Sakina Walji-Bandali, PharmD; Community-University Health Care Center (CUHCC)
Background: Asthma affects 300 million people worldwide and causes 1000 deaths daily - most of which are preventable. What causes this high morbidity and mortality is that asthma is often inappropriately treated as a recurrent acute disease, with exacerbations treated but little or no treatment in between. Access and affordability of medications used for chronic management contributes to this issue as well. Asthma is a disease that can be wide-ranging, but it is typically defined by chronic airway inflammation. It is also characterized by a history of symptoms, which can change over time and are simultaneously accompanied by varying expiratory airflow limitation. Asthma is typically diagnosed based on a patient’s history of symptoms and evidence of variable expiratory airflow limitation. More than one test is typically needed to confirm asthma. Due to the variable presentation of asthma, non-specific symptoms, and low access to quality spirometry, asthma is often either underdiagnosed or overdiagnosed. The primary goal of asthma management is to achieve symptom control, which includes no sleep disturbances and uninhibited physical activity. The long-term goals are focused on risk minimization, such as no exacerbations, improved lung function, no medication adverse effects, and no long-term need for oral corticosteroids (OCS).
Evidence: The Global Initiative for Asthma (GINA) was established in 1993 by the National Heart, Lung, and Blood Institute (NHLBI) and WHO (World Health Organization). GINA works with healthcare professionals, patients, and public health officials around the world to reduce the prevalence of asthma morbidity and mortality. Every year, GINA publishes an updated strategy report to achieve these goals. Members of the GINA Board are leaders who are devoted to asthma research, asthma clinical management, public health, and patient advocacy. The recommendations presented in GINA’s annual strategy report are developed using evidence-based methods based on available data. The GINA Science Committee reviews literature twice yearly to create the strategy report. Their literature search includes randomized controlled trials, observational studies, systematic reviews, and meta-analyses. After assessing the quality, reliability, and interpretation of the results, recommendations are given a Level of Evidence.
Discussion: The newest updates to the GINA Strategy Report were published on May 22, 2024. This latest report addresses a variety of important clinical issues, including allowing different lung function tests in the diagnosis of asthma, clarification on assessing asthma, an added section on remission of asthma (both on and off-treatment), and emphasis on the differences in ICS dosing. It also contains additional descriptions of the choice of initial asthma treatment in adults, children, and adolescents. Overall, there is great importance given to understanding that asthma management needs to be individualized, with a continuous cycle of assessment, treatment, adjustment, and review.
Clinical Impact: One significant update is in the diagnosis of asthma. GINA recognizes that many health professionals do not have access to quality spirometry. Peak expiratory flow (PEF) is less reliable, but it is still better than relying on symptoms alone. Therefore, the diagnostic flowchart includes a wider selection of initial lung function tests to better aid in the diagnosis of asthma. Another critical clarification is assessing asthma control. GINA highlights that assessing symptom control is not enough - the patient’s history of and risk factors for exacerbations in addition to adverse effects of medications must be considered in the overall picture when deciding control. Serious exacerbations are associated with a greater decline in lung function.
Perhaps the most influential updates in the report that affect pharmacy practice are the ones made to initial treatment in adults, adolescents, and children. A more detailed description is included indicating which patients are suitable to start on different steps of asthma management. Additional adjustments have been made to each of the steps, which now include assessing lung function itself or assessing exacerbation history in greater depth. For example, in the 2023 report, patients who were 12+ years old would be started on steps 1-2 if they were having symptoms <4-5 days a week. However, in the latest report, these patients should now start on steps 1-2 if they are having symptoms <3-5 days a week. The updated report also has additional language clarifying to start on step 3 if patients have low lung function, and step 4 if they have had a recent exacerbation. Suggested doses and inhaler types in each step remain the same, regardless of whether Track 1 or Track 2 medications are being utilized. Similar updated recommendations have been made to the stepwise approach to asthma management in children aged 6-11; clarifications have been made on when to start step 1 and step 2.
The approach to management in children aged 5 and younger are the same as the 2023 report. Other essential information for pharmacists that is contained in the report is that of the discussion on vaccines to prevent respiratory infections, including pneumococcus, respiratory syncytial virus (RSV), and pertussis. Lastly, though this has been mentioned in previous reports, additional emphasis has been placed on the utilization of the ICS (inhaled corticosteroid) dosing chart. GINA reminds practitioners that this table merely highlights different dosing of ICS, and does not imply equivalent potency. For instance, switching from one medium-dose ICS to another does not mean they have the same potency.
References:
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2024. Available at: https://ginasthma.org. Accessed 8/15/2024.
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2023. Available at: https://ginasthma.org. Accessed 8/15/2024.