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The diagnosis of asthma is based on a history of variable respiratory symptoms and demonstration of
variable expiratory airflow limitation
Test before treating, wherever possible
Symptoms, variability in lung function, and airway hyperresponsiveness are decreased by ICS, so it is often
more difficult to confirm the diagnosis after controller treatment is started
The flow-chart (Box 1-1) has been updated in 2022 to emphasize the different approach for initial
diagnosis compared with confirming the diagnosis in patients taking controller treatment
Diagnostic approaches for patients taking controller treatment are in Boxes 1-3 and 1-4
At a global level, spirometry before and after bronchodilator is the most useful initial investigation
Optimize the conditions for testing, if possible (e.g. when symptomatic, and after withholding bronchodilators)
In patients on controller treatment, more than one test is often needed
GINA will review GRADE evidence from ERS Task Force on diagnosis of asthma (Louis et al, ERJ 2022)
STEP 5
STEP 4 Add-on LAMA
Medium/high Refer for assessment
STEP 3 of phenotype. Consider
Low dose dose maintenance
CONTROLLER and STEP 2 ICS-LABA high dose maintenance
ALTERNATIVE RELIEVER STEP 1 Low dose maintenance ICS-LABA, ± anti-IgE,
(Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R,
regimen with SABA reliever, SABA taken anti-TSLP
check if the patient is likely to be
RELIEVER: As-needed short-acting beta2-agonist
adherent with daily controller
STEP 5
STEP 4 Add-on LAMA
Medium/high Refer for assessment
STEP 3 of phenotype. Consider
Low dose dose maintenance
CONTROLLER and STEP 2 ICS-LABA high dose maintenance
ALTERNATIVE RELIEVER STEP 1 Low dose maintenance ICS-LABA, ± anti-IgE,
(Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R,
regimen with SABA reliever, SABA taken anti-TSLP
check if the patient is likely to be
RELIEVER: As-needed short-acting beta2-agonist
adherent with daily controller
GINA 2022, Box 3-5A, 1/4 © Global Initiative for Asthma, www.ginasthma.org
Adults & adolescents Confirmation of diagnosis if necessary
Symptom control & modifiable
12+ years risk factors (see Box 2-2B)
Comorbidities
Personalized asthma management Inhaler technique & adherence
Patient preferences and goals
Assess, Adjust, Review
for individual patient needs
Symptoms
Exacerbations
Side-effects
Treatment of modifiable risk factors
Lung function and comorbidities
Patient Non-pharmacological strategies
satisfaction Asthma medications (adjust down/up/between tracks)
Education & skills training
STEP 5 STEP 5
Add-on LAMA
STEP 4 Add-on LAMA
STEP 4
Medium dose
Refer for assessment
STEP 3 Refer
of phenotype. for assessment
Consider
STEP Medium dose
CONTROLLER and STEPS 1 – 2 Low dose 3 maintenance of phenotype.
high dose maintenance Consider
CONTROLLER and RELIEVER Low dose
maintenance maintenance
ICS-formoterol high dose maintenance
ICS-formoterol,
PREFERRED STEPS 1 – low
As-needed 2 dose ICS-formoterol
PREFERRED(Track 1).RELIEVER
Using ICS-formoterol ICS-formoterol
maintenance ICS-formoterol ± anti-IgE,ICS-formoterol,
anti-IL5/5R,
As-needed low dose ICS-formoterol anti-IL4R, ±anti-TSLP
asUsing
(Track 1). relieverICS-formoterol
reduces the risk of ICS-formoterol anti-IgE, anti-IL5/5R,
exacerbations
as reliever reduces the compared
risk of with anti-IL4R, anti-TSLP
See GINA
RELIEVER: As-needed low-dose ICS-formoterol severe
using a SABA reliever
exacerbations compared with asthma guide
using a SABA reliever RELIEVER: As-needed low-dose ICS-formoterol
STEP 5
STEP 4 Add-on LAMA
Medium/high Refer for assessment
STEP 3 of phenotype. Consider
Low dose dose maintenance
CONTROLLER and STEP 2 ICS-LABA high dose maintenance
ALTERNATIVE RELIEVER STEP 1 Low dose maintenance ICS-LABA, ± anti-IgE,
(Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R,
regimen with SABA reliever, SABA taken anti-TSLP
check if the patient is likely to be
RELIEVER: As-needed short-acting beta2-agonist
adherent with daily controller
GINA 2022, Box 3-5A, 2/4 © Global Initiative for Asthma, www.ginasthma.org
Adults & adolescents Confirmation of diagnosis if necessary
Symptom control & modifiable
12+ years risk factors (see Box 2-2B)
Comorbidities
Personalized asthma management Inhaler technique & adherence
Patient preferences and goals
Assess, Adjust, Review
for individual patient needs
Symptoms
Exacerbations
Side-effects
Treatment of modifiable risk factors
Lung function and comorbidities
Patient Non-pharmacological strategies
satisfaction Asthma medications (adjust down/up/between tracks)
Education & skills training
STEP 5
Add-on LAMA
STEP 4
Refer for assessment
STEP 3 Medium dose of phenotype. Consider
CONTROLLER and Low dose maintenance high dose maintenance
STEPS 1 – 2 ICS-formoterol
PREFERRED RELIEVER maintenance ICS-formoterol,
As-needed low dose ICS-formoterol
(Track 1). Using ICS-formoterol ICS-formoterol ± anti-IgE, anti-IL5/5R,
as reliever reduces the risk of anti-IL4R, anti-TSLP
exacerbations compared with See GINA
RELIEVER: As-needed low-dose ICS-formoterol STEP 5 severe
using a SABA reliever
Add-on LAMA asthma guide
STEP 4
Medium/high STEP 5Refer for assessment
STEP 3 of phenotype. Consider
4 maintenanceAdd-on LAMA
STEPdose
CONTROLLER and STEP 2 Low dose Medium/high Refer for high dose maintenance
assessment
STEP 3
maintenance ICS-LABA
ALTERNATIVE RELIEVER STEP 1 Low dose Low dose dose maintenance of phenotype. Consider ± anti-IgE,
ICS-LABA,
CONTROLLER and
Take ICS whenever STEP 2 ICS-LABA high dose maintenance
anti-IL5/5R, anti-IL4R,
(Track 2). Before considering a maintenance ICS maintenance ICS-LABA
ALTERNATIVE RELIEVER STEP
SABA taken1 Low dose ICS-LABA,anti-TSLP
± anti-IgE,
regimen (Track
with SABA reliever,
2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R,
check if the patient
regimen with is likelyreliever,
SABA to be SABA taken anti-TSLP
RELIEVER: As-needed short-acting beta2-agonist
adherentcheck
with ifdaily controller
the patient is likely to be
RELIEVER: As-needed short-acting beta2-agonist
adherent with daily controller
GINA 2022, Box 3-5A, 3/4 © Global Initiative for Asthma, www.ginasthma.org
Adults & adolescents Confirmation of diagnosis if necessary
Symptom control & modifiable
12+ years risk factors (see Box 2-2B)
Comorbidities
Personalized asthma management Inhaler technique & adherence
Patient preferences and goals
Assess, Adjust, Review
for individual patient needs
Symptoms
Exacerbations
Side-effects
Treatment of modifiable risk factors
Lung function and comorbidities
Patient Non-pharmacological strategies
satisfaction Asthma medications (adjust down/up/between tracks)
Education & skills training
STEP 5
Add-on LAMA
STEP 4
Refer for assessment
STEP 3 Medium dose of phenotype. Consider
CONTROLLER and Low dose maintenance high dose maintenance
STEPS 1 – 2 ICS-formoterol
PREFERRED RELIEVER maintenance ICS-formoterol,
As-needed low dose ICS-formoterol
(Track 1). Using ICS-formoterol ICS-formoterol ± anti-IgE, anti-IL5/5R,
as reliever reduces the risk of anti-IL4R, anti-TSLP
exacerbations compared with See GINA
RELIEVER: As-needed low-dose ICS-formoterol severe
using a SABA reliever
asthma guide
STEP 5
STEP 4 Add-on LAMA
Medium/high Refer for assessment
STEP 3 of phenotype. Consider
Low dose dose maintenance
CONTROLLER and STEP 2 ICS-LABA high dose maintenance
ALTERNATIVE RELIEVER STEP 1 Low dose maintenance ICS-LABA, ± anti-IgE,
(Track 2). Before considering a Take ICS whenever maintenance ICS ICS-LABA anti-IL5/5R, anti-IL4R,
regimen with SABA reliever, SABA taken anti-TSLP
check if the
Other controller patientfor
options is likely
eitherto be Add azithromycin (adults) or
RELIEVER:
Low dose ICS whenever As-needed short-acting
Medium dose ICS, or beta2-agonist
Add LAMA or LTRA or
LTRA. As last resort consider
adherent with daily controller
track (limited indications, or less SABA taken, or daily LTRA, add LTRA, or add HDM SLIT, or switch to
adding low dose OCS but
evidence for efficacy or safety) or add HDM SLIT HDM SLIT high dose ICS
consider
Add azithromycin side-effects
(adults) or
Other controller options for either Low dose ICS whenever Medium dose ICS, or Add LAMA or LTRA or
HDM SLIT, or switch to LTRA. As last resort consider
track (limited indications, or less SABA taken, or daily LTRA, add LTRA, or add
high dose ICS adding low dose OCS but
or add HDM SLIT HDM SLIT
evidence for efficacy or safety) consider side-effects
GINA 2022, Box 3-5A, 4/4 © Global Initiative for Asthma, www.ginasthma.org
Background - the risks of ‘mild’ asthma
Patients with apparently mild asthma are still at risk of serious adverse events
30–37% of adults with acute asthma
16% of patients with near-fatal asthma had symptoms less than weekly in previous 3
months (Dusser, Allergy 2007; Bergstrom, 2008)
15–27% of adults dying of asthma
Exacerbation triggers are unpredictable (viruses, pollens, pollution, poor adherence)
Even 4–5 lifetime OCS courses increase the risk of osteoporosis, diabetes, cataract (Price et al, J Asthma
Allerg 2018)
Inhaled SABA has been first-line treatment for asthma for 50 years
Asthma was thought to be a disease of bronchoconstriction
Role of SABA reinforced by rapid relief of symptoms and low cost
Regular use of SABA, even for 1–2 weeks, is associated with increased AHR, reduced bronchodilator
effect, increased allergic response, increased eosinophils (e.g. Hancox, 2000; Aldridge, 2000)
Can lead to a vicious cycle encouraging overuse
Over-use of SABA associated with exacerbations and
mortality (e.g. Suissa 1994, Nwaru 2020)
Starting treatment with SABA trains the patient to
regard it as their primary asthma treatment
The only previous option was daily ICS even when
no symptoms, but adherence is extremely poor
GINA changed its recommendation once evidence for
a safe and effective alternative was available
Long-acting muscarinic antagonists (LAMA) should not be used as monotherapy for asthma
(i.e. without ICS) because of increased risk of severe exacerbations (Baan, Pulm Pharmacol Ther 2021)
Adding LAMA to ICS-LABA: GRADE review and meta-analysis (Kim, JAMA 2021) confirms previous findings
Small increase in lung function (mean difference 0.08 L)
No clinically important benefits for symptoms or quality of life don’t prescribe for dyspnea
Modest overall reduction in exacerbations compared with ICS-LABA (risk ratio 0.83 [0.77, 0.90])
Patients with exacerbations should receive at least medium dose ICS-LABA before considering add-on LAMA
Chromone pMDIs (sodium cromoglycate, nedocromil sodium) have been discontinued globally
© Global Initiative for Asthma, www.ginasthma.org
Management of asthma in low- and middle-income countries
96% of asthma deaths are in low- and middle-income countries (LMIC) (Meghji, Lancet 2021)
Much of this burden is avoidable, especially with ICS (e.g. Comaru, Respir Med 2016)
Barriers include lack of access to essential medications, and prioritization of acute care over chronic care by
health systems (Mortimer, ERJ 2022)
Lack of access to affordable quality-assured inhaled medications (Stolbrink, review for WHO 2022)
Oral bronchodilators have slow onset of action and more side-effects than inhaled
OCS are associated with serious cumulative adverse effects (e.g. sepsis, cataract, osteoporosis) even with
occasional courses (Price, J Asthma Allerg 2018)
GINA supports the initiative by IUATLD towards a World Health Assembly Resolution on equitable
access to affordable care for asthma, including inhaled medicines
In the meantime, if Track 1 is not available due to lack of access or affordability, Track 2 treatment may be
preferable, although less effective in reducing exacerbations
If Track 2 options also not available, taking ICS whenever SABA is taken may be preferable to LTRA or
maintenance OCS because of concerns about efficacy and/or safety
Greatest overall benefit at a population level would be from increasing access to ICS-formoterol
Additional investigations
Consider screening for adrenal insufficiency if patient is on maintenance OCS or high dose ICS-LABA
For patients with eosinophils ≥300/µl, investigate for non-asthma causes including Strongyloides (often
asymptomatic), before considering biologic therapy
For patients with hypereosinophilia, e.g. ≥1500/µl, investigate for conditions such as EGPA
Assessment of inflammatory phenotype
If blood eosinophils or FeNO not elevated, repeat up to 3 times, at least 1–2 weeks after stopping
OCS, or on lowest possible OCS dose
Treatment options for patients with no evidence of Type 2 inflammation on repeated testing
Consider add-on treatment with LAMA or low-dose azithromycin if not already tried
Can also consider anti-IL4R* (if on maintenance OCS) or anti-TSLP* (but insufficient evidence with
maintenance OCS)
Consider maintenance OCS only as last resort, because of serious cumulative adverse effects
*Check local eligibility criteria for specific biologic therapies; TSLP: thymic stromal lymphopoietin
© Global Initiative for Asthma, www.ginasthma.org
© Global Initiative for Asthma 2022, www.ginasthma.org
© Global Initiative for Asthma 2022, www.ginasthma.org
© Global Initiative for Asthma 2022, www.ginasthma.org
© Global Initiative for Asthma 2022, www.ginasthma.org
Changes to treatment figure in children 6–11 years (Box 3-5B)
Symptoms
Exacerbations
Side-effects
Lung function Treatment of modifiable risk factors
Child and parent & comorbidities
satisfaction Non-pharmacological strategies STEP 5
Asthma medications (adjust down or up)
Education & skills training Refer for
phenotypic
Asthma medication options: assessment
STEP 4
Adjust treatment up and down for ± higher dose
individual child’s needs Medium dose ICS-LABA or
STEP 3
ICS-LABA, add-on therapy,
STEP 2 Low dose ICS- OR low dose† e.g. anti-IgE,
PREFERRED STEP 1 LABA, OR medium ICS-formoterol
Daily low dose inhaled corticosteroid (ICS) anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children)
to prevent exacerbations very low dose* and reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
maintenance and Refer for expert
reliever (MART) advice
Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
Other controller options
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
Other controller options
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations STEP 5
Side-effects
Lung function Treatment of modifiable risk factors
Asthma medication options: Child and parent & comorbidities
Adjust treatment up and down for
satisfaction Non-pharmacological strategiesSTEP 4 STEP 5
Asthma medications (adjust down or up)
individual child’s needs STEP 3 training Refer for
Education & skills
phenotypic
Asthma medication options: STEP 2
STEP 4 assessment
PREFERRED
Adjust treatment up STEP
and down
1 for ± higher dose
CONTROLLER
individual child’s needs Medium dose ICS-LABA or
Low dose ICS STEP 3
to prevent exacerbations ICS-LABA, add-on therapy,
and control symptoms taken whenever STEP 2 Low dose ICS- OR low dose† e.g. anti-IgE,
PREFERRED SABASTEP
taken 1 Daily low dose inhaled corticosteroid (ICS) LABA, OR medium ICS-formoterol anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children)
to prevent exacerbations very low dose* and reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
Consider daily maintenance and Refer for expert
Other controller options reliever (MART)
(limited indications, or low dose ICS advice
less evidence for efficacy
or safety)Other controller options Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations STEP 5
Side-effects
Lung function Treatment of modifiable risk factors
Asthma medication options: Child and parent & comorbidities
Adjust treatment up and down for
satisfaction Non-pharmacological strategiesSTEP 4 STEP 5
Asthma medications (adjust down or up)
individual child’s needs STEP 3 training Refer for
Education & skills
phenotypic
Asthma medication options: STEP 2
STEP 4 assessment
PREFERRED
Adjust treatment up STEP
and down
1 for ± higher dose
Daily low dose inhaled corticosteroid (ICS) Medium dose
CONTROLLER
individual child’s needs STEP 3 ICS-LABA or
(see table of ICS dose ranges for children) ICS-LABA,
to prevent exacerbations add-on therapy,
STEP 2 Low dose ICS- OR low dose†
and control symptoms e.g. anti-IgE,
PREFERRED STEP 1 LABA, OR medium ICS-formoterol
Daily low dose inhaled corticosteroid (ICS) anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children)
to prevent exacerbations very low dose* and reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
Daily leukotriene receptor antagonist (LTRA), or maintenance and Refer for expert
Other controller options reliever (MART)
(limited indications, or low dose ICS taken whenever SABA taken advice
less evidence for efficacy
or safety)Other controller options Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations STEP 5
Side-effects
Lung function Treatment of modifiable risk factors
Asthma medication options: Child and parent & comorbidities
Adjust treatment up and down for
satisfaction Non-pharmacological strategiesSTEP 4 STEP 5
Asthma medications (adjust down or up)
individual child’s needs STEP 3 training Refer for
Education & skills
phenotypic
Asthma medication options: STEP 2 Low dose ICS-
STEP 4 assessment
PREFERRED
Adjust treatment up STEP
and down
1 for LABA, OR medium ± higher dose
CONTROLLER
individual child’s needs dose 3 ICS, OR Medium dose ICS-LABA or
STEP
to prevent exacerbations very low dose* ICS-LABA, add-on therapy,
STEP 2 Low dose ICS- OR low dose†
and control symptoms ICS-formoterol e.g. anti-IgE,
PREFERRED STEP 1 LABA, OR medium ICS-formoterol
Daily low dose inhaled corticosteroid (ICS) maintenance and anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children) reliever (MART)
to prevent exacerbations very low dose* and reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
maintenance
Low dose and Refer for expert
Other controller options reliever
(limited indications, or ICS + (MART)
LTRA advice
less evidence for efficacy
or safety)Other controller options Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations STEP 5
Side-effects
Lung function Treatment of modifiable risk factors
Asthma medication options: Child and parent & comorbidities
Adjust treatment up and down for
satisfaction Non-pharmacological strategiesSTEP 4 STEP 5
Asthma medications (adjust down or up) dose
Medium
individual child’s needs STEP 3 training Refer for
Education & skills ICS-LABA, phenotypic
Asthma medication options: STEP 2 OR low dose† assessment
STEP 4
PREFERRED
Adjust treatment up STEP
and down
1 for ICS-formoterol ± higher dose
CONTROLLER
individual child’s needs Medium dose
maintenance ICS-LABA or
STEP 3
to prevent exacerbations ICS-LABA,
and reliever add-on therapy,
STEP 2 Low dose ICS- OR therapy
low dose(MART).
†
and control symptoms e.g. anti-IgE,
PREFERRED STEP 1 LABA, OR medium ICS-formoterol
Daily low dose inhaled corticosteroid (ICS) Refer for expert
anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children)
to prevent exacerbations very low dose* andadvice
reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
maintenance and Add
Refer for tiotropium
expert
Other controller options reliever (MART)
(limited indications, or or add LTRA
advice
less evidence for efficacy
or safety)Other controller options Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on anti-IL5
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as last resort,
less evidence for efficacy consider add-on
or safety) low dose OCS, but
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations STEP 5
Side-effects
Lung function Refer for
Treatment of modifiable risk factors phenotypic
Asthma medication options: Child and parent & comorbidities
assessment
Adjust treatment up and down for
satisfaction Non-pharmacological strategiesSTEP 4 STEP± 5higher dose
Asthma medications (adjust down or up)
individual child’s needs STEP 3 training Refer ICS-LABA
for or
Education & skills
add-on therapy,
phenotypic
Asthma medication options: STEP 2
STEP 4 e.g. anti-IgE,
assessment
PREFERRED
Adjust treatment up STEP
and down
1 for ± higher dose
anti-IL4R
CONTROLLER
individual child’s needs Medium dose ICS-LABA or
STEP 3
to prevent exacerbations ICS-LABA, add-on therapy,
STEP 2 Low dose ICS- OR low dose†
and control symptoms e.g. anti-IgE,
PREFERRED STEP 1 LABA, OR medium ICS-formoterol
Daily low dose inhaled corticosteroid (ICS) anti-IL4R
CONTROLLER dose ICS, OR maintenance
Low dose ICS (see table of ICS dose ranges for children)
to prevent exacerbations very low dose* and reliever
and control symptoms taken whenever
ICS-formoterol therapy (MART).
SABA taken
maintenance and Refer for expert Add-on anti-IL5
Other controller options reliever (MART)
(limited indications, or advice or, as last resort,
less evidence for efficacy consider add-on
or safety)Other controller options Consider daily Daily leukotriene receptor antagonist (LTRA), or Low dose Add tiotropium Add-on low dose OCS, but
anti-IL5
(limited indications, or low dose ICS low dose ICS taken whenever SABA taken ICS + LTRA or add LTRA or, as consider
last resort,side-effects
less evidence for efficacy consider add-on
or safety) low dose OCS, but
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
consider side-effects
RELIEVER As-needed short-acting beta2-agonist (or ICS-formoterol reliever in MART in Steps 3 and 4)
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Treat modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications
Asthma medication options: Education & skills training
STEP 4
Adjust treatment up and down for
individual child’s needs STEP 3 Continue
STEP 2 controller & refer
Double ‘low for specialist
STEP 1
PREFERRED Daily low dose inhaled corticosteroid (ICS) dose’ ICS assessment
CONTROLLER (see table of ICS dose ranges for pre-school children)
CHOICE
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
(limited indications, or short course ICS at intermittent short course of ICS at onset of Consider specialist ICS frequency, or add
less evidence for efficacy onset of viral illness respiratory illness referral intermittent ICS
or safety)
CONSIDER
THIS STEP FOR Infrequent viral Symptom pattern not consistent with asthma but wheezing Asthma diagnosis, and Asthma not
CHILDREN WITH: wheezing and no episodes requiring SABA occur frequently, e.g. ≥3 per year. asthma not well-controlled well-controlled
or few interval Give diagnostic trial for 3 months. Consider specialist referral. on low dose ICS on double ICS
symptoms Symptom pattern consistent with asthma, and asthma Before stepping up, check for alternative diagnosis,
symptoms not well-controlled or ≥3 exacerbations per year. check inhaler skills, review adherence and exposures
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
(limited indications, or short course ICS at intermittent short course of ICS at onset of Consider specialist ICS frequency, or add
less evidence for efficacy onset of viral illness respiratory illness referral intermittent ICS
or safety)
CONSIDER
THIS STEP FOR Infrequent viral Symptom pattern not consistent with asthma but wheezing Asthma diagnosis, and Asthma not
CHILDREN WITH: wheezing and no episodes requiring SABA occur frequently, e.g. ≥3 per year. asthma not well-controlled well-controlled
or few interval Give diagnostic trial for 3 months. Consider specialist referral. on low dose ICS on double ICS
symptoms Symptom pattern consistent with asthma, and asthma Before stepping up, check for alternative diagnosis,
symptoms not well-controlled or ≥3 exacerbations per year. check inhaler skills, review adherence and exposures
Symptoms
Asthma medication options:
Exacerbations STEP 4
Adjust treatment up and down for Side-effects
individual child’s needs Parent satisfaction STEP 3
Treat modifiable risk factors
STEP 2 and comorbidities
Non-pharmacological strategies
STEP 1
PREFERRED Asthma medications
CONTROLLER
Asthma medication options: Education & skills training
STEP 4
CHOICEAdjust treatment up and down for
individual child’s needs STEP 3 Continue
Other controller options Consider intermittent STEP 2 controller & refer
(limited indications, or short course ICS at Double ‘low
STEP 1 for specialist
less evidence for
PREFERRED efficacy onset of viral illness Daily low dose inhaled corticosteroid (ICS) dose’ ICS
or safety) assessment
CONTROLLER (see table of ICS dose ranges for pre-school children)
CHOICE
RELIEVER As-needed short-acting beta2-agonist
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
CONSIDER
(limited indications, or Infrequent
short course
viral ICS at intermittent short course of ICS at onset of Consider specialist ICS frequency, or add
THIS STEP FOR for efficacy
less evidence
wheezing andviral
onset of no illness respiratory illness referral intermittent ICS
CHILDREN WITH:
or safety)
or few interval
RELIEVER symptoms As-needed short-acting beta2-agonist
CONSIDER
THIS STEP FOR Infrequent viral Symptom pattern not consistent with asthma but wheezing Asthma diagnosis, and Asthma not
CHILDREN WITH: wheezing and no episodes requiring SABA occur frequently, e.g. ≥3 per year. asthma not well-controlled well-controlled
or few interval Give diagnostic trial for 3 months. Consider specialist referral. on low dose ICS on double ICS
symptoms Symptom pattern consistent with asthma, and asthma Before stepping up, check for alternative diagnosis,
symptoms not well-controlled or ≥3 exacerbations per year. check inhaler skills, review adherence and exposures
Symptoms
Asthma medication options:
Exacerbations STEP 4
Adjust treatment up and down for Side-effects
individual child’s needs Parent satisfaction STEP 3
Treat modifiable risk factors
STEP 2 and comorbidities
Non-pharmacological strategies
STEP 1
PREFERRED Daily low dose inhaled corticosteroid (ICS) Asthma medications
CONTROLLER
Asthma medication options: (see table of ICS dose ranges for pre-school children)
Education & skills training
STEP 4
CHOICEAdjust treatment up and down for
individual child’s needs STEP 3 Continue
Other controller options Daily leukotriene
STEP 2 receptor antagonist (LTRA), or controller & refer
(limited indications, or intermittent short course of ICS at onset of Double ‘low
STEP 1 for specialist
less evidence for efficacy
PREFERRED respiratory
Daily lowillness
dose inhaled corticosteroid (ICS) dose’ ICS
or safety) assessment
CONTROLLER (see table of ICS dose ranges for pre-school children)
CHOICE
RELIEVER As-needed short-acting beta2-agonist
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
CONSIDER
(limited indications, or short course ICS at Symptom
intermittent shortnot
pattern course of ICS atwith
consistent onset of
asthma but wheezing Consider specialist ICS frequency, or add
THIS STEP FOR for efficacy
less evidence onset of viral illness episodes
respiratory illness referral intermittent ICS
CHILDREN WITH:
or safety) requiring SABA occur frequently, e.g. ≥3 per year.
Give diagnostic trial for 3 months. Consider specialist referral.
RELIEVER Symptom pattern consistent with asthma, and asthmashort-acting
As-needed beta2-agonist
Symptoms
Asthma medication options:
Exacerbations STEP 4
Adjust treatment up and down for Side-effects
individual child’s needs Parent satisfaction STEP 3
Treat modifiable risk factors
STEP 2 and comorbidities
STEP 1
Double
Non-pharmacological ‘low
strategies
PREFERRED Asthma medicationsdose’ ICS
CONTROLLER
Asthma medication options: Education & skills training
STEP 4
CHOICEAdjust treatment up and down for
individual child’s needs STEP 3 Continue
Other controller options STEP 2 Low dose ICS + LTRA controller & refer
(limited indications, or Double ‘low specialist
Consider
STEP 1 for specialist
less evidence for efficacy
PREFERRED Daily low dose inhaled corticosteroid (ICS) referral
dose’ ICS
or safety) assessment
CONTROLLER (see table of ICS dose ranges for pre-school children)
CHOICE
RELIEVER As-needed short-acting beta2-agonist
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
CONSIDER
(limited indications, or short course ICS at intermittent short course of ICS at onset of Consider
Asthma diagnosis, and ICS frequency, or add
specialist
THIS STEP FOR for efficacy
less evidence onset of viral illness respiratory illness referral intermittent ICS
asthma not well-controlled
CHILDREN WITH:
or safety)
on low dose ICS
RELIEVER As-needed short-acting beta2-agonist
Before stepping up, check for alternative diagnosis,
CONSIDER check inhaler skills, review adherence and exposures
THIS STEP FOR Infrequent viral Symptom pattern not consistent with asthma but wheezing Asthma diagnosis, and Asthma not
CHILDREN WITH: wheezing and no episodes requiring SABA occur frequently, e.g. ≥3 per year. asthma not well-controlled well-controlled
or few interval Give diagnostic trial for 3 months. Consider specialist referral. on low dose ICS on double ICS
symptoms Symptom pattern consistent with asthma, and asthma Before stepping up, check for alternative diagnosis,
symptoms not well-controlled or ≥3 exacerbations per year. check inhaler skills, review adherence and exposures
Symptoms
Asthma medication options:
Exacerbations STEP 4
Adjust treatment up and down for Side-effects
individual child’s needs Parent satisfaction STEP 3 Continue
Treat modifiable risk factors
STEP 2 and comorbidities controller & refer
Non-pharmacological strategies for specialist
STEP 1
PREFERRED Asthma medications assessment
CONTROLLER
Asthma medication options: Education & skills training
STEP 4
CHOICEAdjust treatment up and down for
individual child’s needs STEP 3 Continue
Other controller options STEP 2 Add<RA,
controller refer or increase
(limited indications, or Double ‘low ICS frequency, or add
STEP 1 for specialist
less evidence for efficacy
PREFERRED Daily low dose inhaled corticosteroid (ICS) dose’ ICS intermittent ICS
or safety) assessment
CONTROLLER (see table of ICS dose ranges for pre-school children)
CHOICE
RELIEVER As-needed short-acting beta2-agonist
Other controller options Consider intermittent Daily leukotriene receptor antagonist (LTRA), or Low dose ICS + LTRA Add LTRA, or increase
CONSIDER
(limited indications, or short course ICS at intermittent short course of ICS at onset of Consider specialist ICS frequency,
Asthma or notadd
THIS STEP FOR for efficacy
less evidence onset of viral illness respiratory illness referral intermittent ICS
well-controlled
CHILDREN WITH:
or safety)
on double ICS
RELIEVER As-needed short-acting beta2-agonist
Before stepping up, check for alternative diagnosis,
CONSIDER check inhaler skills, review adherence and exposures
THIS STEP FOR Infrequent viral Symptom pattern not consistent with asthma but wheezing Asthma diagnosis, and Asthma not
CHILDREN WITH: wheezing and no episodes requiring SABA occur frequently, e.g. ≥3 per year. asthma not well-controlled well-controlled
or few interval Give diagnostic trial for 3 months. Consider specialist referral. on low dose ICS on double ICS
symptoms Symptom pattern consistent with asthma, and asthma Before stepping up, check for alternative diagnosis,
symptoms not well-controlled or ≥3 exacerbations per year. check inhaler skills, review adherence and exposures
By the ATS/ERS Task Force definition, asthma severity is assessed retrospectively from the
treatment required to control the patient’s asthma, i.e. after at least several months of treatment
(Taylor, ERJ 2008; Reddel, AJRCCM 2009)
By this definition, asthma severity can be assessed only when treatment has been optimized and asthma is
well-controlled, except for patients taking high dose ICS-LABA
Severe asthma is asthma that remains uncontrolled despite optimized treatment with high dose ICS-
LABA, or that requires high dose ICS-LABA to prevent it from becoming uncontrolled (Chung, ERJ 2014)
This definition is widely accepted, and has clinical utility
Severe asthma is distinguished from ‘difficult-to-treat’ asthma that is difficult to treat because of problems
such as poor adherence, incorrect inhaler technique and comorbidities
Mild asthma is currently defined as asthma that is well controlled on low dose ICS or as-needed-only
ICS-formoterol
The utility and relevance of this definition is much less clear
The term ‘mild asthma’ is often interpreted very differently
Patients and clinicians often assume that ‘mild asthma’ means no risk and no need for controller treatment
BUT: up to 30% asthma deaths are in patients with infrequent symptoms (Dusser, Allergy 2007; Bergstrom,
Respir Med 2008)
1. Severe asthma: GINA continues to support the current definitions of severe asthma, and difficult-
to-treat asthma
2. ‘Mild asthma’: GINA suggests that this term should generally be avoided in clinical practice if
possible, because it is used and interpreted in different ways
If used, emphasize importance of ICS-containing treatment to reduce risk of severe or fatal
exacerbations
3. For population-level observational studies: report the controller and reliever treatment not the
‘Step’, and don’t impute severity
e.g. ‘patients prescribed low dose ICS-LABA with as-needed SABA’, not ‘Step 3 patients’ and not
‘moderate asthma’
4. For clinical trials: describe the included patients by their asthma control and treatment (controller
and reliever), and don’t impute severity
5. GINA proposes holding a stakeholder discussion about the definition of mild asthma, to obtain
agreement about the implications for clinical practice and clinical research of the changes in
knowledge about asthma pathophysiology and treatment since the current definition of asthma
severity was published
www.ginasthma.org
Advise patients to continue taking their prescribed asthma medications, particularly inhaled corticosteroids
For patients with severe asthma, continue biologic therapy or OCS if prescribed
Are inhaled corticosteroids (ICS) protective in COVID-19?
In one study of hospitalized patients aged ≥50 years with COVID-19, ICS use in those with asthma was
associated with lower mortality than in patients without an underlying respiratory condition (Bloom, Lancet RM 2021)
Make sure that all patients have a written asthma action plan, advising them to:
Increase controller and reliever medication when asthma worsens (see GINA report Box 4-2)
Take a short course of OCS when appropriate for severe asthma exacerbations
When COVID-19 is confirmed or suspected, or local risk is moderate or high, avoid nebulizers where
possible, to reduce the risk of spreading virus to health professionals and other patients/family
For bronchodilator administration, pressurized metered dose inhaler via a spacer is preferred except for acute
severe asthma
Add a mouthpiece or mask to the spacer if required
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Updated 30 April 2022 © Global Initiative for Asthma, www.ginasthma.org
COVID-19 and asthma – infection control
In healthcare facilities, follow local COVID-19 testing recommendations and infection control procedures if
spirometry or peak flow measurement is needed (e.g. Virant, JACI in Practice 2022)
Use of an in-line filter minimizes the risk of transmission during spirometry, but many patients cough after
performing spirometry; coach the patient to stay on the mouthpiece if they feel the need to cough
If spirometry is not available due to local infection control restrictions, and information about lung function is
needed, consider asking patients to monitor lung function at home
Follow local infection control procedures if other aerosol-generating procedures are needed
Nebulization, oxygen therapy (including nasal prongs), sputum induction, manual ventilation, non-invasive
ventilation and intubation
Follow local health advice about hygiene strategies and use of personal protective equipment, as new
information becomes available in your country or region
49
Updated 30 April 2022 © Global Initiative for Asthma, www.ginasthma.org
COVID-19 vaccines and asthma