GINA 2023 no longer recommends SABA-only as Step 1 therapy. As-needed low-dose ICS-formoterol (SMART) is now the preferred reliever. Evidence shows this reduces severe exacerbations by up to 64% vs SABA-only. Every patient with asthma should have an ICS, not just a "blue reliever."
GINA 2023 — Assess asthma control at every visit. Adjust treatment based on current control level, not symptom severity alone.
| Feature | Well Controlled | Partly Controlled | Uncontrolled |
|---|---|---|---|
| Daytime symptoms | ≤2 days/week | >2 days/week | 3+ criteria of partly |
| Nocturnal waking | None | Any | |
| Reliever use | ≤2 days/week | >2 days/week | |
| Activity limitation | None | Any | |
| Lung function (FEV1/PEF) | ≥80% predicted | <80% predicted | |
| Exacerbations | None in past year | ≥1/year | 1 in any week |
High reliever (SABA) use
>1 canister/month = danger sign
Poor ICS adherence / technique
Most common cause of poor control
Smoking
Reduces ICS efficacy; accelerates decline
FEV1 <60% predicted
Independent risk for exacerbations
Blood eosinophils >300/μL
Predicts exacerbations; guides biologics
Previous near-fatal asthma
ICU/intubation = highest risk
Obesity
Reduces ICS response, harder to control
Anxiety/depression
Poor adherence + perception mismatch
Onset: Asthma = childhood/young adult; COPD = >40yrs, smoker
Reversibility: Asthma = significant (≥12%+200mL); COPD = incomplete
Eosinophils: High in asthma; variable in COPD
ICS response: Excellent in asthma; partial in COPD
Smoking: Not required in asthma; typically present in COPD
Features of both asthma and COPD present simultaneously
Criteria: Age >40, smoking history, incomplete reversibility + atopy/allergy or eosinophilia
Treatment: ICS + LABA (never LABA alone in ACO — risk of death)
Prognosis: Worse than either alone — more exacerbations, faster decline
Hypertension
HTN management module
Diabetes
DM management module
Emergency
All emergency protocols
Drug Database
Full dosing & interactions
Based on GINA 2023, GOLD 2024, BTS/SIGN 2023, NICE NG115 (Asthma) & NG115 (COPD). Always individualise management. Refer severe/difficult cases to respiratory specialist.