evidence-based strategy for asthma management and prevention, which can be adapted for local
circumstances (e.g. medication availability). This article summarizes key recommendations from GINA
2021, and the evidence underpinning recent changes.
GINA recommends that asthma in adults and adolescents should not be treated solely with short-acting β2-
agonist (SABA), because of the risks of SABA-only treatment and SABA overuse, and evidence for
benefit of inhaled corticosteroids (ICS). Large trials show that as-needed combination ICS–formoterol
reduces severe exacerbations by ⩾60% in mild asthma compared with SABA alone, with similar
exacerbation, symptom, lung function, and inflammatory outcomes as daily ICS plus as-needed SABA.
Key changes in GINA 2021 include division of the treatment figure for adults and adolescents into two
tracks. Track 1 (preferred) has low-dose ICS–formoterol as the reliever at all steps: as needed only in Steps
1–2 (mild asthma), and with daily maintenance ICS–formoterol (maintenance-and-reliever therapy, “MART”)
in Steps 3–5. Track 2 (alternative) has as-needed SABA across all steps, plus regular ICS (Step 2) or ICS–
long-acting β2-agonist (Steps 3–5). For adults with moderate-to-severe asthma, GINA makes additional
recommendations in Step 5 for add-on long-acting muscarinic antagonists and azithromycin, with add-on
biologic therapies for severe asthma. For children 6–11 years, new treatment options are added at Steps 3–4.
Across all age groups and levels of severity, regular personalized assessment, treatment of modifiable risk
factors, self-management education, skills training, appropriate medication adjustment, and review remain
essential to optimize asthma outcomes.
The authors thank Rebecca Decker, GINA Executive Director, and Kristi Rurey, GINA Project Manager, for supporting and coordinating the GINA Science Committee and Board, Dr. Ruth Hadfield for assistance with literature research, GINA Advocates and Assembly members across many countries for identifying clinicians’ needs and concerns, Kate Chisnall for assistance with graphics, and Jennifer Harman for editorial assistance. They thank Richard Beasley, Alan Kaplan, Hugo Neffen, Michael Schatz, Hesham Tarrif, and Richard van Zyl-Smit for their helpful review of the manuscript. They acknowledge the outstanding and dedicated work of Dr. Suzanne Hurd as Scientific Director of GINA and Dr. Claude Lenfant as Executive Director, from the inception of GINA in 1993 until their retirement in 2015.
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