Diagnostic Steps and Treatment Recommendations for Asthma According to GINA 2025
The Global Initiative for Asthma (GINA) 2025 guidelines recommend a structured approach to asthma diagnosis that requires objective pulmonary function testing, with treatment based on a stepwise approach that includes inhaled corticosteroids (ICS) for all patients, even those with mild asthma.
Diagnostic Steps
Step 1: Clinical Assessment
- Focus on recurrent wheeze (most specific symptom with sensitivity 0.55-0.86 and specificity 0.64-0.90) 1
- Document pattern, frequency, and severity of respiratory symptoms
- Identify triggers and response to previous treatments
- Assess risk factors for persistent asthma (parental history, allergic rhinitis, blood eosinophilia) 1
Step 2: Objective Testing (at least two abnormal tests required for diagnosis)
Spirometry with bronchodilator reversibility testing (first-line)
- Abnormal results: FEV1 or FEV1/FVC < lower limit of normal (LLN) or <80% predicted
- Positive bronchodilator response: ≥12% and/or ≥200 mL improvement 1
FeNO measurement (recommended before spirometry)
- Cut-off value: ≥25 ppb indicates airway inflammation 1
Peak Expiratory Flow (PEF) variability
- Measured over 2 weeks with twice-daily readings
- Significant variability: ≥12% 1
Challenge testing (when other tests inconclusive)
- Direct bronchial challenge with methacholine
- Indirect testing using exercise (treadmill/bicycle) 1
Step 3: Diagnostic Trial (if needed)
- A trial of ICS treatment may be considered when diagnosis remains uncertain
- Important: Diagnosis should not be based solely on symptom improvement but must include objective improvement in lung function tests after 4-8 weeks 2, 1
Treatment Recommendations
General Principles
- All patients should receive ICS-containing therapy - GINA no longer recommends SABA-only treatment at any step 3
- Treatment follows two tracks with a stepwise approach based on symptom control 3
Track 1 (Preferred)
- Step 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol
- Steps 3-5 (Moderate-Severe): Daily maintenance ICS-formoterol plus as-needed ICS-formoterol (MART approach) 3
Track 2 (Alternative)
- Step 1: As-needed SABA with low-dose ICS taken whenever SABA is used
- Step 2: Daily low-dose ICS plus as-needed SABA
- Steps 3-5: Daily ICS-LABA at increasing doses plus as-needed SABA 3
Step 5 Add-on Options for Severe Asthma
- Long-acting muscarinic antagonists (LAMA)
- Azithromycin (in adults)
- Biologic therapies based on inflammatory phenotype 3
Monitoring and Follow-up
- Regular assessment of symptom control and risk factors
- Monitoring of lung function to detect early deterioration
- Follow-up visits every 2-4 weeks after initial therapy, then every 1-3 months 4
- Adjust treatment based on control (step up if not controlled, consider step down after 3 months of good control) 2
Risk Factors for Asthma-Related Death
- History of asthma requiring intubation/mechanical ventilation
- Hospitalization or emergency care for asthma in past year
- Current or recent oral corticosteroid use
- No current ICS use
- Overuse of SABA (>1 canister/month)
- Poor adherence to medication
- Comorbidities including food allergies 4
Special Considerations
- For children under 5 years, diagnosis is more challenging and relies more heavily on clinical assessment
- Consider referral to an asthma specialist for patients with:
- Difficulty achieving or maintaining control
- ≥2 courses of oral corticosteroids in one year
- Hospitalization for asthma
- Step 4 care or higher required 2
The GINA 2025 guidelines emphasize the importance of objective testing for diagnosis, ICS-containing therapy for all patients, and a personalized approach to treatment based on symptom control and risk factors.