Gina Hoots, MSEd, RRT-ACCS, RPFT, CCSH, AE-C, CHC
The Global Initiative for Asthma, or GINA, guidelines are considered
the gold standard for asthma care worldwide. This provides an
overview of the key updates and takeaways of the most effective
strategies to gain and maintain control of asthma. While asthma is a
chronic disease, following the recommendations from leading experts
can help your patients breathe easier and enjoy life fully.
Key Changes in the 2023 GINA Asthma Guidelines
The latest GINA guidelines for 2023 bring important updates for the
management of asthma. The GINA Science Committee reviewed over
3,000 recent studies, and several key changes have been made.
Of significance, there is new terminology for asthma medications to
provide more clarity. The terms “maintenance treatment” and “ICS-containing treatment” now replace “controller medications”. “Anti-
inflammatory relievers” or “AIR” refers to inhalers like ICS-formoterol
that provide quick relief while reducing inflammation. Distinguishing
between using an AIR alone or as “maintenance and reliever therapy”
(MART) with an ICS is key.
GINA also added guidance on explaining the “asthma management
cycle” of assessing symptoms, adjusting treatment, and reviewing
the response to patients. This reminds clinicians and patients of the
essential elements of good asthma control.
The 2023 GINA guidelines provide the latest recommendations to
help people effectively manage their asthma. Following these
guidelines can help reduce symptoms, prevent attacks, and maintain
good lung function and quality of life. Patients should talk to their
doctors about the options in the new guidelines and develop an
asthma action plan tailored to their needs.
Asthma Medication Terminology Explained
Maintenance medications, also known as ‘controllers,’ are taken
regularly to control asthma symptoms and reduce inflammation in
the airways. The most common are inhaled corticosteroids (ICS),
which can be combined with long-acting beta agonists (LABA) for
more severe asthma. ICS are considered the most effective
maintenance treatment for controlling asthma.
Relievers, such as short-acting beta agonists (SABA), provide quick
relief of asthma symptoms. Common in the United States, generic
albuterol includes brand names include Ventolin and Proair.
Relievers should only be used occasionally and as directed.
Anti-inflammatory relievers (AIR) have dual purposes, reducing
inflammation and relieving symptoms. Inhaled corticosteroid-formoterol (ICS-formoterol) and inhaled corticosteroid-short-acting
beta agonist (ICS-SABA) inhalers can be used as both maintenance
and reliever therapy for asthma. Using an AIR inhaler for both
purposes is known as maintenance and reliever therapy (MART).
For example, budesonide-formoterol (Symbicort) can be taken
regularly to control asthma and used as needed to relieve symptoms.
When starting or adjusting treatment, the asthma management cycle
involves assessing symptoms, adjusting medications based on GINA
guidelines, and reviewing response. Understanding these terms and
the cycle of care can help patients better manage their asthma.
Using the correct terminology and understanding the different types
of asthma medications is key to properly managing this chronic
respiratory disease. Caregivers should work closely with doctors to
determine the best asthma action plans for their patients based on
symptom severity and lifestyle factors. With the right approach,
people of all ages can keep their asthma well-controlled and live
active lives.
Ongoing Discussion About Defining Mild Asthma
There is ongoing discussion in the medical community about clearly
defining mild asthma. The current definition is retrospective, based
on a patient’s symptoms and lung function over the previous few
weeks. However, doctors use the term “mild asthma” in various ways
during diagnosis, education, and treatment.
GINA continues to discuss this issue with patients, primary care
physicians, and specialists. They aim to provide interim guidance for
using the term “mild asthma” appropriately in different contexts. For
example, during diagnosis of a new patient, a doctor may describe
asthma as mild based on symptoms and initial tests. When educating
health professionals, a standard definition helps ensure patients get
the same quality of care.
In studies and clinical trials, a precise definition of mild asthma is
necessary to evaluate treatment effects. However, no consensus
has emerged on a universal definition. Factors like symptom
frequency, nighttime awakenings, medication use, and lung function
all provide insight, but no single measure is definitive. A patient’s
own perception of “mild” symptoms may also differ from their
doctor’s assessment.
Resolving this complex issue will require ongoing collaboration
between GINA, health organizations, and the asthma community. An
updated, comprehensive definition of mild asthma could help
improve communication, education, and the development of tailored
treatment plans for patients. Patients would also benefit from a
better understanding of how doctors diagnose and categorize the
severity of their asthma.
New Advice for Managing Severe Asthma
New biologic therapies for severe asthma are providing more
treatment options, especially for those with allergic or eosinophilic
inflammation. According to the updated GINA guidelines, these
advanced treatments should only be considered for patients with
severe asthma whose symptoms remain uncontrolled despite
optimized standard treatment.
Some biologics are approved for children as young as 6 years old.
However, as with any medication, the risks and benefits must be
carefully considered for each patient before prescribing biologic
therapy, especially in pediatrics. Close monitoring is needed to
determine if treatment goals are being met and whether adjustments
or alternative treatments may be needed.
For the most severe and refractory asthma cases, newer biologics
targeting other inflammatory pathways may provide relief when other
treatments have failed. But the high cost of these advanced biologics
underscores the need for improved access to affordable, essential
asthma medications worldwide. Overall, biologics have expanded
options for managing severe asthma, but should only be used when
standard treatments are not enough. Careful patient selection and
close monitoring remains key.
Asthma Management Cycle
The GINA 2023 report summarizes the asthma management cycle in
seven steps. First, assess the patient’s symptoms and risk factors to
determine their asthma control and severity. Then, select initial
treatment based on asthma severity, and provide the patient with an
action plan for managing exacerbations.
Regular follow-up is needed to monitor the patient’s symptom control
and risk factors, and adjust treatment as needed. At each visit,
healthcare professionals should review the patient’s symptom control
and risk factors, lung function, inhaler technique, and adherence.
Adjustments to treatment may involve stepping up or stepping
down therapy depending on the level of symptom control.
For patients with persistent symptoms and/or exacerbations despite
regular treatment, consider alternative diagnoses or triggers, as well
as difficult-to-treat asthma. Adjustments may also be needed for life
changes like pregnancy or older age.
The asthma management cycle aims to empower patients to achieve
and maintain good symptom control, optimize their lung function and
quality of life, and reduce the risk of asthma exacerbations. By
routinely following this cycle, doctors and patients can work together
to find and adjust treatment plans tailored to the patient’s needs. The
key is to take an individualized, patient-centered approach.
GINA continues to update asthma guidelines based on the latest
research to provide the best care and management
recommendations for people living with asthma. The most recent
updates cover diagnosis and management of asthma for both
children and adults. The guidelines are meant to be a helpful
reference for doctors and caregivers.
For caregivers, the guidelines highlight the importance of creating
asthma action plan, ensuring proper use of inhalers and spacers,
reducing asthma triggers in the home, and helping manage asthma in
schools or workplaces. Patient education and open communication with
doctors are key. While asthma cannot be cured, with the right
treatment and management, people can live active and unrestricted
lives.
Asthma Guidelines: The Latest From GINA
