Key recommendations for primary care from the 2022 Global Initiative for Asthma (GINA) update

Abstract

The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention and management worldwide. GINA develops and publishes evidence-based, annually updated resources for clinicians. GINA guidance is adopted by national asthma guidelines in many countries, adapted to fit local healthcare systems, practices, and resource availability. GINA is independent of industry, funded by the sale and licensing of its materials. This review summarizes key practical guidance for primary care from the 2022 GINA strategy report. It provides guidance on confirming the diagnosis of asthma using spirometry or peak expiratory flow. GINA recommends that all adults, adolescents and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, either taken regularly, or (for adults and adolescents with "mild" asthma) as combination ICS-formoterol taken as needed for symptom relief. For patients with moderate-severe asthma, the preferred regimen is maintenance-and-reliever therapy (MART) with ICS-formoterol. Asthma treatment is not "one size fits all"; GINA recommends individualized assessment, adjustment, and review of treatment. As many patients with difficult-to-treat or severe asthma are not referred early for specialist review, we provide updated guidance for primary care on diagnosis, further investigation, optimization and treatment of severe asthma across secondary and tertiary care. While the GINA strategy has global relevance, we recognize that there are special considerations for its adoption in low- and middle-income countries, particularly the current poor access to inhaled medications.

Fig. 1. The GINA diagnostic flowchart 2022.

PEF peak expiratory flow. Source: Box 1–1 in GINA report 2022. Box numbers within the figure refer to the GINA 2022 report. Reproduced with permission from ref. .

Fig. 2. Investigating poor symptom control and/or exacerbations despite treatment.

ICS inhaled corticosteroid, NSAID nonsteroidal anti-inflammatory drug, GERD gastro-esophageal reflux disease. Reproduced with permission from ref. .

Fig. 3. Approach to initial treatment in patients with asthma and/or COPD.

GOLD Global Initiative for Obstructive Lung Disease, ICS inhaled corticosteroid, LABA long-acting β₂ agonist; LAMA long-acting muscarinic antagonist. A summary of differentiating and diagnostic features in people with Asthma, COPD and Asthma + COPD. Source: Box 5–2 in GINA 2022. Reproduced with permission from ref. .

Fig. 4. Two-track options for personalized management of asthma for adults and adolescents, to control symptoms and minimize future risk.

HDM house dust mite, ICS inhaled corticosteroid, LABA long-acting beta₂ agonist, LAMA long-acting muscarinic antagonist, LTRA leukotriene receptor antagonist, OCS oral corticosteroids, SABA short-acting beta₂ agonist, SLIT sublingual immunotherapy. Box number refers to the GINA 2022 report. Before starting, stepping up or down or switching between tracks, patients should be assessed using the “assess, adjust, review” cycle shown at the top of the figure. Refer to the GINA report for more information about Step 5 options, including biologic therapies for patients with severe asthma. Source: Box 3–5A in GINA report 2022. Reproduced with permission from ref. .

Fig. 5. Initial medications for adults and adolescents diagnosed with asthma.

ICS inhaled corticosteroid, LABA long-acting beta₂ agonist, LAMA long-acting muscarinic antagonist, MART maintenance and reliever therapy with ICS–formoterol, OCS oral corticosteroids, SABA short-acting beta₂ agonist. Initial medications for adults and adolescents diagnosed with asthma, with guidance on initial levels of medication for each treatment track based on symptoms and lung function where appropriate. Refer to the GINA report for other treatment components, including treatment of modifiable risk factors and comorbidities, non-pharmacologic strategies, and education and skills training. Source: Box 3.4Bi in GINA report 2022. Reproduced with permission from ref. .

Fig. 6. Initial medications for children aged 6–11 years diagnosed with asthma.

BUD-FORM budesonide–formoterol, ICS inhaled corticosteroid, LABA long-acting beta₂ agonist, LTRA leukotriene receptor antagonist, MART maintenance and reliever therapy with ICS–formoterol, OCS oral corticosteroids, SABA short-acting beta₂ agonist. Initial treatment for children aged 6–11 years diagnosed with asthma, with guidance on initial levels of medication for each treatment track based on symptoms and lung function where appropriate. Source: Box 3–4Di in GINA report 2022. Refer to the GINA report for other treatment components, including treatment of modifiable risk factors and comorbidities, non-pharmacologic strategies, and education and skills training. Reproduced with permission from ref. .

Fig. 7. Investigating and managing difficult-to-treat asthma in adult and adolescent patients.

ICS inhaled corticosteroid, LABA long-acting beta₂ agonist, LAMA long-acting muscarinic antagonist, LTRA leukotriene receptor antagonists, SABA short-acting beta₂ agoinst, OCS oral corticosteroid. The GINA strategy includes a decision tree about the management of difficult-to-treat and severe asthma spanning primary through tertiary care. The section of the flow diagram applicable to generalists in primary and secondary care is shown here. Source: Box 3–16A in GINA report 2022. Reproduced with permission from ref. .

Fig. 8. Proportion of adults with difficult-to-treat or severe asthma.

Severe asthma is a subset of those with “difficult-to-treat” asthma. Source: Box 3–15 in GINA report 2022, data from Hekking et al.. Reproduced with permission from ref. .