Global Initiative for Asthma: Updates in the 2021 GINA Report

The Global Strategy for Asthma Management and Prevention is a report written by an international panel of experts on the Global Initiative for Asthma (GINA) Science Committee. This summary outlines the most important updates made in the 2021 review.¹ 

Updated guidance on COVID-19 and asthma

According to the latest research, the risk of acquiring COVID-19 infection or COVID-19 related death is not increased in patients with well-controlled asthma. However, the risk of COVID-19 death is increased in people who have recently needed oral corticosteroids for their asthma, and in hospitalized patients with severe asthma. This implicates the importance of maintaining good asthma control. For patients with severe asthma, continue biologic therapy or oral corticosteroids if prescribed. Continuing the use of inhaled corticosteroids (ICS) is particularly stressed. For better infection control, it is advised to avoid aerosol-generating procedures during appointments. GINA recommends COVID-19 vaccination for people with asthma.

Recommended asthma treatment figure 

In 2019, GINA recommended that all adults and adolescents (≥12 years of age) with asthma should receive ICS-containing controller treatment to reduce the risk of serious exacerbations. The use of short-acting β2-agonists (SABA) alone should be avoided. In 2021 the recommended treatment scheme was updated to have two optional tracks, based on the chosen reliever (Figure 1). In the preferred Track 1, low dose ICS-formoterol is used as the reliever. An alternative option, Track 2, includes the use of a SABA as the reliever, together with a controller treatment. The treatment tracks include options for stepping up the treatment and enable switching between them according to the patient’s needs and preferences. The treatment recommendations for children are also updated accordingly and are easily readable from the report figures.

Figure 1. Adapted from The Global Initiative for Asthma (GINA) 2021, Global Strategy for Asthma Management and Prevention. 

The recommendations on the use of maintenance and reliever therapy (MART) with ICS-formoterol in the Steps 3–5 have been updated for both adults and children. In Step 5, triple therapy combination ICS - long-acting β2-agonist - long-acting muscarinic antagonist (ICS-LABA-LAMA) is now added as an option for adult patients. Add-on azithromycin treatment three days a week is now also an option after specialist referral. New information on eligibility for add-on biologic therapy for severe Type 2 asthma has been added. 

Other changes in GINA 2021

GINA also updated the suggested total daily ICS doses for ‘low’, ‘medium’ and ‘high’ dose treatment options with different ICSs, for both adults and children with asthma. The definition of severe asthma has been reworded to omit reference to GINA Steps. In addition, GINA does not distinguish between ‘intermittent’ and ‘mild persistent’ asthma. The new definition of mild asthma will be assessed during 2021.

Other updates include new recommendations on bronchodilator withholding times for spirometry as well as vitamin D insufficiency correction for primary prevention. The guidelines for the description of populations in clinical trials or observational studies are also updated. The full report is available at the GINA website. Local and national guidelines and licensed drug doses should be taken into account when assessing and treating patients. 

References: 

1. Global Initiative for Asthma (GINA). What’s new in GINA 2021? GINA Global Strategy for Asthma Management and Prevention. Available at https://ginasthma.org/gina-reports/. Accessed 2021-05-27.

Date of preparation: January 2022 / EASYH-1956