GINA Updates Guidance on Asthma Diagnosis, Management

AUTHOR:
Sahar Barfchin, MD
Nemours/Alfred I. duPont Hospital for Children, New Castle County, Delaware

CITATION:
Barfchin S. GINA updates guidance on asthma diagnosis, management. Published online November 2, 2021. Consultant360.

Reddel HK, Bacharier LB, Bateman ED, et al. Global Initiative for Asthma (GINA) strategy 2021 – executive summary and rationale for key changes. Am J Respir Crit Care Med. Published online October 18, 2021. https://doi.org/10.1164/rccm.202109-2205pp

Asthma is a common diagnosis encountered by physicians in all settings, including the primary care office, emergency department, and inpatient units. It has a global impact with potential for high morbidity and mortality, with about 300 million people affected worldwide.¹ Our understanding of the etiology, risk factors, and even precise definition of asthma is continually changing, and therefore, recommendations on diagnosis and treatment of asthma are frequently updated. There are 2 major organizations that US clinicians turn to for guidance on asthma diagnosis and treatment: the Global Initiative for Asthma (GINA) and National Heart Lung and Blood Institute (NHLBI), an arm of the US National Institutes of Health. The NHLBI’s National Asthma Education and Prevention Program periodically convenes expert panels to update their guidelines, the most recent of which was published in 2020. GINA reviews new evidence twice yearly and updates its Strategy Report yearly. The GINA 2021 Strategy Report was published in October 2021 and provides updated recommendations for the diagnosis and management of asthma.²

The 2021 GINA Strategy focuses on its previous recommendation against the use of monotherapy with short-acting β agonists (SABA) in adults and adolescents. Instead, GINA recommends the use of combination inhaled corticosteroid (ICS) and formoterol, a long-acting β agonist, for all severity classifications. In steps 3 to 5 of its treatment pathway, combination ICS-formoterol is used as both maintenance and reliever therapy (MART). This recommendation does not extend to other ICS-LABA combinations, as they have not been shown to improve morbidity and mortality over SABA only, as has ICS-formoterol.

To help clarify the recommended treatment regimen, GINA 2021 introduces 2 new tracks for the treatment of adults and adolescents with asthma. Track 1 is preferred and recommends the use of low-dose ICS-formoterol as the reliever in all steps, and Track 2 is an alternative that outlines the use of SABA across all steps. Track 2 is in line with traditional, older GINA recommendations but is provided as a practical consideration in cases when ICS-formoterol is not available or not preferred by the patient.

The argument for ICS-formoterol as both reliever and controller hinges heavily on ease of use and simplification of medication regimen, thereby increasing adherence. GINA cites studies showing that even in cases of mild asthma, as needed ICS-formoterol use decreases the risk of severe asthma exacerbations by 60% or more compared with SABA alone, and that treatment of asthma with SABA alone is associated with increased risk of asthma-related death. Of note, GINA makes a point to not distinguish between intermittent and mild persistent asthma, as the distinction is not evidence-based and does not predict response to ICS.

Another significant change in GINA Strategy in 2021 is the recommendation to use ICS whenever SABA is used in children aged 6 to 11 years. Therefore, there is a global recommendation for all patients with asthma, who are older than age 6 years, to be treated with ICS-containing therapy rather than SABA alone.

The current GINA recommendations stand in contrast to the most recent NHLBI Asthma Management Guidelines. The latter continue to recommend SABA only use for intermittent asthma, although the 2020 update did add a recommendation of short-course ICS along with SABA to be initiated at the start of a respiratory tract infection for children aged 0 to 4 years.³ Similar to the GINA recommendations, the 2020 NHLBI guidelines do recommend SMART (similar to MART) therapy for moderate to severe persistent asthma. Both organizations focus on shared decision-making with the patient or family and consideration of barriers to care and adherence. They also both strongly emphasize the importance of proper inhaler-use technique.  

Recent updates from the 2 major organizations that US clinicians rely on for asthma guidance may not bring their recommendations in line with each other, but both are evidence-based and reliable. Clinicians, along with their patients, will need to decide which set of recommendations work best for them. There are many practical considerations, like availability and cost of various medications, as well as simplicity of treatment regimens. The new GINA Strategy provides a simpler and potentially more effective approach to asthma management.

References

1. Dharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. Front Pediatr. Published online June 18, 2019. https://doi.org/10.3389/fped.2019.00246

2. Reddel HK, Bacharier LB, Bateman ED, et al. Global Initiative for Asthma (GINA) strategy 2021 - executive summary and rationale for key changes. Am J Respir Crit Care Med. Published online October 18, 2021. https://doi.org/10.1164/rccm.202109-2205pp

3. Expert Panel Working Group of the NHLBI administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270. https://doi.org/10.1016/j.jaci.2020.10.00