What is the recommended treatment approach for managing asthma according to the latest GINA (Global Initiative for Asthma) guidelines?

GINA 2025 Asthma Management Recommendations

The latest GINA guidelines recommend a stepwise approach to asthma management with inhaled corticosteroids (ICS) as the cornerstone of treatment, with two preferred tracks: maintenance and reliever therapy or fixed-dose therapy, both personalized to patient needs and risk factors. 1

Core Treatment Principles

• ICS-based controllers should be initiated as early as possible in asthma management 1
• Short-acting beta-2 agonists (SABA) alone without regular ICS are no longer recommended for symptom relief in asthma 1
• Treatment should be personalized based on risk factors for poor outcomes, patient compliance, and expectations 1

Stepwise Treatment Approach

Track 1: Maintenance and Reliever Therapy

• Uses ICS-formoterol as both maintenance and as-needed relief medication 1
• Provides more flexible dosing that adjusts to symptom variability 1
• May lead to better asthma control with lower overall corticosteroid exposure 2

Track 2: Fixed-Dose Therapy

• Uses regular fixed doses of controller medications with separate reliever 1
• Traditional approach with scheduled dosing of medications 3
• May be preferred for patients who benefit from consistent dosing regimens 1

Step-Up and Step-Down Strategies

Step-Up Long-Term Strategy

• Indicated for persistent lack of control over extended periods 3
• Involves increasing the overall medication regimen 3
• May include increasing ICS dose or adding additional controllers like LABA 4

Step-Up Short-Term Strategy

• Used during temporary loss of control (e.g., viral respiratory infections) 3
• Treatment intensification typically lasts 3-10 days until control is regained 3
• May involve temporarily doubling ICS dose or adding oral corticosteroids 3

Step-Down Considerations

• Should be attempted once good control has been maintained for 3 months 2
• Gradual reduction in corticosteroid dose to minimize risk of relapse 5
• Careful monitoring of symptoms, lung function, and exacerbation risk during reduction 5

Severe Asthma Management

• Add-on treatments should be considered before initiating phenotype-specific treatments 1
• Biologic agents are recommended for appropriate phenotypes of severe asthma 1
• Aspirin desensitization may be considered in specific cases 1

Monitoring and Follow-Up

• Regular assessment of symptom control, lung function, and exacerbation risk 4
• Inhaler technique should be checked and recorded at each visit 6
• Peak expiratory flow (PEF) monitoring can help assess variability and response to treatment 6
• Follow-up within 1-4 weeks after treatment changes is recommended 6

Common Pitfalls to Avoid

• Underuse of corticosteroids is a major factor in poor asthma outcomes 6
• Failure to recognize severity by both clinicians and patients can lead to delayed treatment 6
• Overreliance on SABAs without adequate anti-inflammatory therapy 1
• Inadequate step-down planning after achieving control can lead to overtreatment 5
• Failure to address comorbidities that may worsen asthma control 2

Special Considerations

• Patients transitioning from systemic corticosteroids to inhaled therapy require careful monitoring for adrenal insufficiency 5
• Strong CYP3A4 inhibitors should be avoided with ICS/LABA combinations due to increased risk of systemic effects 5
• Paradoxical bronchospasm may occur with inhaled medications and requires immediate discontinuation 5
• Cardiovascular effects should be monitored in patients using LABAs, especially those with pre-existing cardiovascular disorders 5