The burden of asthma exacerbations and mortality is disproportionately seen in low- and middle-income countries (LMIC), where essential inhaled medications such as short-acting beta2-agonists (SABA) and inhaled corticosteroids (ICS) are often unavailable or unaffordable. Asthma is often managed as a recurrent acute event with high-dose SABA and oral corticosteroids (OCS), which have cumulative long-term adverse effects. Guidelines developed for LMICs are based on the historical assumption, unsupported by evidence and unchallenged until recently, that patients with asthma symptoms <1–3 times per week do not need ICS.
The Global Initiative for Asthma (GINA) recommends a simple single-inhaler strategy across all treatment steps from the time of diagnosis, using low-dose combination ICS-formoterol, which can be used for both symptom relief and maintenance controller treatment. Used only as-needed, ICS-formoterol reduces the risk of emergency visits or hospitalisations by two-thirds compared with SABA-only treatment. The same inhaler can be added as regular maintenance treatment if needed, reducing severe exacerbations compared with a higher dose of ICS plus as-needed SABA. The single-inhaler ICS-formoterol strategy also avoids setting up SABA reliance, requires only one medication strength for most asthma patients, and avoids confusion about different inhaler techniques.
This paradigm-changing GINA strategy has great potential to reduce asthma burden, but ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. To make progress, a World Health Assembly Resolution on universal access to affordable and effective asthma care is needed, along with cost-effectiveness analyses of the GINA strategy for the context of LMICs.
GAN gratefully acknowledges funding from the University of Auckland and Wellcome (Grant number 203919/Z/16/Z) as well as sponsorship from AstraZeneca and GlaxoSmithKline that has helped to make the GAN Symposium 2024 possible. We thank the speakers and the organisations they represent for their contributions including securing their own funding to enable their participation. The Symposium programme was developed independently by the GAN Steering Group.
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