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

Helen K Reddel; Leonard B Bacharier; Eric D Bateman; Christopher E Brightling; Guy G Brusselle; Roland Buhl; Alvaro A Cruz; Liesbeth Duijts; Jeffrey M Drazen; J Mark FitzGerald; Louise J Fleming; Hiromasa Inoue; Fanny W Ko; Jerry A Krishnan; Mark L Levy; Jiangtao Lin; Kevin Mortimer; Paulo M Pitrez; Aziz Sheikh; Arzu A Yorgancioglu; Louis-Philippe Boulet

doi:10.1016/j.arbres.2021.10.003

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

Arch Bronconeumol. 2022 Jan;58(1):35-51. doi: 10.1016/j.arbres.2021.10.003. Epub 2021 Oct 28.

[Article in English, Spanish]

Authors

Helen K Reddel¹, Leonard B Bacharier², Eric D Bateman³, Christopher E Brightling⁴, Guy G Brusselle⁵, Roland Buhl⁶, Alvaro A Cruz⁷, Liesbeth Duijts⁸, Jeffrey M Drazen⁹, J Mark FitzGerald¹⁰, Louise J Fleming¹¹, Hiromasa Inoue¹², Fanny W Ko¹³, Jerry A Krishnan¹⁴, Mark L Levy¹⁵, Jiangtao Lin¹⁶, Kevin Mortimer¹⁷, Paulo M Pitrez¹⁸, Aziz Sheikh¹⁹, Arzu A Yorgancioglu²⁰, Louis-Philippe Boulet²¹

Affiliations

¹ The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia. Electronic address: [email protected].
² Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, United States.
³ Department of Medicine, University of Cape Town, Cape Town, South Africa.
⁴ Leicester National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom.
⁵ Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium; Departments of Epidemiology and Respiratory Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁶ Pulmonary Department, Mainz University Hospital, Mainz, Germany.
⁷ Federal University of Bahia, Salvador, Bahia, Brazil.
⁸ Department of Pediatrics, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁹ Divisions of Medical Communication and Pulmonary Medicine, Department of Medicine, Brigham and Woman's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
¹⁰ University of British Columbia, Vancouver, British Columbia, Canada.
¹¹ Imperial College London, London, United Kingdom.
¹² Kagoshima University, Kagoshima, Japan.
¹³ The Chinese University of Hong Kong, Hong Kong.
¹⁴ Breathe Chicago Center, University of Illinois Chicago, Chicago, IL, United States.
¹⁵ Locum General Practitioner, London, United Kingdom.
¹⁶ China-Japan Friendship Hospital, Peking University, Beijing, China.
¹⁷ Department of Respiratory Medicine, Liverpool University Hospitals National Health Service Foundation Trust, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
¹⁸ Pediatric Respiratory Division, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil.
¹⁹ Usher Institute, University of Edinburgh, Edinburgh, United Kingdom.
²⁰ Department of Pulmonology, Celal Bayar University, Manisa, Turkey.
²¹ Institut universitaire de cardiologie et de pneumologie de Québec, Canada; Département de médecine, Université Laval, Québec, Québec, Canada.

PMID: 35245179
DOI: 10.1016/j.arbres.2021.10.003

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: Asma; Asthma; Asthma diagnosis; Asthma management; Asthma prevention; Diagnóstico del asma; Gestión del asma; Prevención del asma.