The 2023 update of the Global Initiative for Asthma (GINA) strategy report was recently published following the evidence gathering review process that is conducted by the GINA Scientific Committee on a bi-annual basis. Key updates included clarification around the terms ‘controller’ and ‘maintenance’ medications, detailed practical guidance on medications and doses for Track 1 treatment, and a renewed statement on the use of biologic therapies for severe asthma.

What is the GINA strategy report?

GINA is a self-funded and independent organization that aims to improve asthma awareness, prevention, and management on a global scale.¹ The GINA strategy report details the most recent advances in clinical evidence relating to asthma management and care. Updates to the report are published annually, but are based on a bi-annual literature review process. Such frequent reviews mean that the GINA report is a valuable and unique resource that can provide a contemporary consensus on clinical evidence that most national clinical guidelines typically do not have scope for.²

Detailed within the GINA strategy report are recommendations on asthma diagnosis, assessment and treatment. Diagnosis is based on the identification of a characteristic pattern of symptoms (such as wheezing, shortness of breath and chest tightness) with variable expiratory airflow limitation.^1,3 Guidance on asthma assessment focusses on the evaluation of symptom control, risk of adverse outcomes, lung function and disease severity.¹

Once an initial diagnosis is made and a patient has been assessed, GINA recommend a step-wise treatment regime that can be adapted over time. Two distinct ‘tracks’ can be followed, depending on the choice of reliever therapy. Track 1 (the preferred track) includes a low-dose combination of inhaled corticosteroid (ICS)-formoterol as the reliever therapy while in Track 2, short-acting β2-agonist (SABA) is used as an alternative reliever.¹

Key 2023 updates

Terminology

Among the 2023 updates was clarification around terminology frequently used to define types of asthma medications, including, ‘maintenance’ and ‘controller’ medications.¹ To avoid confusion, ‘controller’ has been replaced where appropriate with ‘maintenance treatment’ or ‘ICS-containing treatment’. Clarification around the term ‘anti-inflammatory reliever (AIR)’ (reliever inhaler that contains both a low-dose ICS and a rapid-acting bronchodilator) used alone (AIR-only) in Steps 1–2, or as maintenance-and-reliever therapy (MART) in Steps 3–5, has also been included.¹

Track 1 and Track 2 treatment paths

Further updates to the treatment recommendations were the addition of practical guidance on the medications and doses specified in Track 1 and the addition of an as-needed combination of ICS-SABA as reliever medication for Track 2.¹ The latter update was accompanied by an important note that Track 1, with as-needed ICS-formoterol, remains the preferred approach. This is due to it’s simplicity, favoured by both patients and clinicians, and the plethora of evidence supporting its superiority in reducing a patient’s risk of exacerbations compared to ICS-SABA.¹ This guidance, originally published in 2019, addressed concerns regarding the long-standing approach of commencing asthma treatment with SABA alone, which posed a significant risk of more frequent severe exacerbations.⁴

Biologic therapy

Finally, important clarification on the use of biologic therapy for asthma treatment was provided in GINA’s updated guidance on managing severe asthma. The authors stated that regardless of regulatory approval, GINA recommends biologic therapy for asthma only if asthma is severe and only if existing treatment has been optimised. This timely clarification comes in the wake of a recent surge in the development and approval of biologic therapy for asthma treatment⁵ along with reports of inappropriate escalation to biologics among patients with mild-to-moderate asthma or suboptimal maintenance medication adherence.^6,7

Other updates of interest

Asthma Management in low- and middle-income countries

In company with GINA’s 2023 World Asthma Day theme of “Asthma Care for All”, the 2023 GINA strategy report now includes a section dedicated to asthma management in low- and middle-income countries.¹ Approximately 90% of the asthma burden of disease falls upon people living in these regions, where access to essential inhaled medications is limited or non-existent.⁸ As per their general guidelines, GINA recommend treatment with ICS-containing medications wherever possible, however states that Track 2 treatment (SABA reliever) may be preferrable in circumstances where Track 1 treatment (ICS-formoterol reliever) cannot be initiated due to restricted availability or affordability of medications.¹

Use of digital interventions for adherence to asthma medications

As promised in the 2022 GINA report, the 2023 update has included new evidence around digital tools for asthma management. The latest report highlighted findings from a 2022 Cochrane review where digital interventions, such as electronic monitoring of maintenance inhaler use and text messages, were shown to improve adherence to maintenance treatment, reduce exacerbations, and improve asthma control.^1,9

What might future GINA report updates contain?

Still under discussion is the topic of asthma diagnosis following an ongoing review of the European Respiratory Society’s clinical practical guidelines for the diagnosis of asthma in children and adults.^10,11 GINA believes that further work is needed to establish the utility of their proposed diagnosis algorithms in clinical practice. Nearer completion are a review of updated evidence on subcutaneous allergen immunotherapy and sublingual immunotherapy for patients with asthma as well as a pocket guide for managing severe asthma in children aged 6–11 years.

The GINA Strategy Report is designed to be relevant globally and, as such, it is recommended that its guidance should be used concordantly with national or local clinical guidelines. It is intended as a resource that enables the most recent evidence to be applied at the discretion of the practicing clinician, and in the context of local regulations and resources.

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