GINA strategy 2021: management of

asthma
By Global Initiative for Asthma1 June 2021

This Guidelines summary is taken from the GINA 2021 pocket guide

for asthma management and prevention. It outlines recommendations
for the management of asthma in adults, adolescents, and children
aged 6–11.

Download the full global strategy for asthma management and

prevention:

Global strategy for asthma management and prevention

2021 Pocket guide for asthma management and prevention

This summary is adapted from the GINA pocket guide, which itself is a
summary of the GINA 2021 report for primary healthcare providers. It
does not contain all of the information required for managing asthma,
for example about the safety of treatments, and it should be used in
conjunction with the full GINA 2021 report. When assessing and
treating patients, healthcare professionals are strongly advised to use
their own professional judgement and to take into account local and
national regulations and guidelines.

Read the related Guidelines in Practice article: GINA asthma strategy:

what’s new for 2021?
 Management of asthma

General principles

 The long-term goals of asthma management are risk

reduction and symptom control. The aim is to reduce the
burden to the patient and to reduce their risk of asthma-
related death, exacerbations, airway damage, and medication
side-effects. The patient’s own goals and preferences
regarding their asthma and its treatment should also be
identified

Population-level recommendations about ‘preferred’ asthma

treatments represent the best treatment for most patients in
a particular population. In steps one to five, there are
population-level recommendations for different age groups.
In step five, there are also different population-level
recommendations depending on the inflammatory phenotype
—type 2 or non-type 2.

Patient-level treatment decisions should take into account

any individual characteristics, risk factors, comorbidities, or
phenotype that predict how likely the patient’s symptoms
and exacerbation risk are to be reduced by a particular
 treatment, together with their personal goals, and practical
issues such as inhaler technique, adherence, and
affordability.

 A partnership between the patient and their healthcare

providers is important for effective asthma management.
Training healthcare providers in communication skills may
lead to increased patient satisfaction, better health
outcomes, and reduced use of healthcare resources

 Health literacy —that is, the patient’s ability to obtain,

process, and understand basic health information to make
appropriate health decisions—should be taken into account
in asthma management and education.
The asthma management cycle to minimise risk and control
symptoms
Algorithm 1: The asthma management cycle of shared
decision-making
SHOW FULLSCREEN
 Copyright 2021, reproduced with permission, Global Initiative for Asthma, available
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 Asthma management involves a continuous cycle

to assess, adjust treatment, and review response (see
Algorithm 1)

 Assessment of a patient with asthma includes not

only symptom control, but also the patient’s individual risk
factors and comorbidities that can contribute to their burden
of disease and risk of poor health outcomes, or that may
predict their response to treatment. Patients (or parents of
children with asthma) should be asked about their goals and
preferences for asthma treatment, as part of shared decision-
making about asthma treatment options

 Treatment to prevent asthma exacerbations and control

symptoms includes:
o medications: GINA now recommends that every adult and
adolescent with asthma should receive inhaled
corticosteroid (ICS)-containing controller medication to
reduce their risk of serious exacerbations, even patients with
infrequent symptoms. Every patient with asthma should have
a reliever inhaler for as-needed use, either low dose ICS-
formoterol or short-acting beta2 agonist (SABA)
o treating modifiable risk factors and comorbidities (see the
full report)
o using non-pharmacological therapies and strategies as
appropriate

 Importantly, every patient should also be trained in essential

skills and guided asthma self-management, including:


o asthma information

o inhaler skills

o adherence

o written asthma action plan

o self-monitoring of symptoms and/or peak flow

o regular medical review

 The patient’s response should be evaluated whenever
treatment is changed. Assess symptom control,
exacerbations, side-effects, lung function, and patient (and
parent, for children with asthma) satisfaction.

Recommendations for mild asthma

 For safety, GINA no longer recommends treatment of asthma
in adults and adolescents with SABA alone, without ICS.
There is strong evidence that SABA-only treatment, although
providing short-term relief of asthma symptoms, does not
protect patients from severe exacerbations, and that regular
or frequent use of SABA increases the risk of exacerbations 

 GINA now recommends that all adults and adolescents with

asthma should receive ICS-containing controller treatment to
reduce their risk of serious exacerbations and to control
symptoms

 For adults and adolescents, the treatment options for mild

asthma are:
o as-needed low-dose ICS-formoterol (preferred) or

o regular low-dose ICS, plus as-needed SABA.

Starting asthma treatment

 For the best outcomes, ICS-containing treatment should
be initiated as soon as possible after the diagnosis of
asthma is made, because:

1-patients with even mild asthma can have severe

exacerbations

2-low-dose ICS markedly reduces asthma hospitalisations

and death

3-low-dose ICS is very effective in preventing severe

exacerbations, reducing symptoms, improving lung function,
and preventing exercise-induced bronchoconstriction, even
in patients with mild asthma

4-early treatment with low-dose ICS is associated with better

lung function than if symptoms have been present for more
than 2–4 years

5-patients not taking ICS who experience a severe

exacerbation have lower long-term lung function than those
who have started ICS

6-in occupational asthma, early removal from exposure and

early treatment increase the probability of recovery

For most adults or adolescents with asthma, treatment can

be started at step two with either as-needed low-dose ICS-
formoterol (preferred), or regular daily low-dose ICS with as-
needed SABA. Most patients with asthma do not need higher
doses of ICS, because at a group level, most of the benefit
(including prevention of exacerbations) is obtained at low
doses. For ICS doses,
  see Box 9 in the pocket guide report

 Consider starting at step three (for example maintenance and

reliever therapy [MART] with low-dose ICS-formoterol) if, at
initial presentation, the patient has troublesome asthma
symptoms on most days; or is waking from asthma once or
more a week

 If the patient has severely uncontrolled asthma at initial

asthma presentation, or the initial presentation is during an
acute exacerbation, start regular controller treatment at step
four (or example medium-dose ICS-formoterol MART); a
short course of oral corticosteroids may also be needed

 Consider stepping down after asthma has been well-

controlled for 3 months. However, in adults and adolescents,
ICS should not be completely stopped

 Before starting initial controller treatment (see Algorithms 3

and 5):
o record evidence for the diagnosis of asthma

o document symptom control and risk factors

o assess lung function, when possible

o train the patient to use the inhaler correctly, and check their
technique
o schedule a follow-up visit

 After starting initial controller treatment (see Algorithms 2

and 4):
o review response after 2–3 months, or according to clinical
urgency
o see Algorithms 3 and 5 for ongoing treatment and other key
management issues
o consider step down when asthma has been well-controlled
for 3 months.

For information on suggested daily ICS doses for the low,

medium, and high options in Algorithms 2–5, see Box 3–6 in
the full report.

Stepwise approach for adjusting treatment for

individual patient needs

Algorithm 2: The GINA asthma treatment strategy—adults and

adolescents

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available
from www.ginasthma.org
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Algorithm 3: Initial treatment—adult or adolescent with a diagnosis of

asthma
Copyright 2021, reproduced with permission, Global Initiative for Asthma, available
from www.ginasthma.org
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Algorithm 4: The GINA asthma treatment strategy—children 6–11 years

Copyright 2021, reproduced with permission, Global Initiative for Asthma, available
from www.ginasthma.org
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Algorithm 5: Initial treatment—children 6–11 years with a diagnosis of

asthma

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 For clarity, treatment options for adults and adolescents in

Algorithm 2 are shown as two tracks, based on the choice of
reliever

 In track one, the reliever is low-dose ICS-formoterol. This is

the preferred approach recommended by GINA, because it
reduces the risk of severe exacerbations compared with
using a SABA reliever (options shown in track two)
 Once asthma treatment has been started (see Algorithms 3
and 5), ongoing decisions are based on a cycle of shared
decision-making to assess the patient, adjust their treatment
(pharmacological and non-pharmacological) if needed, and
review their response (see Algorithm 1). Treatment can be
stepped up or down along one track using the same reliever
at each step, or it can be switched between tracks, according
to the individual patient’s needs

 The preferred controller treatments at each step for adults

and adolescents are summarised and in Algorithm 2 for
adults and adolescents, and Algorithm 4 for children aged 6–
11 years. For more details, including for children aged 5
years and younger, see the full report.
Stepping up asthma treatment

 Asthma is a variable condition, and periodic adjustment of

controller treatment by the clinician and/or patient may be
needed
o sustained step-up (for at least 2–3 months): if symptoms
and/or exacerbations persist despite 2–3 months of
controller treatment, assess the following common issues
before considering a step-up:
 incorrect inhaler technique
 poor adherence
 modifiable risk factors, for example smoking
 are symptoms due to comorbid conditions, for example
allergic rhinitis
o short-term step-up (for 1–2 weeks) by clinician or by patient
with written asthma action plan, for example during viral
infection or allergen exposure
o day-to-day adjustment by patient with as-needed low-dose
ICS formoterol for mild asthma, or ICS-formoterol
maintenance and reliever therapy. This is particularly
effective in reducing severe exacerbations.
Stepping down treatment when asthma is well-controlled

 Consider stepping down treatment once good asthma

control has been achieved and maintained for 3 months, to
find the lowest treatment that controls both symptoms and
exacerbations, and minimises side-effects:
o choose an appropriate time for step-down (no respiratory
infection, patient not travelling, not pregnant)
o assess risk factors, including history of previous
exacerbations or emergency department visit, and low lung
function
o document baseline status (symptom control and lung
function), provide a written asthma action plan, monitor
closely, and book a follow-up visit
o step down through available formulations to reduce the ICS
dose by 25–50% at 2–3-month intervals (see Box 3-9 in full
report for details of how to step down different controller
treatments)
o if asthma is well-controlled on low dose ICS or leukotriene
receptor antagonist therapy, as-needed low-dose ICS-
formoterol is a step-down option based on three large
 studies in mild asthma. Smaller studies have shown that low
dose ICS taken whenever SABA is taken (with combination or
separate inhalers) is more effective as a stepdown strategy
than SABA alone
o do not completely stop ICS in adults or adolescents with
asthma unless this is needed temporarily to confirm the
diagnosis of asthma
o make sure a follow-up appointment is arranged.

Treating modifiable risk factors



 Exacerbation risk can be minimised by optimising asthma

medications, and by identifying and treating modifiable risk
factors. Some examples of risk modifiers with consistent
high-quality evidence are:
o guided self-management: self-monitoring of symptoms
and/or peak expiratory flow, a written asthma action plan,
and regular medical review
o use of a regimen that minimises exacerbations: prescribe an
ICS-containing controller, either daily, or, for mild asthma, as-
needed ICS-formoterol. MART with ICS-formoterol reduces
the risk of severe exacerbations compared with if the reliever
is SABA
o avoidance of exposure to tobacco smoke
o confirmed food allergy: appropriate food avoidance; ensure
availability of injectable adrenaline for anaphylaxis
o school-based programmes that include asthma self-
management skills
o referral to a specialist centre, if available, for patients with
severe asthma, for detailed assessment and consideration of
add-on biologic medications and/or sputum-guided
treatment.
o

Non-pharmacological strategies and interventions

Read the related Guidelines in Practice article

Full guideline:

Global Initiative for Asthma. 2021 Pocket guide for asthma management and
prevention. April 2021. Available at: www.ginaasthma.org.

Published date: 1995.

Last updated: April 2021.