What is the first line treatment for asthma according to GINA (Global Initiative for Asthma) guidelines?

GINA First-Line Treatment for Asthma

According to the most recent GINA guidelines, all adults and adolescents with asthma should receive inhaled corticosteroid (ICS)-containing medication as first-line treatment, with as-needed low-dose ICS-formoterol as the preferred reliever therapy—SABA monotherapy is no longer recommended. 1, 2

Preferred Treatment Approach (Track 1)

The cornerstone of GINA's current strategy is ICS-containing therapy from the outset, even for mild asthma. 1, 2

Step 1-2 (Mild Asthma):

• Preferred: As-needed low-dose ICS-formoterol as sole therapy 3, 1
• This approach prevents exacerbations while providing symptom relief 1
• Formoterol's rapid onset makes it suitable for both maintenance and reliever use 1
• Alternative: Daily low-dose ICS plus as-needed SABA (if ICS-formoterol unavailable) 3, 1

Step 3-4 (Moderate Asthma):

• Daily maintenance low-to-medium dose ICS-formoterol PLUS as-needed ICS-formoterol (SMART therapy) 3, 1
• This dual approach reduces exacerbations more effectively than fixed-dose therapy 3
• Studies primarily used budesonide-formoterol, though other ICS/formoterol combinations are theoretically effective 3

Step 5-6 (Severe Asthma):

• High-dose ICS-LABA with consideration for add-on therapies 3
• Add tiotropium (LAMA) before phenotype-specific biologics 1
• Consider anti-IgE, anti-IL5/5R, or anti-IL4R based on phenotypic assessment 3

Critical Implementation Points

SABA-only therapy is explicitly contraindicated as first-line treatment because it fails to address underlying inflammation and increases exacerbation risk. 2, 4

Age-Specific Considerations:

• Ages ≥12 years: ICS-formoterol preferred as reliever at all steps 3
• Ages 5-11 years: GINA does not recommend SMART therapy; use daily ICS with SABA reliever 3
• Under 5 years: Diagnosis relies on symptoms; bronchodilator response is variable 1

Formoterol vs. Salmeterol:

• Only formoterol should be used for SMART therapy due to rapid onset 3, 1
• Salmeterol has delayed onset and is unsuitable for reliever therapy 3

Evidence Strength and Nuances

The shift away from SABA monotherapy represents a major paradigm change supported by recent evidence showing ICS-formoterol as needed reduces severe exacerbations compared to SABA alone. 4 Real-world data from the PRIME study demonstrated that SABA-only therapy was associated with declining lung function and more severe exacerbations over 6 months. 4

Important caveat: While ICS-formoterol as needed is as effective as daily ICS for preventing exacerbations, some studies suggest it may be slightly inferior for day-to-day symptom control. 3 This should be part of shared decision-making with patients who prioritize symptom control over exacerbation prevention.

Dose-Response Considerations:

• The dose-response curve for ICS is relatively flat 5
• High starting doses provide minimal additional benefit over low-to-moderate doses for most efficacy parameters 6
• Start with low-dose ICS and add combination therapy rather than escalating to high-dose ICS monotherapy 5, 6

Essential Adjuncts to Pharmacotherapy

Every patient requires: 1

• Written asthma action plan
• Proper inhaler technique training
• Clear understanding of "relievers" versus "preventers"
• Identification and reduction of allergen/irritant exposure