patients should receive ICS-containing therapy.

What is the maximum daily formoterol dose with ICS-formoterol?

A total of 72 mcg metered dose per day for adults and adolescents, and 48 mcg for children 6-11 years using budesonide-formoterol MART.

Source

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024 update. Summary published by Guideline Central, May 7, 2024. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.