2014 Global Initiative for Asthma (GINA) Latest Update
Bronchial asthma (asthma) is derived from the ancient Greek word aazein, which means “rapid breathing”.
Hippocrates first used the word to describe the condition more than 2,000 years ago, and more than 2,000 years later, the Global Initiative for Asthma (GINA) committee was formed and developed in an effort to improve asthma care worldwide.
Since its inception in 1993, the GINA committee has worked to promote asthma control strategies worldwide.
Since their initial publication in 1995, the GINA guidelines have been continuously revised and updated to collate and reflect the latest advances in the field of asthma, maintain the authority of the guidelines, and guide clinicians worldwide in the standardized use of medications for the treatment of asthma.
In May 2014, the GINA committee revised the GINA guidelines again based on data from several recent studies. Compared with the previous version, the 2014 GINA guidelines have made more updates in the definition, diagnosis, evaluation and treatment of asthma, etc. In this article, we will explain the content of these aspects so that you can check the gaps and understand the changes in the new version of the guidelines.
New definition: Asthma is a heterogeneous disease
The first important update to the 2014 GINA guidelines is the definition of asthma: asthma is a heterogeneous disease, often characterized by chronic airway inflammation and a history of time-varying respiratory symptoms such as wheezing, shortness of breath, chest tightness and cough, with variable expiratory airflow limitation.
While previous guidelines emphasize asthma as “a chronic inflammatory disease of the airways,” the 2014 GINA guidelines emphasize asthma as “a heterogeneous condition. This definition is based on consensus and takes into account the typical features of asthma, while differentiating it from other respiratory diseases.
New diagnosis: the significance of variable expiratory airflow limitation
Consistent with the revised definition of asthma, the diagnosis of asthma needs to be based on identifying a characteristic pattern of respiratory symptoms, such as wheezing, shortness of breath (dyspnea), chest tightness or cough, with an emphasis on identifying variable expiratory airflow limitation.
Clinicians need to increase the likelihood of an asthma diagnosis for patients with the following typical respiratory symptoms, and obtaining evidence of excessive changes in expiratory lung function is a necessary component of an asthma diagnosis.
(1) More than 1 symptom (wheezing, shortness of breath, chest tightness, and cough), especially in adult patients;
(2) Symptoms are often worse at night or in the morning;
(3) Symptoms vary in expression and intensity over time;
(4) Symptoms are triggered by viral infections (colds), exercise, exposure to allergens, weather changes, laughing, or irritants such as car exhaust, smoke, or strong odors.
The 2014 GINA guidelines summarize the initial asthma diagnostic process in the following steps.
Figure 1. Initial asthma diagnosis process
New treatment goals: symptom control and risk reduction together
2014 GINA
The guidelines detail in a separate chapter that the pre-treatment asthma assessment should include asthma control, treatment issues, and coexisting conditions. Particular emphasis is placed on a comprehensive assessment and description of asthma control, focusing not only on asthma symptom control, but also on future risk assessment.
Figure 2. 2014 GINA guidelines for the assessment of asthma control in adults, adolescents and children aged 6-11 years
As can be seen, in addition to changing the name from “current clinical control” to “asthma symptom control,” the main change is the removal of lung function from the assessment of symptom control and the inclusion of lung function only as a risk factor for future risk.
Accordingly, achieving overall asthma control (OAC), i.e., both symptom control (previously known as current clinical control) and reduction of future risk, has become the new goal of asthma treatment.
At the same time, the guidelines also list in detail the risk factors that lead to poor asthma prognosis, fully reflecting the importance of future risk assessment in the treatment of asthma.
New treatment protocols: the “three updates” of the stepwise treatment protocol
With the new treatment goals in mind, each patient will have to continually adjust their treatment plan based on their current level of asthma control and changes in the current status of asthma control. 2014 GINA
The 2014 GINA guidelines provide “three major updates” to the ladder regimen: 1.
1. increase the number of preferred control medications recommended for each step of the ladder
The guidelines make different recommendations for preferred control medications for different steps of the ladder, based on the evaluation of average data on symptoms, asthma exacerbations and lung function in clinical studies.
Figure 3.
LTRA and theophylline are no longer recommended as first-line asthma medications
LTRA blocks only the leukotriene pathway compared to ICS, which blocks the inflammatory response from all channels. The effectiveness and toxicity of theophylline need to be evaluated and confirmed.
Upgrade the status of ICS and ICS/LABA in asthma treatment
The 2014 GINA guidelines recommend ICS/LABA as the preferred treatment option for patients with moderate to severe asthma. This update is based on several pieces of evidence-based medicine in recent years.
As early as 1997, results from the FACET study in the New England Journal of Medicine1 showed that ICS in combination with LABA resulted in better asthma outcomes than ICS alone.
compared to ICS alone;
A 2013 real-world study2 found that the ICS+LABA group (0.45) had better control of asthma compared to the ICS+LTRA group (0.36) in terms of the proportion of treatment days covered.
A 2013 real-world study2 found higher adherence in the ICS+LABA group (0.45) than in the ICS+LTRA group (0.36) in terms of the proportion of treatment days covered;
The results of the most recent Cochrane data retrospective analysis in 20143 showed that the ICS+LABA group significantly reduced the risk of asthma exacerbations requiring systemic hormone therapy by 13% compared with the ICS+LTRA group
The results of the latest Cochrane data review3 in 2014 showed that the ICS+LABA group had a significantly lower risk of asthma exacerbations requiring systemic hormone therapy than the ICS+LTRA group.
Increased recommendation for on-demand ICS/formoterol for moderate to severe asthma
Careful readers will notice that in Figure 3, under “Relievers,” the 2014 GINA guidelines add a recommendation for on-demand ICS/formoterol for patients with moderate-to-severe asthma.
Formoterol is a common LABA drug with a rapid onset of bronchodilation, similar to salbutamol.4 A retrospective analysis of 2013 Cochrane data
5 evaluated the efficacy of budesonide/formoterol maintenance remission therapy with a single inhalation device and current best clinical practice, including inhaled hormone maintenance.
The results showed that budesonide/formoterol maintenance remission with a single inhalation device significantly reduced the risk of acute asthma exacerbations requiring oral hormone therapy by 17% compared with conventional best clinical practice; and that budesonide/formoterol maintenance remission with a single inhalation device significantly reduced the risk of acute asthma exacerbations compared with ICS alone.
compared to ICS alone, budesonide/formoterol reduced the risk of acute asthma exacerbations requiring oral hormone therapy by more than 40%.
Based on this evidence, the 2014 GINA guidelines clarify the benefits of ICS/formoterol maintenance-remission therapy: ICS/formoterol maintenance and remission regimens significantly reduce acute asthma exacerbations at lower ICS doses while providing similar levels of asthma control compared with fixed-dose ICS/LABA or high-dose ICS maintenance therapy plus on-demand SABA
6-10 (Level of Evidence A).
concluding remarks
The 2014 GINA guidelines will be a new beginning for asthma care with a redefinition of asthma, clarification of diagnosis and comprehensive assessment, and updated and improved stepwise treatment protocols.
The GINA committee will continue to raise awareness among clinicians and lead us to the forefront of asthma care.