Asthma management based on GINA guidelines

Diagnosis and the geriatric difficulty. Asthma is chronic airway inflammation with bronchial hyper-responsiveness and variable airflow obstruction, causing episodic wheeze, cough, chest tightness and dyspnoea, which is fully or partly reversible. It is under-diagnosed and misdiagnosed in older people, who have reduced awareness of bronchoconstriction, an impaired bronchodilator response from reduced beta-2 receptor density, and coexisting COPD. Confirm with spirometry showing reversibility or peak flow variability, and exclude heart failure, COPD, GORD, vocal cord dysfunction and drug-induced cough.

Assessment of control (GINA framework). Over the last 4 weeks ask about daytime symptoms more than twice a week, any night waking due to asthma, reliever use more than twice a week, and activity limitation — none = well controlled, 1–2 = partly controlled, 3–4 = uncontrolled. Separately assess risk factors for exacerbation (poor adherence, incorrect inhaler technique, high SABA use, low FEV , comorbidity) and treatment side effects.

The central GINA principle. Short-acting beta-2 agonist (SABA)-only treatment is no longer recommended at any step — it increases exacerbations and asthma death. Every adult with asthma should receive inhaled-corticosteroid-containing therapy, either as regular treatment or, at minimum, as ICS-formoterol taken whenever a reliever is needed.

GINA Track 1 (preferred) — ICS-formoterol reliever.

Add-on and add-back therapy in older adults. Adding a LABA gives better control than increasing the ICS dose, but a LABA must never be used as monotherapy because it does not treat inflammation. LAMAs (tiotropium, glycopyrronium, aclidinium) are of limited benefit alone but are useful added to ICS-LABA in the old, where reduced beta-2 receptor density relatively increases anticholinergic benefit — but they are contraindicated in urinary retention and glaucoma. Leukotriene modifiers are simple oral agents with proven efficacy in older adults; slow-release theophylline has a narrow therapeutic index. Biologics for severe disease target IgE (omalizumab), IL-5 (mepolizumab, reslizumab, benralizumab) and IL-4/IL-13 (dupilumab), but efficacy and safety data in patients over 65 remain sparse, so their use should be restricted to carefully selected cases.

Practical points and drugs to avoid. Always use an MDI with a spacer to reduce oropharyngeal candidiasis and dysphonia and to overcome coordination problems; tobacco smoking limits the efficacy of inhaled corticosteroids. Monitor control by symptoms, night-time relief, peak flow and where available exhaled nitric oxide. Beta-blockers (including topical glaucoma drops), verapamil, aspirin and NSAIDs can worsen asthma. Watch for ICS-related osteoporosis, cataract, glaucoma, skin thinning and dysphonia in long-term use, and give a written asthma action plan with carer involvement where cognition is impaired.

GINA 2024–2025 strategy reports have consolidated the two-track approach with anti-inflammatory reliever therapy as the preferred option at every step, and now explicitly extend anti-inflammatory reliever (AIR) therapy to mild asthma, so that no patient is left on SABA alone. They also formalise anti-inflammatory reliever combinations of ICS with a short-acting beta-2 agonist (ICS-SABA) as an alternative where ICS-formoterol is unavailable, emphasise biomarker-based phenotyping (blood eosinophils, FeNO, IgE) before escalating to a biologic, and highlight treatable traits and comorbidity management (obesity, GORD, rhinosinusitis, OSA, anxiety) — an approach that fits geriatric multimorbidity particularly well.