Global Initiative for Asthma (GINA) Guidelines - Update
Date: 08/01/25
The Global Initiative for Asthma (GINA) provides evidence-based asthma management strategies for health professionals. These updates aim to enhance personalized care, improve asthma control, and reduce exacerbations.
The updated GINA guidelines reflect a shift toward personalized, proactive asthma management. By integrating updated diagnostic tools, flexible treatment strategies, and a focus on severe asthma management, these guidelines aim to improve patient outcomes and reduce its burden. For detailed information, consult the full 2024 GINA Report.
Key recommendations for clinical practice
1. Diagnostic approach including peak expiratory flow (PEF)
GINA recognizes that access to spirometry can be limited in some settings. Therefore, GINA has revised its diagnostic flowchart. While spirometry remains the gold standard, peak expiratory flow (PEF) is now emphasized as a viable alternative, especially in resource-limited environments. This change facilitates early asthma diagnoses.
2. Management strategies for adults and adolescents
There are two tracks recommended for therapy initiation and management.
Track 1: Anti-Inflammatory Reliever (AIR) Therapy (Preferred Track)
For patients aged twelve and older with mild asthma, GINA recommends therapy to be initiated with a low-dose inhaled corticosteroid (ICS)-formoterol inhaler as both maintenance and reliever therapy. This approach simplifies treatment regimens and has been shown to reduce severe exacerbations more effectively than short-acting beta-agonist (SABA) monotherapy.
Step 1 & 2 | Step 3 | Step 4 | Step 5 |
|---|---|---|---|
As-needed-only low dose ICS-fomoterol | Low dose maintenance ICS-fomoterol | Medium dose maintenance ICS-fomoterol |
|
Reliever: As-needed low dose ICS-fomoterol* | |||
*Using ICS-fomoterol as the reliever reduces the risk of exacerbation compared with using a SABA reliever and is a simpler regimen
Track 2: Maintenance and Reliever Therapy (MART)
For patients with more frequent symptoms, GINA advises low-dose ICS-formoterol as maintenance therapy, combined with as-needed use for symptom relief. This strategy offers flexibility and aligns with the goal of minimizing SABA overuse, which is associated with increased asthma-related risks.
Step 1 | Step 2 | Step 3 | Step 4 | Step 5 |
|---|---|---|---|---|
Take ICS whenever SABA is taken | Low dose maintenance ICS | Low dose maintenance ICS-LABA | Medium high dose maintenance ICS-LABA |
|
Reliever: As-needed low dose ICS-fomoterol* | ||||
*Before considering a regimen with SABA reliever, check if the patient is likely to adhere to daily controller treatment
3. Shifting away from SABA-alone
The 2024 guidelines emphasize that all adults and adolescents with asthma should not be treated with SABAs alone as a reliever and instead should be on an ICS-containing therapy. This shift is driven by the increased risk of exacerbation and other adverse outcomes associated with SABA-alone use.
4. Importance of written asthma action plans
The updates also highlight the importance of having written asthma action plans and tailoring asthma management to the individual. This includes educating patients about their condition, triggers, and proper inhaler technique.
5. Focus on early intervention
GINA's 2024 guidelines stress the importance of starting ICS-formoterol treatment early to prevent the need for oral steroids during exacerbations.
6. Stepwise treatment adjustments
The guidelines provide detailed recommendations for escalating or de-escalating treatment based on symptom frequency, exacerbation history, and lung function. For instance, patients with symptoms occurring 1–2 days per week should start with low-dose ICS whenever SABA is used. Those with daily symptoms or low lung function may require medium-dose ICS-long-acting beta agonist (LABA) plus as-needed SABA or low-dose ICS-formoterol MART.
7. Leukotriene receptor antagonist (LTRA) therapy
The decision to add a leukotriene receptor antagonist (LTRA) such as montelukast (Singulair®) should be a shared clinical decision, given the potential for neuropsychiatric adverse effects.
8. Severe asthma management and add-on therapies
For patients with severe asthma, defined by uncontrolled symptoms despite high-dose ICS-LABA therapy, GINA recommends assessing the clinical and inflammatory phenotype to guide treatment.
Add-on therapies include tiotropium, low-dose azithromycin, and biologic agents such as benralizumab (Fasenra®), dupilumab (Dupixent®), mepolizumab (Nucala®), omalizumab (Xolair®), reslizumab (Cinqair™), and Tezepelumab (Tezspire®). These biologics have demonstrated substantial reductions in severe exacerbations and potential reductions in oral corticosteroid use.
9. Additional Considerations
- Fractional Concentration of Exhaled Nitric Oxide (FeNO): FeNO remains a valuable tool for guiding treatment decisions in patients with severe asthma, particularly in assessing airway inflammation
- Vaccination: Vaccination against respiratory illnesses, including pneumococcus, respiratory syncytial virus (RSV), and pertussis is emphasized to prevent respiratory infections in asthma patients
Meridian Preferred Agents for Asthma
Category | Preferred Agents |
|---|---|
Inhaled corticosteroids (ICS) |
|
Combination agents |
|
Short-acting beta 2-agonists (SABA) |
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Anticholinergic |
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Biologic agents |
|
References
1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2024. Updated May 2024.
2. Meridian Preferred Drug List.