Global Initiative for Asthma Strategy 2021: Executive Summary and Rationale for Key Changes

Abstract

The Global Initiative for Asthma (GINA) Strategy Report provides clinicians with an annually updated evidence-based strategy for asthma management and prevention, which can be adapted for local circumstances (e.g., medication availability). This article summarizes key recommendations from GINA 2021, and the evidence underpinning recent changes. GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting β₂-agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS-formoterol reduces severe exacerbations by ⩾60% in mild asthma compared with SABA alone, with similar exacerbation, symptom, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA. Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two tracks. Track 1 (preferred) has low-dose ICS-formoterol as the reliever at all steps: as needed only in Steps 1-2 (mild asthma), and with daily maintenance ICS-formoterol (maintenance-and-reliever therapy, "MART") in Steps 3-5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS-long-acting β₂-agonist (Steps 3-5). For adults with moderate-to-severe asthma, GINA makes additional recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on biologic therapies for severe asthma. For children 6-11 years, new treatment options are added at Steps 3-4. Across all age groups and levels of severity, regular personalized assessment, treatment of modifiable risk factors, self-management education, skills training, appropriate medication adjustment, and review remain essential to optimize asthma outcomes.

Keywords: asthma; asthma diagnosis; asthma management; asthma prevention.

Figure 1.

Global Initiative for Asthma assessment of asthma control in adults, adolescents, and children 6–11 years. For a version of this figure with full reference citations, please see Box 2-2 in Reference . P450 inhibitors include cytochrome P450 inhibitors such as ritonavir, ketoconazole, and itraconazole. *Based on SABA (as-needed ICS–formoterol reliever not included); excludes reliever taken before exercise. For children 6–11 years, see also Box 2-3 in Reference . For specific risk reduction strategies, see Box 3-8 in Reference . ^†“Independent” risk factors are those that are significant after adjustment for the level of symptom control. Reproduced by permission from Reference (Box 2-2). BD = bronchodilator; Fe_NO = fractional exhaled nitric oxide; GERD = gastroesophageal reflux disease; ICS = inhaled corticosteroid; OCS = oral corticosteroid; SABA = short-acting β₂-agonist.

Figure 2.

Personalized asthma management cycle of care. Reproduced by permission from Reference (Box 3-2).

Figure 3.

Personalized management for adults and adolescents to control symptoms and minimize risk. For ICS doses, see Box 3-6 in Reference . Reproduced by permission from Reference (Box 3-5A). HDM = house dust mite; ICS = inhaled corticosteroid; LABA = long-acting β₂-agonist; LAMA = long-acting muscarinic antagonist; LTRA = leukotriene receptor antagonist; OCS = oral corticosteroid; SABA = short-acting β₂-agonist; SLIT = sublingual immunotherapy.

Figure 4.

Personalized management for children 6–11 years to control symptoms and minimize future risk. For ICS doses for children, see Box 3-6 in Reference . For MART doses, see Table E2 and the downloadable resource in the online supplement. Reproduced by permission from Reference (Box 3-5B). BUD-FORM = budesonide–formoterol; ICS = inhaled corticosteroid; LABA = long-acting β₂-agonist; LTRA = leukotriene receptor antagonist; MART = maintenance-and-reliever therapy; OCS = oral corticosteroid; SABA = short-acting β₂-agonist.

Figure 5.

Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 yr). SABA doses are for albuterol. Reproduced by permission from Reference (Box 4-3). PEF = peak expiratory flow; pMDI = pressurized metered-dose inhaler; SABA = short-acting β₂-agonist.

Figure 6.

Personalized management of asthma in children 5 years and younger. Reproduced by permission from Reference (Box 6-5). ICS = inhaled corticosteroid; LTRA = leukotriene receptor antagonist; SABA = short-acting β₂-agonist.