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HelixTalk Episode #104 - Breathtaking Updates from Global INitiative for Asthma (GINA) Guidelines 2019

Date posted: November 12, 2019, 6:00 am

In this episode, we will discuss what is the latest and greatest from the GINA (Global INitiative for Asthma) 2019 guidelines, including new recommendations regarding rescue inhalers, tiotropium, and azithromycin for asthma.


Key Concepts

  • NAEPP is the widely practiced guidelines in the US, but the last update was in 2007.  GINA represents “global” guidelines (not specific to the United States) and are updated yearly with twice yearly literature review.
  • As-needed low dose inhaled corticosteroids (ICS) with formoterol is a preferred option for steps 1 and 2 of asthma (mild asthma) in those 12 years and older. A short-acting beta agonist (SABA) as-needed as acute reliever is no longer recommended in these patients by the 2019 GINA guidelines. 
  • Tiotropium fine mist inhaler add-on is preferred over biologics in step 5 of asthma therapy. It is also recommended as an add-on therapy as an alternative controller option for step 4 patients.
  • Off-label use of low dose azithromycin (500 mg three times a week) is recommended for persistent symptomatic asthma despite moderate-high dose ICS + LABA. Data showed reduced exacerbations and improved asthma related quality of life, but safety issues and concerns for resistance may limit its widespread use.


  1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019. Available from:
  2. National Asthma Education and Prevention Program Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma. October 2007. Available from:
  3. O'Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled Combined Budesonide-Formoterol as Needed in Mild Asthma. N Engl J Med. 2018 May 17;378(20):1865-1876. doi: 10.1056/NEJMoa1715274.
  4. Bateman ED, Reddel HK, O'Byrne PM, et al. As-Needed Budesonide-Formoterol versus Maintenance Budesonide in Mild Asthma. N Engl J Med. 2018 May 17;378(20):1877-1887. doi: 10.1056/NEJMoa1715275.