What is the Global Initiative for Asthma (GINA) Classification?
The Global Initiative for Asthma (GINA) Classification is a globally recognized and widely utilized framework for the classification and management of asthma. Developed by an international panel of experts, GINA provides evidence-based guidelines and recommendations for healthcare professionals to assess and treat asthma patients.
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Table of Contents
Historical Context and Development of GINA
The Global Initiative for Asthma (GINA) was established in 1993 in collaboration with the National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). The primary objective of GINA is to improve the lives of people with asthma through a global strategy for asthma management and prevention. The GINA Classification, a crucial component of the initiative, was developed to provide a standardized approach to classifying asthma severity and controlling symptoms.
Read more: What is Asthma?
Evolution of GINA Classification
Historically, asthma was classified by severity based on symptom frequency and lung function into categories such as intermittent, mild persistent, moderate persistent, and severe persistent asthma. These categories guided initial treatment steps. However, this system was limited as asthma symptoms and control levels fluctuate over time, and treatment response varies between individuals.
In recent years, GINA has shifted focus from static severity classification to assessing asthma control and risk during treatment, aiming for optimal long-term management rather than labeling fixed disease categories.
GINA’s Current Approach to Asthma Classification
GINA now classifies asthma based on two main dimensions:
1. Assessment of Asthma Control
2. Assessment of Risk of Adverse Outcomes
GINA Framework
The GINA framework defines asthma as a heterogeneous, chronic inflammatory disease of the airways. Diagnosis is based on a two-part assessment: a clinical history of variable respiratory symptoms and objective evidence of variable expiratory airflow limitation. Patients typically present with more than one hallmark symptom of asthma, including wheezing, shortness of breath, chest tightness, or cough. These symptoms are notable for their variability in both occurrence and intensity, often worsening at night or on waking, and are commonly triggered by factors such as exercise, laughter, allergens, or viral infections.
For a definitive diagnosis, GINA emphasizes the importance of objective testing to demonstrate variable airflow limitation. This is usually confirmed by a significant increase in forced expiratory volume in 1 second (FEV₁) after inhalation of a bronchodilator — specifically, an increase of more than 200 mL and greater than 12% of the pre-bronchodilator value. Alternatively, excessive diurnal variability in peak expiratory flow (PEF) — defined as greater than 10% variation — can also support the diagnosis. This requirement for objective evidence acts as a critical safeguard against misdiagnosis.
Furthermore, the GINA strategy acknowledges that in long-standing asthma, airflow limitation may become permanent, complicating the diagnostic process and underscoring the progressive nature of the disease if not adequately managed.
Principles of GINA’s Assessment and Classification
A core tenet of the GINA framework is its continuous, personalized management approach, encapsulated in the "assess-treat-review" cycle. This cycle forms the operational backbone for all asthma management recommendations. The assessment phase is comprehensive, evaluating not only a patient’s current symptom control but also their risk factors for future poor outcomes, lung function, comorbidities, self-management skills, and patient preferences. Based on this detailed assessment, a treatment plan—including both pharmacological and non-pharmacological strategies—is adjusted. The patient’s response to the adjusted treatment is then reviewed at follow-up, completing the cycle and informing the next round of assessment and decision-making.
A fundamental conceptual distinction within the GINA strategy is the difference between assessing asthma "control" and classifying asthma "severity." Asthma control is a dynamic measure of how well a patient’s symptoms are managed and their risk of adverse events is mitigated. It is evaluated based on two domains: symptom control and risk factors for future poor outcomes. Symptom control is determined by the frequency of daytime symptoms, night waking, reliever medication use, and activity limitation over the previous four weeks. GINA considers good control to be achieved when patients experience infrequent symptoms, require little or no reliever medication, and can lead productive, physically active lives with normal or near-normal lung function.
In contrast, asthma severity is a retrospective classification. It is not assessed at diagnosis but determined after a patient has been on treatment for several months. Severity is defined by the level of treatment required to achieve and maintain good control of both symptoms and future risk. This represents a significant departure from older classification systems that relied on a static label based on initial symptom frequency. Under the GINA framework, a patient who requires high-dose inhaled corticosteroids (ICS) to remain symptom-free is considered to have more severe asthma than a patient with a similar initial symptom profile who achieves control with low-dose ICS. This conceptual shift directs clinical focus toward the patient’s response to therapy and their long-term prognosis rather than their initial presentation.
A critical component of GINA’s assessment is the identification and management of risk factors for poor asthma outcomes. GINA emphasizes that this assessment should be conducted at diagnosis and periodically thereafter, especially after an exacerbation. The presence of these risk factors increases the patient’s future risk of exacerbations, lung function decline, or medication side effects, even if current symptoms are well controlled. The most significant modifiable risk factor is the overuse of short-acting beta2-agonists (SABAs), with the use of more than three 200-dose canisters per year associated with an increased risk of exacerbations and death.
Other major risk factors include a history of severe exacerbations (e.g., requiring intubation or intensive care), low FEV₁ (especially <60% predicted), and the presence of certain comorbidities. The GINA strategy highlights the importance of assessing multimorbidity, noting that conditions such as obesity, chronic rhinosinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea, depression, and anxiety can complicate asthma control. Non-pharmacological factors such as poor adherence, incorrect inhaler technique, smoking, and allergen exposure are also crucial risk factors. By focusing on these modifiable and non-modifiable factors, GINA provides a comprehensive framework for proactive, preventative care.
Table 1: GINA-Identified Risk Factors for Poor Asthma Outcomes (2024)
| Category | Specific Risk Factors |
|---|---|
| Symptom & Medication Use |
• Overuse of SABA >3 × 200-dose canisters/year or daily use • No ICS-containing treatment, or poor adherence • Incorrect inhaler technique • No written asthma action plan |
| Exacerbation History |
• History of intubation or ICU admission for asthma • ≥1 severe exacerbation in the last 12 months |
| Lung Function |
• Low FEV₁, especially <60% predicted • High bronchodilator responsiveness |
| Inflammatory Markers |
• High blood eosinophils • High FeNO despite ICS treatment |
| Comorbidities & Lifestyle |
• Obesity • Chronic rhinosinusitis • GERD • OSA • Confirmed food allergy • Smoking or e-cigarette use • Allergen exposure if sensitized |
| Other |
• Major psychosocial problems • Poor access to healthcare • Low health literacy |
The GINA Stepwise Treatment Strategy
The GINA stepwise approach to asthma management is centered around a major paradigm shift that began in 2019: the recommendation against the use of SABA-only therapy for adults and adolescents with asthma. This fundamental change was driven by a compelling body of evidence demonstrating that SABA-only treatment while providing quick symptom relief, does not address the underlying airway inflammation present in most patients, even those with mild or infrequent symptoms. Research has consistently shown that regular or frequent SABA use without a concomitant anti-inflammatory controller medication is associated with an increased risk of severe exacerbations, hospitalizations, and even death.
The scientific justification for this change was solidified by large-scale clinical trials. Studies like SYGMA demonstrated that a regimen of as-needed low-dose ICS-formoterol reduced severe exacerbations by over 60% compared to SABA-only treatment, while achieving similar symptom control and lung function as daily ICS therapy. This evidence established a safer and more effective alternative to decades of clinical practice, fundamentally reframing asthma from a disease of intermittent symptoms to one of chronic inflammation requiring early and consistent anti-inflammatory intervention.
The GINA framework for adults and adolescents now presents a five-step, two-track treatment strategy. This two-track system is a reflection of GINA's pragmatic approach to global implementation, providing a preferred pathway while acknowledging the need for flexibility based on local conditions.
Track 1 (Preferred)
This track, often referred to as the anti-inflammatory reliever (AIR) approach, uses a single inhaler containing low-dose ICS-formoterol as the as-needed reliever medication for all steps. For patients with mild asthma (Steps 1 and 2), this is used on an as-needed basis only. For those with moderate-to-severe asthma (Steps 3-5), this same medication is also used for daily maintenance, a strategy known as Maintenance And Reliever Therapy (MART). This track is preferred because it has a strong evidence base for reducing the risk of severe exacerbations compared with regimens where SABA is the reliever.
Track 2 (Alternative)
This track is for situations where the preferred Track 1 is not feasible due to medication availability or other factors. It uses a SABA as the as-needed reliever and a separate ICS-containing medication for daily control. For mild asthma (Step 1), a low-dose ICS is taken simultaneously with the SABA whenever symptoms occur. From Step 2 onward, a daily maintenance ICS is prescribed alongside the as-needed SABA reliever. This alternative pathway still aligns with GINA's core principle of ensuring all patients receive an ICS-containing therapy to mitigate the risks associated with SABA monotherapy.
Table 2: Track 1 (Preferred) – ICS–Formoterol as Reliever (AIR/MART Approach)
| Step | Treatment Regimen | Notes |
|---|---|---|
| Step 1 | As-needed low-dose ICS–formoterol | For patients with infrequent symptoms. No daily maintenance dose. |
| Step 2 | As-needed low-dose ICS–formoterol | For patients with symptoms <3–5 days/week; reduces exacerbations compared to SABA. |
| Step 3 | Low-dose maintenance ICS–formoterol + as-needed ICS–formoterol | MART (Maintenance and Reliever Therapy) – for patients with symptoms most days or waking due to asthma ≥1×/week. |
| Step 4 | Medium-dose maintenance ICS–formoterol + as-needed ICS–formoterol | MART, used when Step 3 is insufficient. |
| Step 5 | Refer for phenotypic assessment ± add-on therapy (e.g., LAMA, biologics, low-dose oral corticosteroids) | For severe uncontrolled asthma despite Step 4. |
Table 3: Track 2 (Alternative) – SABA as Reliever
| Step | Treatment Regimen | Notes |
|---|---|---|
| Step 1 | Take low-dose ICS whenever SABA is taken | For patients with very infrequent symptoms. |
| Step 2 | Daily low-dose ICS + as-needed SABA | Reduces exacerbations vs. SABA alone. |
| Step 3 | Low-dose ICS–LABA + as-needed SABA | For patients uncontrolled on Step 2. |
| Step 4 | Medium/high-dose ICS–LABA + as-needed SABA | For persistent symptoms despite Step 3. |
| Step 5 | Refer for specialist assessment ± add-on therapy | Consider LAMA, biologics, or low-dose OCS. |
Note: This table provides a simplified overview. For a comprehensive list of medications and dosages, refer to the full GINA report.(alert-passed)
🔹 Why is formoterol used in Track 1?
Rapid onset (similar to SABA)
Long duration → works as both a reliever and controller
Allows use in single inhaler for both purposes (AIR/MART approach)
🔹 Key GINA principles
All adults/adolescents should receive ICS-containing treatment (no SABA-only therapy)
Choose Track 1 where possible, as it reduces severe exacerbations compared with Track 2
Review control, inhaler technique, adherence, and comorbidities before stepping up
Step down if control is maintained for 2–3 months
Non-Pharmacological Interventions
Beyond pharmacological interventions, the GINA strategy places significant emphasis on non-pharmacological interventions and patient education as integral parts of management. A crucial component is the provision of a written asthma action plan for every patient. This plan provides clear, personalized instructions on how to recognize worsening asthma, when to increase medication, and when to seek urgent medical care.
Inhaler technique is another critical focus, with GINA recommending that healthcare professionals train patients on correct usage and check their technique at every visit to ensure medication is delivered effectively.
Read more: How to use an Inhaler?
Finally, the strategy advocates for the comprehensive management of modifiable risk factors and comorbidities, including providing smoking cessation advice, counseling on environmental control, and addressing conditions like obesity or GERD that can impede asthma control.
Global Implementation Challenges and Adaptations
While GINA's recommendations are evidence-based and clinically sound, their successful implementation on a global scale is hindered by significant practical barriers, particularly in low- and middle-income countries (LMICs). This disparity is a key reason GINA positions its document as a "global strategy" rather than a rigid set of guidelines.
The disproportionate burden of asthma in resource-constrained settings is exacerbated by several systemic challenges. Diagnosis is often based solely on a patient's symptoms because diagnostic tools such as spirometry and peak flow meters are either unavailable or unaffordable. This lack of objective confirmation can lead to both underdiagnosis and misdiagnosis. Furthermore, the cornerstone of GINA's treatment strategy—inhaled corticosteroids and combination inhalers—is frequently inaccessible due to high cost or lack of availability in rural areas. This forces a reliance on less effective oral therapies or, more commonly, on SABA alone, perpetuating the very practice GINA has worked to eliminate.
Patient-level barriers also contribute to suboptimal management. Adherence to medication is often poor due to a lack of understanding, cultural beliefs about inhalers, and the cost of treatment. This is compounded by a shortage of trained healthcare personnel, which impedes the consistent delivery of guideline-based care and effective patient education.
GINA’s 2025 World Asthma Day theme, "Make Inhaled Treatments Accessible for ALL," serves as a powerful acknowledgment of this crisis. The organization has highlighted that the lack of access to essential inhaled medications is a major contributor to the fact that 96% of global asthma deaths occur in LMICs, and that even in high-income countries, high costs can lead to poorly controlled asthma and preventable deaths. These advocacy efforts demonstrate GINA's recognition that addressing systemic and economic barriers is as vital as advancing clinical science.
To bridge this gap, GINA and other organizations have proposed practical adaptations. In settings where spirometry is unavailable, a clinical diagnosis based on the history of variable symptoms is a necessary starting point, with validated questionnaires used to standardize symptom monitoring. Simple educational tools and pictorial asthma action plans have proven effective in LMICs for improving adherence. For pharmacological treatment, dry powder inhalers may be a cost-effective alternative to pressurized inhalers, and in cases where inhaled medications are completely inaccessible, oral theophylline or leukotriene receptor antagonists may offer partial control with appropriate caution. Finally, task-sharing strategies, where trained non-physician health workers take on roles in asthma education and follow-up, have shown promise in improving outcomes in underserved regions.
Conclusion
The Global Initiative for Asthma (GINA) Classification plays a pivotal role in the global strategy for asthma management and prevention. Its evidence-based approach to classifying asthma severity and controlling symptoms has significantly influenced the standard of care for asthma patients worldwide. By providing a clear framework for healthcare professionals, GINA enhances the quality of asthma management, promotes patient education, and facilitates consistency in research and clinical practice. As the understanding of asthma continues to evolve, GINA remains at the forefront, guiding efforts to improve the lives of individuals affected by this chronic respiratory condition.
Reference
Global Initiative for Asthma (GINA), 2024. Global Strategy for Asthma Management and Prevention. [online] Available at: https://ginasthma.org/2024-report/ [Accessed 21 July 2025].
Reddel, H.K., Bacharier, L.B., Bateman, E.D., Brightling, C.E., Brusselle, G.G., Buhl, R., Cruz, A.A., Fleming, L.J., Inoue, H., Ko, F.W., and Krishnan, J.A., 2019. Global Initiative for Asthma Strategy 2019: executive summary and rationale for key changes. European Respiratory Journal, 53(6), p.1900737.
National Institute for Health and Care Excellence (NICE), 2021. Asthma: diagnosis, monitoring, and chronic asthma management. [online] Available at: https://www.nice.org.uk/guidance/ng80 [Accessed 5 May 2025].
Beasley, R., Semprini, A. and Mitchell, E.A., 2015. Risk-benefit ratio of LABA in asthma: urgent need for real-world surveillance. The Lancet, 385(9975), pp.1157–1159.
