【Spain】GEMA 5.4: Updates in Asthma Management

The Spanish Guide for Asthma Management (GEMA) is a clinical practice guide aimed at improving the quality of care provided by healthcare professionals to people with asthma. Version 5.4 of the manual incorporates, as one of the most significant innovations, an updated version of GEMA Paciente, a document that uses informal and simple language for non-medical professionals.

Consultation of GEMA version 5.4 can also be done with iaGEMA, an Artificial Intelligence (AI) tool. Essentially, iaGEMA has two objectives: first, to be a quick consultation tool for healthcare professionals, who until now had to search in the paper or digital GEMA booklet. Consulting such documents—whether paper or digital—always takes a certain amount of time (searching the index, looking at the chapter, finding exactly where the answer is within the chapter), while AI allows the user to ask a question and then, very quickly, this advanced tool provides the appropriate answer. Secondly, iaGEMA acts as a kind of ‘problem-case’ consultant, meaning the doctor or nurse presents the case and the application helps them, in that context of clinical problem-solving, to make decisions regarding a specific patient.

Delving into the actual contents of the guide, it is worth noting that the new GEMA determines that overweight or obesity during pregnancy is associated with a possible development of asthma pathology in the child to be born. This is explained by a study conducted in the United States involving thousands of children. This publication provides robust evidence on a contingency that had not been confirmed until now, and thus it is demonstrated that, indeed, children of women who are overweight while pregnant have, from birth, a higher risk of developing asthma.

Furthermore, version 5.4 includes an identification of extreme climate variations (hurricanes, tornadoes, thunderstorms, etc.) that act as triggers for asthma crises or exacerbations. This identification stems from a very interesting article that reviews what has been published to date on the subject, and which now confirms that these climatic and meteorological phenomena are associated with a possible manifestation of crises or severe acute exacerbations of asthma.

Another topic addressed focuses on the impact of recurrent exacerbations on the future risk of asthma and a possible decrease in response to subsequent treatments. Thus, in recent years, data from very large sample populations have confirmed what was suspected: that asthma crises, especially if severe, can lead to a series of consequences for the future. This means that, although these people overcome the crises, the episodes they have suffered will, over time, favor the appearance of a deterioration in lung capacity and greater obstruction of airflow, and therefore they will suffer a more severe disease and present worse response rates to treatments.

On the other hand, GEMA 5.4 establishes a period of three years to determine the possible achievement of complete asthma remission and proposes a new subtype of complete remission, known as ‘remission in asthma and chronic rhinosinusitis with nasal polyps (CRSwNP)’. It is obvious to everyone that the topic of remission has been, and is, a recurring debate among experts, especially because the concept of remission is arbitrary; it is not a diagnostic concept based on a biopsy, for example, but is based on a series of diagnostic and clinical circumstances through which different levels of disease quiescence are established.

Well, our guide has incorporated a consensus driven by GEMA itself and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) in which a new type of remission is defined, which is remission in the unified airway of asthma and nasal involvement. According to this, in addition to the established or mostly accepted criteria for complete remission, it also contemplates the incorporation of improvement indicators for CRSwNP associated with asthma.

The new concept of complete remission is much more demanding than previous ones, as it takes nasal involvement into account. This is important because complete remission can only be considered if it has been previously confirmed that the nasal discomfort linked to polyposis has also been quelled. It is worth remembering that asthma is a disease that affects two organs, the bronchi and the nose, and it is the damage suffered in the nasal organ that often conditions a worse quality of life. In summary, according to the new complementary concept of complete remission of the unified airway, if a person with severe asthma has managed to reduce the severity of the asthma but has not improved the nasal involvement suffered, it will be considered that they have not yet achieved complete remission.

But perhaps the most innovative contribution of this edition of our guide is the one revolving around the incorporation of combination treatments for individuals suffering from severe asthma and CRSwNP.