What are the overall goals of asthma management according to the Global Strategy for Asthma Management and Prevention?

Updated: Nov 20, 2020
  • Author: Michael J Morris, MD, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

The goals for successful management of asthma outlined in the 2007 NHLBI publication "Global Strategy for Asthma Management and Prevention" (see the images below) include the following [1] :

  • Achieve and maintain control of asthma symptoms
  • Maintain normal activity levels, including exercise
  • Maintain pulmonary function as close to normal as possible
  • Prevent asthma exacerbations
  • Avoid adverse effects from asthma medications
  • Prevent asthma mortality
Asthma symptoms and severity. Recommended guidelin Asthma symptoms and severity. Recommended guidelines for determination of asthma severity based on clinical symptoms, exacerbations, and measurements of airway function. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.
Stepwise approach to pharmacological management of Stepwise approach to pharmacological management of asthma based on asthma severity. Adapted from Global Strategy for Asthma Management and Prevention: 2002 Workshop Report.

Stepwise pharmacologic therapy

The pharmacologic treatment of asthma is based on stepwise therapy. Asthma medications should be added or deleted as the frequency and severity of the patient's symptoms change. The 2007 NAEPP guidelines offer the recommendations below. [1]

Step 1 for intermittent asthma is as follows:

  • Controller medication not indicated
  • Reliever medication is a short-acting beta-agonist (SABA) as needed for symptoms

Step 2 for mild persistent asthma is as follows:

  • Preferred controller medication is a low-dose inhaled corticosteroid
  • Alternatives include cromolyn, leukotriene receptor antagonist (LTRA), [110] or theophylline

Step 3 for moderate persistent asthma is as follows:

  • Preferred controller medication is either a low-dose inhaled corticosteroid (ICS) plus a long-acting beta-agonist (LABA) (combination medication preferred choice to improve compliance) [111] or an inhaled medium-dose corticosteroid
  • Alternatives include an low-dose ICS plus either a LTRA or theophylline

Step 4 for moderate-to-severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled medium-dose corticosteroid plus a LABA (combination therapy)
  • Alternatives include an inhaled medium-dose corticosteroid plus either an LTRA or theophylline

Step 5 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA

Step 6 for severe persistent asthma is as follows:

  • Preferred controller medication is an inhaled high-dose corticosteroid plus LABA plus oral corticosteroid

The 2019 GINA guidelines include the stepwise recommendations below for medication and symptom control. [106]

The preferred reliever medication is specified as low-dose ICS-formoterol, which is an off-label use. Other reliever options include as-needed SABA. See the following stepwise approach:

  • Step 1: As-needed low-dose ICS-formoterol (off-label); other options are low dose ICS taken whenever SABA is taken
  • Step 2: Daily low-dose ICS, or as-needed low-dose ICS-formoterol (off-label); other options are leukotriene receptor antagonist (LTRA) or low-dose ICS taken whenever SABA is taken
  • Step 3: Low-dose ICS/LABA; other options include medium-dose ICS or low-dose ICS + LTRA
  • Step 4: Medium-dose ICS-LABA; other options are high-dose ICS, add-on tiotropium, or add-on LTRA
  • Step 5: High-dose ICS-LABA; refer for phenotypic assessment with or without add-on therapy (eg, tiotropium, anti-IgE, anti-IL5/5R, and IL4R; other options are to add low-dose OCS, but consider adverse effects

The change in GINA guidelines from SABA to ICS-formoterol as the recommended as-needed inhaler was based on the SYGMA I/II trials published in 2018. SYGMA I showed that as-needed budesonide-formoterol was superior to as-needed terbutaline but was inferior to budesonide maintenance therapy. Exacerbation rates were similar for budesonide-containing strategies, both of which were lower than terbutaline. SYGMA II concluded that as needed budesonide-formoterol was noninferior to budesonide maintenance therapy for the rate of severe exacerbations but was inferior for controlling asthma symptoms. Both trials showed a reduction in overall ICS exposure with as-needed budesonide/formoterol.

 


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