Asthma: Updated Diagnosis and Management Recommendations from GINA
Am Fam Physician. 2020 Jun 15;101(12):762-763.
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Key Points for Practice
• As-needed SABA therapy alone is not recommended because of severe exacerbations and mortality risks.
• As-needed use of a low-dose ICS/formoterol combination is preferred in adolescents and adults with mild asthma.
• As-needed use of a low-dose ICS and a SABA is preferred in children six to 11 years of age with mild asthma.
• Controller therapy should be shifted to once-daily administration if symptoms are not controlled with as-needed therapy, minimizing the ICS dose when possible.
From the AFP Editors
Asthma is a serious global health problem. The latest update to the Global Initiative for Asthma (GINA) guidelines includes significant changes to treatment recommendations, especially a recommendation against using a short-acting beta2 agonists (SABA) such as albuterol as sole therapy.
The diagnosis of asthma continues to require characteristic symptoms and evidence of variable airflow limitation on pulmonary function testing. The characteristic symptoms, especially in adults, include wheezing, shortness of breath, cough, and chest tightness that are worse at night or early in the morning; vary over time and in intensity; and are triggered by viral infections (colds), exercise, allergen exposure, changes in weather, laughter, or irritants. Features that decrease the likelihood of asthma include cough in the absence of other respiratory symptoms, chronic production of sputum, shortness of breath associated with light-headedness or paresthesia, chest pain, and exercise-induced dyspnea with noisy inspiration.
An asthma diagnosis should be confirmed with pulmonary function testing to avoid overtreatment and to ensure that other diagnoses are not missed. In one study, 2% of adults diagnosed with asthma had serious cardiorespiratory conditions that were missed.
In asthma, lung function can vary between normal and severely obstructed, especially when poorly controlled. In adults with characteristic symptoms, an increase or decrease in forced expiratory volume in one second (FEV1) of greater than 12% and 200 mL from baseline or a change in peak expiratory flow of at least 20% is consistent with asthma.
Bronchial provocation testing is useful for ruling out asthma but less useful for making the diagnosis, and it should be limited to diagnosing asthma in athletes or in patients with symptoms despite normal spirometry findings or when spirometry is unavailable. Although the presence of atopy increases the likelihood of allergic asthma, its absence does not rule out asthma.
In patients taking controller treatment, it may be necessary to step down the dose to confirm an asthma diagnosis. Patients should be advised to reduce their inhaled corticosteroid (ICS) dose by 25% to 50% or stop any other long-acting medication.
Asthma severity is defined by the treatment required to control symptoms and exacerbations. Well-controlled asthma involves daytime symptoms or as-needed medication use twice a week or less, no activity limitation, and no waking with symptoms. Severity is assessed after several months of regular controller treatment.
Mild: Asthma is well controlled with step 1 or 2 treatment.
Moderate: Asthma is well controlled with step 3 treatment.
Severe: Step 4 or 5 treatment is required to control symptoms, or symptoms are uncontrolled despite this treatment.
GINA recommends that a SABA not be prescribed as sole therapy because short-acting medications increase the risk of severe exacerbations and death. Adding an ICS daily or as needed reduces this risk. GINA also recommends using the lowest dose of ICS tolerated, including reducing the corticosteroid dose after symptoms are controlled.
Clinicians should check inhaler adherence and treat any modifiable risk factors (Table 1) before
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Sumi Sexton, MD, editor-in-chief.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
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