The Global Initiative for Asthma (GINA), established in 1993, is an organization dedicated to improving asthma care worldwide. GINA publishes a comprehensive, evidence-based strategy document annually, providing healthcare professionals with updated recommendations for diagnosing and managing asthma. This global strategy aims to enhance asthma awareness, prevention, and management, thereby working to reduce the prevalence, illness, and deaths associated with the condition.
Core Principles of GINA Assessment
GINA’s approach to asthma management centers on personalized care. The assessment framework evaluates asthma control across two distinct domains. The first considers a patient’s symptom control over the past four weeks, assessing aspects like daytime symptoms, night waking, and activity limitations due to asthma.
The second domain focuses on identifying risk factors for future poor outcomes, such as severe asthma exacerbations, a decline in lung function, or medication side effects. Even individuals with good symptom control can still be at risk for severe exacerbations, making this dual assessment important. This comprehensive evaluation ensures treatment decisions are tailored to both current symptom burden and the potential for future complications.
The Shift Away From SABA-Only Treatment
GINA guidelines now advise against using short-acting beta2-agonists (SABA), such as albuterol, as the sole treatment for asthma. Evidence highlights the risks associated with SABA-only therapy, even in mild asthma. SABA medications provide quick symptom relief by opening airways but do not address the underlying airway inflammation that characterizes asthma.
Relying solely on SABA can mask worsening inflammation, potentially leading to a reduced response to the medication over time. Studies show that SABA-only treatment is linked to an increased risk of severe asthma exacerbations, hospitalizations, and even asthma-related deaths. GINA recommends that all adults and adolescents with asthma receive inhaled corticosteroid (ICS)-containing medication, either regularly or as needed, to treat underlying inflammation and reduce serious events.
The Stepwise Approach to Asthma Management
GINA employs a five-step approach to manage asthma based on an individual’s control and severity. This framework is divided into two main “tracks” to guide therapy. Track 1, the preferred approach, uses an inhaled corticosteroid-formoterol combination as both the daily controller and the as-needed reliever medication. This single-inhaler strategy, known as Maintenance-and-Reliever Therapy (MART, has shown effectiveness in reducing severe exacerbations.
For Steps 1 and 2 in Track 1, low-dose ICS-formoterol is taken only as needed for symptoms. In Steps 3 through 5, ICS-formoterol is used as a daily maintenance treatment, with additional doses taken as needed for symptom relief. Track 2, an alternative, involves using a SABA as a quick-relief medication alongside a separate daily controller, typically an ICS or an ICS-long-acting beta2-agonist (ICS-LABA) in higher steps. Treatment is “stepped up” if asthma control is not achieved, or “stepped down” when good control has been maintained for at least two to three months to find the lowest effective dose.
Advanced Therapies for Severe Asthma
Step 5 of the GINA guidelines addresses severe asthma, where symptoms remain uncontrolled despite optimized treatment with high-dose inhaled corticosteroids and long-acting beta2-agonists. For these patients, additional add-on therapies are considered. These options include long-acting muscarinic antagonists (LAMA), which help relax the airways, and biologic agents.
Biologic therapies are specialized medications that target specific inflammatory pathways involved in severe asthma. Examples include anti-IgE (omalizumab), anti-IL-5 (mepolizumab, reslizumab, benralizumab), anti-IL-4/IL-13 (dupilumab), and anti-TSLP (tezepelumab). Referral to an asthma specialist is recommended at this stage to confirm the diagnosis, identify treatable traits, and determine the most appropriate advanced therapy. These treatments are used in addition to, not as a replacement for, standard inhaled medications.
Creating a GINA-Based Asthma Action Plan
A written Asthma Action Plan is a useful tool for individuals to manage their asthma effectively in partnership with their healthcare provider. This personalized document outlines what medications to take, when to take them, and what actions to implement based on changes in symptoms or peak expiratory flow readings. The plan commonly uses a “zone” system to guide responses.
The Green Zone indicates good asthma control, where symptoms are absent, and regular maintenance medications should continue. The Yellow Zone signals worsening asthma, with symptoms like increased coughing, wheezing, or nighttime awakenings, prompting specific instructions for intensifying therapy, such as increasing inhaled corticosteroid doses. The Red Zone signifies a severe asthma flare-up, detailing actions that require immediate medical attention, including emergency contact numbers. This plan empowers patients to proactively manage their condition and reduce the risk of severe exacerbations.