Important Recommendations in GINA 2025
All adults and adolescents with asthma must receive inhaled corticosteroid (ICS)-containing medication and should never be treated with short-acting beta-agonist (SABA) alone. 1
Core Treatment Framework: Two-Track System
GINA 2025 divides asthma management into two distinct treatment tracks 1:
Track 1 (Preferred Track)
- Use as-needed combination low-dose ICS-formoterol as the reliever medication 1
- This approach provides both symptom relief and anti-inflammatory protection with each use
- Preferred for adults and adolescents aged 12 years and older 2
Track 2 (Alternative Track)
- Uses SABA as the reliever medication alongside a separate ICS inhaler 1
- Less preferred due to risk of SABA overuse without adequate anti-inflammatory coverage
Stepwise Treatment Approach by Severity
Mild Persistent Asthma
- Low-dose inhaled corticosteroids are the preferred controller medication 2
- Alternative: as-needed low-dose ICS-formoterol for adults and adolescents 1
- Never use SABA monotherapy, even for mild disease 1
Moderate Persistent Asthma
- Preferred treatment is low-dose ICS plus long-acting beta-agonist (LABA) 2
- Maintenance-and-reliever therapy (MART) with ICS-formoterol is the preferred regimen 3
- Alternative options include medium-dose ICS alone or low-dose ICS plus leukotriene modifier 4
Severe Persistent Asthma
- High-dose ICS plus LABA is the preferred treatment 2
- Consider adding tiotropium or leukotriene receptor antagonist before oral corticosteroids 5
- Refer to asthma specialists before initiating oral corticosteroids 5
- Biologic therapy (omalizumab) may be added for patients aged 12 years and older with allergic asthma inadequately controlled on high-dose ICS/LABA 6, 7
Critical Safety Warnings
LABA Use
- LABAs must never be used as monotherapy due to increased risk of severe exacerbations and death 2
- Always combine with ICS therapy; FDA has issued a black-box warning against LABA monotherapy 6
Asthma Control Assessment
- Define "well-controlled" asthma as: daytime symptoms ≤2 days/week, no nighttime awakenings, rescue inhaler use ≤2 days/week, no activity limitations, and lung function ≥80% of personal best 4
- Assess control at regular intervals using validated tools like the Asthma Control Test 2
Essential Management Components
Written Asthma Action Plan
- Every patient must have a written asthma action plan 1
- Include daily medications, recognition of worsening symptoms, medication adjustments during exacerbations, and when to seek emergency care 4
- Provide copies to all caregivers and schools for children 6
Monitoring and Adjustment
- Step up therapy after verifying adherence, proper inhaler technique, and environmental trigger control 2
- Step down therapy if asthma has been well-controlled for at least 3 months 2, 4
- Schedule visits every 2-4 weeks after starting new treatment, then every 1-3 months once controlled 4
Specialist Referral Criteria
- Refer patients requiring Step 4 care or higher to an asthma specialist 2
- Refer before initiating oral corticosteroids for severe asthma to explore biologic options 5
Age-Specific Considerations
- Treatment recommendations are divided into three age groups: children under 5 years, children 5-11 years, and patients 12 years and older 2
- For children aged 4-11 years with persistent asthma, use low-dose ICS (100 mcg fluticasone/salmeterol combination twice daily) 8
- For children under 5 years, increase ICS dose before adding LABA 9
Common Pitfalls to Avoid
- Verify inhaler technique at every visit—poor technique renders treatment ineffective 10
- Monitor for overuse of SABA (>1 canister per month indicates need to increase controller therapy) 6
- Never abruptly discontinue corticosteroids when initiating new therapy 7
- Assess for oral candidiasis and advise patients to rinse mouth after ICS use 10, 8