It is time to change the way we manage mild asthma: an update in GINA 2019

Abstract

Asthma is a heterogeneous lung disease, usually characterised by chronic airway inflammation. Although evidence-based treatments are available in most countries, asthma control remains suboptimal, and asthma-related deaths continue to be an ongoing concern. Generally, it is believed that between 50 to 75% of patients with asthma can be considered as having mild asthma. Previous versions of Global Initiative for Asthma (GINA) suggested that mild asthma in adults can be well managed with either reliever medications, for example, short-acting beta 2 agonists (SABA) alone or with the additional use of controllers such as regular low-dose inhaled corticosteroids (ICS). Given the low frequency or non-bothersome nature of symptoms in mild asthma, patients’ adherence towards their controller medications, especially to ICS is usually not satisfactory. Such patients often rely on SABA alone to relieve symptoms, which may contribute to SABA over-reliance. Overuse of relievers such as SABAs has been associated with poor asthma outcomes, such as exacerbations and even deaths. The new GINA 2019 asthma treatment recommendations represent significant shifts in asthma management at Steps 1 and 2 of the 5 treatment steps. The report acknowledges an emerging body of evidence suggesting the non-safety of SABAs overuse in the absence of concomitant controller medications, therefore does not support SABA-only therapy in mild asthma and has included new off-label recommendations such as symptom-driven (as-needed) low dose ICS-formoterol and “low dose ICS taken whenever SABA is taken”. The GINA 2019 report highlights significant updates in mild asthma management and these recommendations represent a clear deviation from decades of clinical practice mandating the use of symptom-driven SABA treatment alone in those with mild asthma. While the new inclusions of strategies such as symptom-driven (as-needed) ICS-formoterol and “ICS taken whenever SABA is taken” are based on several key trials, data in this context are still only emergent data, with clear superiority of as needed ICS-formoterol combinations over maintenance ICS regimens yet to be established for valid endpoints. Nevertheless, current and emerging data position the clinical asthma realm at a watershed moment with imminent changes for the way we manage mild asthma likely in going forward.

Associations among chronic obstructive pulmonary disease with asthma, pneumonia, and corticosteroid use in the general population

“…However, the short course OSs (ex. 5days) in the GINA 2019 was still a critical role in the acute of asthma or COPD with AE in GOLD 2019 in the ER or hospitalization based on the precise medicine [68,69]. This speculation warrants further research.…”

Bringing asthma care into the twenty-first century

“…For many years, the lowest treatment step, recommended in most guidelines for intermittent or mild asthma, has been a shortacting β 2 -agonist (SABA) reliever, which relieves bronchoconstriction rapidly and effectively but does not reduce the underlying inflammation usually present even in mild asthma 16,17 . The recommendation for SABA alone as initial treatment for mild asthma dates back to the era when asthma was thought to be a disease only of bronchoconstriction 10,18 .…”

Sialic Acid-Siglec Axis as Molecular Checkpoints Targeting of Immune System: Smart Players in Pathology and Conventional Therapy

“…The molecular mechanisms of glycome machinery and its therapeutic targeting are extensively studied. According to the GINA (Global Initiative for Asthma) and GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines, the main goal of conventional therapies in respiratory obstructive diseases is the limiting of inflammation [121][122][123]. However, in contrast to bronchial asthma, the inefficient management of COPD is related to the low sensitivity of patients to corticosteroids, and relatively high risk of exacerbation due to bacterial or viral infections [124].…”