Managing adult asthma: The GINA guidelines

Key points

• The 2019 GINA guidelines recommend for the first time that every patient with asthma be treated with an inhaled corticosteroid (ICS), taken daily or as needed, even in mild disease.
• Management is stepwise, escalating and de-escalating treatment according to symptom control.
• Before stepping up, clinicians should check adherence, affordability, inhaler technique, modifiable risk factors, triggers and comorbidities.
• Asthma is more common and more severe in women, Black people and families with low income.
• Asthma-COPD overlap is treated with low- or medium-dose ICS plus a long-acting beta-agonist (LABA) and/or a long-acting muscarinic antagonist (LAMA); triple therapy is reasonable for refractory symptoms.

Overview

This Cleveland Clinic Journal of Medicine review summarizes adult asthma management according to the 2019 Global Initiative for Asthma (GINA) guidelines, using case studies of mild, moderate and severe asthma. Asthma affects nearly 25 million people in the United States (about 7.7%), and more than 3,400 asthma deaths were reported in 2018. The main change from older guidelines is that short-acting beta-agonists (SABAs) alone are no longer used without any ICS, because ICS treat the underlying inflammation.

Diagnosis and principles

Asthma is characterized by recurrent wheezing, shortness of breath, chest tightness and cough that vary over time, so the examination may be normal. Diagnosis requires a compatible history plus evidence of variable, significantly reversible expiratory airflow limitation on spirometry or peak flow. Triggers include respiratory infections, allergens, weather changes, poor air quality, tobacco smoke, exercise and stress. Stepped-up therapy can be short-term (1-2 weeks) when a trigger is temporary, such as a respiratory infection.

Mild asthma (Steps 1-2)

For symptoms less than twice a month without risk factors (Step 1), options are as-needed low-dose ICS-LABA (for example budesonide-formoterol) or low-dose ICS and SABA used together as needed. For symptoms twice a month or more (Step 2), options are as-needed low-dose ICS-LABA or daily low-dose ICS with an as-needed reliever. Compared with as-needed SABA alone, daily low-dose ICS halved severe exacerbations in one study, and as-needed low-dose ICS-LABA reduced them by 64% in another. Formoterol is the only LABA recommended as a reliever because of its rapid action.

Moderate and severe asthma (Steps 3-5)

Step 3 is daily low-dose ICS-LABA plus as-needed low-dose ICS-LABA or SABA; in asthma uncontrolled on daily low-dose ICS, adding a daily LABA reduced exacerbations by 20%. Step 4 is daily medium-dose ICS-LABA plus as-needed SABA, considering high-dose ICS, a leukotriene receptor antagonist and a LAMA, with specialist referral if control is not achieved. In Step 5, a LAMA may be added, specialist referral is strongly recommended and patients should be evaluated for biologic therapy.

Asthma-COPD overlap

The overlap syndrome is common in older patients and smokers and has been reported in 1.1% to 4.5% of the general population and in up to 27% and 33% of patients with asthma and COPD, respectively. These patients have frequent exacerbations, faster lung function decline and higher mortality. Recommendations are based mostly on expert opinion, and specialist referral for confirmation is encouraged.

Frequently asked questions

Do patients with mild asthma need an inhaled corticosteroid?

Yes. Under GINA 2019, all patients should receive ICS, either daily or as needed, because this improves symptoms and reduces serious exacerbations even in mild asthma.

What should be checked before increasing asthma treatment?

Adherence and affordability of medication, inhaler technique, modifiable risk factors, triggers and comorbidities.

How is asthma-COPD overlap treated?

With low- or medium-dose ICS plus a LABA and/or LAMA as needed for symptom control, and triple therapy for refractory symptoms.

Source

Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleveland Clinic Journal of Medicine. 2020;87(9):569-575. DOI: 10.3949/ccjm.87a.19136. 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.