Global Strategy for Asthma Management and Prevention 2024

Publication Date: May 7, 2024
Last Updated: May 7, 2024

Key Changes to the 2024 Guidance

  • Diagnosis of asthma: The diagnostic flowchart for clinical practice (Box 1-1) has been revised, recognizing that, globally, a large proportion of health professionals do not have access (or timely access) to spirometry in their clinical practice. Although peak expiratory flow (PEF) is less reliable than spirometry, it is better than relying on symptoms alone. The flowchart allows for selection of different initial lung function tests, depending on local resources. The criteria for identifying variable expiratory airflow limitation (Box 1-2) have also been clarified, and more details provided about bronchodilator withholding.
  • GINA again reviewed, but has not adopted, the recommendation by the American Thoracic Society and European Respiratory Society Technical Standards Committee to change the criterion for bronchodilator responsiveness from an increase from baseline of ≥12% and 200 mL to an increase from baseline of >10% predicted. The Technical Standards Committee based this recommendation on data for survival, and had explicitly avoided making any recommendation about the use of this criterion for diagnostic decisions in clinical practice. This topic will be considered by GINA again when data from additional populations, and for other asthma outcomes, have been published, to inform the implications of the proposed new criterion for diagnosis of asthma in clinical practice.
  • Cough variant asthma: more information has been added about this clinical phenotype of asthma, which is common in some countries. Cough variant asthma may be difficult to distinguish from other causes of chronic cough in clinical practice, as spirometry may be normal and variable airflow limitation may be identified only from bronchial provocation testing. Some patients may later also develop wheezing and bronchodilator responsiveness. The treatment of cough variant asthma is the same as for asthma in general; the cough may return if inhaled corticosteroids (ICSs) are stopped.
  • Assessment of asthma control: We clarify that assessment of symptom control should not be limited to the most recent 4 weeks, but that there are no validated tools for assessing symptom control over longer periods than this, and that recall-error for symptoms is common. GINA continues to emphasize that assessing symptom control is not enough – the patient’s risk factors for exacerbations (including history of exacerbations), for accelerated decline in lung function and for medication adverse effects must also be assessed (Box 2-2). While ICS markedly reduce asthma exacerbations and, in patients not taking ICS, serious exacerbations are associated with greater decline in lung function, there is no clear evidence that use of ICS per se prevents long-term development of persistent airflow limitation. GINA goal of asthma treatment (Box 3-2): The goal of asthma treatment is to achieve the best possible longterm asthma outcomes for the individual patient, including both long-term symptom control and long-term minimization of risk of exacerbations, lung function decline and medication adverse effects (including long-term adverse effects of OCS). It is also important to elicit the patient/caregiver’s goals for asthma treatment, as these may differ from medical goals.
  • Remission of asthma: There has been extensive recent discussion in the clinical and research community about asthma remission on treatment, in the context of biologic therapy for severe asthma. Several proposed definitions and criteria for their operationalization have been published. A new section of the GINA 2024 report outlines a framework for clinical practice and research about clinical and complete (pathophysiological) remission in children and in adults, both off-treatment and on-treatment. These perspectives should also be considered for discussions with patients and parents/caregivers. The concept of asthma remission on treatment is consistent with the GINA long-term goal of asthma treatment (Box 3-2), but individual patient goals should be achievable.
  • Initial asthma treatment in adults and adolescents (Tracks 1 and 2): Key changes have been made to the recommendations about the choice of initial treatment step for adults and adolescents in both Tracks 1 and 2, with updating of Boxes 4-4 and 4-5 about choice of initial treatment step. The suggested criteria at each step for initial treatment are based on evidence (where available) and on consensus, so the thresholds are not precise. The new flowchart for initial asthma treatment (Box 4-5) includes the GINA cycle of asthma management as a reminder that asthma treatment is not just about medications.
  • For Track 1, as-needed-only low-dose ICS-formoterol has been the preferred treatment option for both Step 1 and Step 2 since 2021, so together they are called ‘Steps 1–2’. Accordingly, the descriptions of evidence and other considerations are now also presented for Steps 1–2 together. A common question is which patients should instead start treatment at Step 3, i.e., with low-dose ICS-formoterol being taken as maintenance-and-reliever therapy (MART) rather than as-needed-only. There is no specific evidence to guide this choice, but clinical factors that are suggested for consideration of starting with MART (if permitted by local regulators) include symptoms every day, current smoking, low lung function, a recent severe exacerbation or a history of life-threatening exacerbation, impaired perception of bronchoconstriction (e.g. low initial lung function but few symptoms), severe airway hyperresponsiveness, or current exposure to a seasonal allergic trigger.
  • For Track 2, the previous description of patients suitable for Step 1 treatment (having asthma symptoms less than twice a month and no risk factors for exacerbations) was introduced in GINA 2014 to limit the use of short-acting beta2 agonist (SABA)-only treatment, as its risks in asthma were already well known.13 This criterion for Step 1 treatment has now been replaced, since GINA has recommended against SABA-only treatment since 2019. Another consideration for choosing between Step 1 and Step 2 treatment is that, although maintenance ICS almost halved the risk of serious exacerbations in patients with symptoms ≤2 days/week in a clinical trial, such patients would be very unlikely to take daily ICS if it was prescribed in clinical practice. Therefore, for patients with such infrequentsymptoms, taking ICS whenever SABA is taken (Track 2, Step 1) is preferred over daily ICS plus as-needed SABA (Track 2, Step 2) to ensure that patients receive at least some ICS, rather than taking SABA alone.
  • GINA 2024 treatment figure for adults and adolescents, Box 4-6,. There are no major changes from 2023 in the main treatment figure. In the arrowed circle (also Box 3-3), ‘asthma medications’ has been changed to ‘asthma medications including ICS’ as a reminder that all patients with asthma should receive ICS-containing therapy. New short versions of the main treatment figure are shown at the start of the sections of text about Steps 1–4 for Track 1 (Box 4-7) and Track 2 (Box 4-9) respectively.
  • Medications and doses for Track 1 anti-inflammatory reliever (AIR) therapy: Following requests from clinicians, Box 4-8, has been expanded to show all the relevant ICS-formoterol devices (dry-powder inhalers [DPIs] and pressurized metered-dose inhalers [pMDIs]) and doses for AIR therapy by age-group and treatment step, with the corresponding dosing regimens and maximum number of inhalations in a single day. More devices and doses may become available in the future.
  • Beclometasone-formoterol for MART (Box 4-7). There is evidence from randomized controlled trials and meta-analyses in approximately 40,000 patients for the long-term safety and efficacy of as-needed budesonideformoterol up to a maximum total of 72 mcg formoterol (54 mcg delivered dose) in a single day (total of as-needed and maintenance doses, if used) for adults and adolescents, together with data from earlier randomized controlled trials with as-needed formoterol. Based on this extensive evidence, GINA suggests that the same maximum total dose of formoterol (with ICS) in a single day (72 mcg metered dose) should also apply for adults and adolescents prescribed MART with beclometasone-formoterol 100/6 mcg, i.e. a maximum total of 12 inhalations in a single day. For children 6–11 years prescribed MART with budesonide-formoterol, the maximum recommended total dose of formoterol (with ICS) in a single day is 48 mcg metered dose (36 mcg delivered dose). Most patients need far fewer doses in any day than the maximum doses recommended.
  • ICS-formoterol as reliever with other ICS-LABAs: GINA previously recommended against use of ICS-formoterol as the reliever for patients using maintenance treatment with a combination of ICS and long-acting beta2 agonist (LABA) with a non-formoterol LABA, because of lack of evidence for safety or efficacy with this approach (p.69). This recommendation is now supported by an analysis suggesting that taking two different LABAs in this way may be associated with increased adverse events.
  • Leukotriene receptor antagonists: Wherever montelukast is mentioned throughout the report, there is a reminder to advise patients/parents/caregivers about the potential risk of neuropsychiatric adverse events associated with this medication. These include new-onset nightmares and behavioral problems and, in some cases, suicidal ideation. High-dose inhaled corticosteroids: Wherever this is suggested as a treatment option throughout the report for adults and adolescents, it is again stated that this is only for short-term use, e.g., 3–6 months, to minimize the potential for adverse effects.
  • Add-on long-acting muscarinic antagonists (LAMA): Subgroup analyses suggest that the reduction in severe exacerbations requiring OCS associated with triple therapy (ICS+LABA+LAMA) was seen primarily in patients with a history of asthma exacerbations in the previous year.
  • Severe asthma with good response to Type 2-targeted therapy: Advice about reduction in asthma therapy in patients who have had a good asthma response to therapy targeting Type 2 inflammation has been updated and clarified, with the highest priority to reduce and cease maintenance oral corticosteroids (OCS), if used. Some previous randomized controlled trials included a rapid ICS dose reduction in patients on biological therapies in order to induce loss of asthma control, but this is not relevant to clinical practice). A randomized controlled trial in adult patients with a good response to benralizumab found that, with randomization to MART, most could have their maintenance ICS-formoterol dose slowly reduced. However, the findings suggest that in patients with severe asthma, maintenance doses of ICS-formoterol should not be stopped. This study also provides support for use of MART in patients taking Step 5 treatment. Additional advice about stepping down treatment once asthma is well controlled is in Box 4-13.
  • Initial asthma treatment in children 6–11 years: Boxes 4-10 and 4-11 about initial asthma treatment in children 6–11 years have been updated. These recommendations are based on evidence (where available) and on consensus. The flowchart includes the GINA cycle of asthma management, as a reminder that asthma treatment is not just about medications. Symptom levels and lung function prompting a particular starting treatment step are similar to those for adults and adolescents. In the text about treatment steps, additional details about studies, populations and outcomes in the 6–11 years age group have been added, including the ICS doses used in the studies of taking ICS whenever SABA is taken .
  • Low, medium and high doses of inhaled corticosteroids. Box 4-2 lists low, medium and high doses of various ICS, alone or in combination with LABA. GINA has emphasized for many years that this table does not imply potency equivalence, but this continues to be assumed. For clarity, an example has been added: if you switch a patient’s treatment from a ‘medium’ dose of one ICS to a ‘medium’ dose of another ICS, this may represent a decrease (or increase) in potency, so the patient’s asthma may become unstable (or they may be at increased risk of adverse effects). After any change of treatment or inhaler device, patients should be monitored to ensure stability.
  • Allergen immunotherapy. The section on allergen immunotherapy has been updated following a systematic review of publications about subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) for asthma by a GINA Science Committee working group. Information is also included about the quality assurance, personnel, training, safety and administrative protocols that must be observed for preparation and safe delivery of SCIT. For patients with severe asthma, allergen immunotherapy may be considered as an add-on treatment, but only after asthma symptoms and exacerbations have been controlled.

Asthma Definition and Diagnosis

What is asthma?

  • Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms, such as wheeze, shortness of breath, chest tightness and cough, that vary over time and in intensity, together with variable expiratory airflow limitation. One or more symptoms (e.g., cough) may predominate. Airflow limitation may later become persistent.
  • Asthma is usually associated with airway hyperresponsiveness and airway inflammation, but these are not necessary or sufficient to make the diagnosis.
  • Recognizable clusters of demographic and clinical characteristics are called ‘clinical asthma phenotypes’. In most instances, these do not correlate strongly with specific pathological processes or treatment responses. However, biomarkers reflecting pathophysiological processes are useful in the assessment of difficult-to-treat asthma and treatment of severe asthma.

Overview

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Global Strategy for Asthma Management and Prevention

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