Symptom versus exacerbation control: an evolution in GINA guidelines?

Abstract

The article traces the concept of asthma control within GINA guidelines over the past 25 years. In the first 15 years after 1995, the main objective of asthma management was to obtain the control of all clinical and functional characteristics of asthma. A landmark study (GOAL) showed for the first time that a good control of asthma is a reasonable outcome that can be achieved in a large proportion of asthmatics with a regular appropriate treatment. In the following years, more emphasis was placed on the role of exacerbations as critical manifestations of poor asthma control, whose frequency is associated with excessive FEV1 decline and increased risk of death. Accordingly, the 2014 GINA report makes a clear distinction between the control of the day-by-day symptoms and the reduction in the risk of severe exacerbations, stating that both conditions should be obtained. The 2019 update included a significant change in the management of mild asthma, prioritizing the prevention of exacerbations to that of mild symptoms. This view was repeated in the 2021 update, where the prevention of exacerbations, together with an acceptable symptom control with a minimal use of rescue medication, appeared to be the real main goal of asthma management. While a discrepancy between current symptoms and exacerbations may be present in mild asthma, a significant relationship between these two features is observed in moderate-severe asthma: a persistent poor symptom control is a major risk factor for exacerbations, whereas achieving symptom control through regular treatment is associated with a reduction in exacerbation rate. Thus, the opinion that frequent symptoms are not important in the absence of acute exacerbations should be discouraged, whereas education of patients to a good symptom perception and to improve adherence to regular treatment should be implemented. Furthermore, the persistence of risk factors, such as increased airway inflammation, even in a patient with minor daily symptoms, should be considered for optimizing treatment.

Keywords: GINA guidelines; asthma control; asthma exacerbation; regular pharmacologic treatment; rescue medication use.

Figure 1.

Control of asthma according to Global Initiative for Asthma (GINA) in documents between 2002 and 2005. Adapted from Global Initiative for Asthma, www.ginasthma.org.

Figure 2.

Definition of well-controlled and totally controlled asthma used in the GOAL study. Adapted from: Bateman et al. ^aSymptom score: 1 was defined as ‘symptoms for one short period during the day’. Overall scale: 0 (none) to 5 (severe). ^bExacerbations were defined as deterioration in asthma requiring treatment with oral corticosteroid or emergency department visit or hosptalization.

Figure 3.

Levels of asthma control according to Global Initiative for Asthma (GINA) in documents between 2006 and 2013. Adapted from Global Initiative for Asthma, www.ginasthma.org.

Figure 4.

GINA assessment of asthma control in adults, adolescents, and children 6–11 years, according to GINA documents from 2014. Adapted from: Global Initiative for Asthma, www.ginasthma.org, update 2014. GINA, Global Initiative for Asthma.

Figure 5.

Current level of control may predict the risk of future exacerbations: (a) Future risk of exacerbations using ACQ-5 at randomization as a predictor. Mean number of exacerbations over time stratified by ACQ-5 at randomization. (b) Data pooled from all patients randomized to budesonide/formoterol maintenance and reliever therapy or higher maintenance dose ICS/LABA plus SABA (n = 5480). ACQ-5 < 0.50, n = 355; ACQ-5 ⩾ 0.50–<0.75, n = 250; ACQ-5 ⩾ 0.75–<1.00, n = 261; ACQ-5 ⩾ 1.00–<1.25, n = 686; ACQ-5 ⩾ 1.25–<1.50, n = 345; ACQ-5 ⩾ 1.50, n = 3583. Adapted from Bateman et al.