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The Global Initiative for Asthma (GINA) was established in 1993 by the World Health Organization and the US National Heart Lung and Blood Institute to improve asthma awareness, prevention and management worldwide. GINA develops and publishes evidence-based, annually updated resources for clinicians. GINA guidance is adopted by national asthma guidelines in many countries, adapted to fit local healthcare systems, practices, and resource availability. GINA is independent of industry, funded by the sale and licensing of its materials. This review summarizes key practical guidance for primary care from the 2022 GINA strategy report. It provides guidance on confirming the diagnosis of asthma using spirometry or peak expiratory flow. GINA recommends that all adults, adolescents and most children with asthma should receive inhaled corticosteroid (ICS)-containing therapy to reduce the risk of severe exacerbations, either taken regularly, or (for adults and adolescents with “mild” asthma) as combination ICS–formoterol taken as needed for symptom relief. For patients with moderate–severe asthma, the preferred regimen is maintenance-and-reliever therapy (MART) with ICS–formoterol. Asthma treatment is not “one size fits all”; GINA recommends individualized assessment, adjustment, and review of treatment. As many patients with difficult-to-treat or severe asthma are not referred early for specialist review, we provide updated guidance for primary care on diagnosis, further investigation, optimization and treatment of severe asthma across secondary and tertiary care. While the GINA strategy has global relevance, we recognize that there are special considerations for its adoption in low- and middle-income countries, particularly the current poor access to inhaled medications.

Geneviève Pelletier,1 Krystelle Godbout,1,2 Marie-Ève Boulay,1 Louis-Philippe Boulet,1,2 Mathieu C Morissette,1,2 Andréanne Côté1,2 1Quebec Heart and Lung Institute – Laval University, Quebec, QC, Canada; 2Department of Medicine, Faculty of Medicine, Laval University, Quebec, QC, CanadaCorrespondence: Andréanne Côté, Quebec Heart and Lung Institute – Laval University, 2725 chemin Sainte-Foy, Quebec, QC, G1V 4G5, Canada, Tel +1 418 656 4747, Fax +1 418 656 4762, Email andreanne.cote@criucpq.ulaval.caPurpose: Monoclonal antibodies targeting interleukin-5 (IL5) and its receptor (IL5R), used for severe asthma treatment, reduce eosinophils to almost complete depletion. Fractional exhaled nitric oxide (FeNO), a surrogate marker of eosinophilic airway inflammation, is expected to decrease after their initiation. Our center noticed increased FeNO levels in a few patients in whom anti-IL5/IL5R therapy was initiated. Limited data are available on the kinetics of T2 inflammation biomarkers after initiation of a biologic in that population. This study aims to identify if a subgroup of severe asthma patients experiences increased FeNO levels after initiation of anti-IL5/IL5R therapy and to describe their clinical characteristics.Patients and Methods: This is a retrospective case series of 5 patients on Benralizumab (4M:1F) and 8 on Mepolizumab (5M:3F) who showed a significant increase in FeNO (> 20% AND > 25 ppb) following initiation of an anti-IL5/IL5R treatment. Clinical data, expiratory flows, and inflammation were extracted from the patients’ chart at initiation of treatment (T0), 3 months (T1) and 12 months (T2) post-treatment. Descriptive statistics were used.Results: In patients treated with Benralizumab, the increase in FeNO was observed between T0 and T1 (mean delta = 82 ± 72 ppb) with a subsequent decrease (N = 3). In most patients taking Mepolizumab (N = 6), the FeNO increase was observed between T1 and T2 (mean delta = 57 ± 35 ppb). Under treatment, no Benralizumab patient experienced asthma exacerbation while two on Mepolizumab did. All patients had a significant decrease in blood eosinophils.Conclusion: Although initiation of anti-IL5/IL5R may cause a transient rise in FeNO levels in a subgroup of patients, it does not appear to affect clinical outcomes. A compensatory mechanism involving other inflammatory pathways such as IL13 or IL4, both involved in FeNO production, could theoretically explain these findings. Further investigation is needed to elucidate the actual underlying mechanisms.Keywords: biologics, biomarkers, Benralizumab, Mepolizumab

OBJECTIVE: To improve the use of asthma action plans (AAPs) among primary care physicians. SOURCES OF INFORMATION: In a 2017 article, recent asthma guidelines and adult studies (January 2010 to March 2016) addressing acute loss of asthma control were reviewed to develop an evidence-based tool to help guide physicians in creating AAPs to maximize adherence and minimize errors. Evidence supporting the effects of AAPs is level I. Evidence supporting the recommendations in the tool ranges from level I to consensus. MAIN MESSAGE: A lack of knowledge about and training in creating appropriate AAP content is an important barrier to the use of AAPs, as is the fact that instructions provided by asthma guidelines are often difficult to integrate into real-world practice. In order to address these issues, a freely accessible, practical, evidence-based tool has recently been created, addressing both the knowledge and the practical barriers to AAP creation. This tool has been formatted as a printable bedside chart for the point of care, but could also be integrated into a computerized electronic decision support system in the future. CONCLUSION: Asthma action plans, in conjunction with asthma education and regular follow-up, can improve patients’ symptoms and quality of life and reduce hospitalization. This novel point-of-care tool provides practical advice on how to complete AAPs to improve patients’ asthma self-management.