GINA 2026: Achieving the best possible outcomes for people with asthma

Misdiagnoses, SABA-only treatment, and preventable deaths continue to haunt current asthma management but the latest report from the Global Initiative for Asthma (GINA) provides a road map to avoiding these issues, with the goal that all people living with asthma achieve the best possible long-term outcomes

The goals of asthma management are to prevent asthma deaths and reduce the burden of asthma on individuals, families and health systems and, for the individual, to achieve long-term asthma control, including:

• Few/no asthma symptoms
• No sleep disturbance due to asthma
• Unimpaired physical activity
• No exacerbations
• Improved or stable personal best lung function
• No requirement for maintenance oral corticosteroids, and
• No medication side-effects

It all starts with the diagnosis.

Failure to confirm a diagnosis of asthma risks unnecessary treatment for those who do not have the condition, or missed diagnoses of other serious conditions, the latest update to GINA asthma guidelines warns.

In one study of adults with an asthma diagnosis in the previous 5 years, the diagnosis could not be confirmed in a third, despite repeated testing. Some of these patients had serious cardiorespiratory conditions that had been misdiagnosed as asthma. Conversely, a Canadian study found that people with undiagnosed asthma had worse quality of life and more unscheduled healthcare visits than those with diagnosed asthma.

• In a patient presenting with chronic or recurrent respiratory symptoms, consider if the symptoms, history and examination are typical of asthma.
• If so, and if spirometry (or PEF) is available, perform lung function tests before and after bronchodilator. PEF is less reliable than spirometry but better than no objective measurement of lung function. If variable expiratory airflow is not confirmed, repeat tests during episodes of symptoms or consider additional tests.
• If spirometry is not available, consider biomarkers such as elevated FeNO or blood eosinophils. (Lower levels do not rule out asthma.)
• If other diagnoses are unlikely, treat empirically with ICS-containing treatment.
• If the patient presents with severely uncontrolled respiratory symptoms/signs, treat as exacerbation.

Responsiveness to bronchodilator (previously termed reversibility) is indicated by rapid improvements in FEV1 or PEF, measured soon after inhalation of a rapid-acting bronchodilator such as 200–400mcg salbutamol, or sustained improvement over days or weeks after initiation of ICS treatment.

The current recommendation is that an increase in FEV1 of 12% and ≥200 mL from baseline (or, if spirometry is not available, an increase in PEF of at least 20% from baseline) is a positive response consistent with asthma. GINA does not support an alternative proposal, of a change from baseline of >10% of the patient’s predicted value, even though this has been incorporated in some spirometry software.

It can be difficult to confirm a diagnosis of asthma with objective tests in patients who are already being treated for asthma with ICS. Consider repeating responsiveness tests after withholding bronchodilator: 4 hours for SABA, 24–48 hours for long-acting bronchodilators. If normal, consider:

• Other diagnoses, and
• Stepping down ICS-containing treatment.
  • If symptoms re-emerge and lung function falls, asthma is confirmed. Step up ICS-containing treatment to previous lowest effective dose
  • If there is no change in symptoms or lung function at lowest dose of maintenance ICS, consider stopping treatment or switching to as-needed ICS-formoterol. Monitor the patient closely for at least 12 months.

Asthma control

Asthma control is the extent to which treatment reduces or resolves the features of asthma. The two areas to assess are symptom control and risk of adverse outcomes. Poor symptom control places a significant burden on patients, but even patients with good symptom control can have severe exacerbations.

Assess symptom control in adults and young people (aged >11) from the frequency of day- and night-time symptoms, night waking and activity limitation, and for patients using SABA, frequency of SABA use. Tools for assessment include the Asthma Control Tests (ACT)and Asthma Control Questionnaire (ACQ).

Separately assess the patient’s risk factors for exacerbations, even if their symptom control is good. These include:

• History of ≥1 exacerbation in the previous year
• SABA-only treatment
• Socioeconomic problems
• Poor adherence
• Incorrect inhaler technique
• Low FEV1
• Smoking
• Raised blood eosinophils or FeNO

In patients on an anti-inflammatory reliever (AIR), such as needed low dose ICS-formoterol, average frequency of use over the past 4 weeks should be assessed and taken into account when reviewing the patient’s ICS dose or need for MART.

Investigate further if there are few symptoms but low symptoms, and consider alternative diagnoses if there are frequent symptoms despite good lung function.

In children aged 6-11, assessment of asthma control is based on symptoms, limitation of activities and use of rescue medication. Review carefully the impact of asthma on the child’s daily activities, including sports, play and social life and school attendance. Children with poorly controlled asthma may avoid strenuous activities, so their asthma may appear to better controlled than it is. Children also vary considerably in the degree of airflow obstruction before they complain of breathlessness or use their reliever. Parents or carers may report irritability, tiredness and mood changes when the child’s asthma is poorly controlled – and they have better long-term recall than the child, so ask them!

Suitable tools for assessing control in children include the Childhood Asthma Control Test (cACT). The Test for Respiratory and Asthma Control in Kids (TRACK) has been evaluated in children aged 5 years and younger.

A history of any exacerbation in the past 12 months should prompt review of the child’s medications, adherence and inhaler technique.

Assessing the severity of asthma (a retrospective process) can be useful, particularly for identifying patients whose asthma is refractory to high-intensity treatment with high-dose ICS + LABA, who may benefit from biologic treatment.

GINA recommends avoiding the term ‘mild asthma’. Although it is commonly used in clinical practice to describe patients with infrequent or mild symptoms, it is often incorrectly assumed that these patients are not at risk and do not need ICS-containing treatment. Even patients with infrequent symptoms can have severe or fatal exacerbations, and this risk is substantially reduced with ICS-containing treatment.

Control-based asthma management

Asthma treatment is adjusted in a continual cycle of assessment, treatment, and review of response in both symptom control, future risk of exacerbations and side effects, and patient preferences.

As in previous years, GINA’s preferred approach to therapy for adults and adolescents is an ICS-containing regimen, either as anti-inflammatory reliever – AIR – using ICS and formoterol in a single, combination inhaler as needed, or maintenance and reliever treatment – MART – again with combined ICS-formoterol, used daily or on a regularly scheduled basis. Combinations of ICS with non-formoterol LABAs, or ICS-SABA cannot be used for MART.

TABLE 1. RECOMMENDED TREATMENT FOR ADULTS AND ADOLESCENTS

Track 1 is the preferred approach because it reduces the risk of severe exacerbations, is simpler, and patients only need to use a single medication, single dose, and single device across treatment steps.

Patients whose asthma is not controlled on Step 4 therapy should be referred for expert assessment, phenotyping and add-on treatment for severe asthma.

Consider stepping down treatment when asthma symptoms have been well controlled, and lung function has been stable for at least 3 months. Stepping down ICS doses by 25–50% is feasible and safe in most patients, but:

• Engage the patient in the process
• Document their asthma status (symptom control, lung function and risk factors)
• Provide a written asthma action plan
• Ensure the patient has sufficient medication to resume their previous dose if necessary
• Monitor symptoms and/or PEF, and
• Schedule a follow-up appointment

TABLE 2. INITIAL TREATMENT IN CHILDREN AGED 6-11 YEARS

GINA says that from the available clinical trials, there is no clear advantage in efficacy between as-needed combination ICS-formoterol and as-needed ICS-SABA. But if separate ICS and SABA inhalers are prescribed, it is highly likely that the SABA inhaler would be used in preference to the ICS, leaving the child at risk of exacerbations.

Results from the important CARE study, comparing low-dose budesonide-formoterol with SABA alone, in children 5 – 15 years, showed that the ICS-formoterol combination used as-needed for symptom relief, reduced the risk of moderate to severe exacerbations by nearly half. There was no difference in growth rates between the two groups of children. Although the exact formulation used in this study has been discontinued, alternatives are available.

Be aware that regular SABA treatment or SABA overuse (at any treatment step) should be avoided. Use of 3 or more SABA inhalers in a year (average usage 12 inhalations/week) is associated with double the risk of emergency visits. Use of regular or frequent LABA without ICS is also strongly discouraged because of the risk of exacerbations.

Children aged 5 years and younger

Good control of asthma can be achieved in almost all young children.

Consider:

• The preferred medication option at each treatment step to control asthma symptoms and minimise future risk
• Response to previous treatment
• Patient characteristics that contribute to symptoms or risk of flare-ups, including
  • Clinical phenotype
  • Comorbidities including allergic rhinitis
  • Environment exposures, such as smoking in the home by parent/carer
  • Parent/carer preferences (goals, beliefs and concerns about medications)
  • Practice issues such as inhaler technique and adherence

GINA recommends a stepwise approach, based on symptom control, risk of exacerbations and side effects, and response to initial treatment. Generally, treatment for preschool children includes long-term daily use of low-dose ICS to maintain good asthma control. Initially, treatment should be given for 2–3 months to establish effectiveness (See Table 3). Children aged 5 years or less should be provided with SABA for as-needed symptom relief, by pMDI with mouthpiece or face mask as appropriate (Table 4).

• If a child needs more than 4 puffs of salbutamol in less than 4 hours, urgent medical care should be sought.

TABLE 3. ASTHMA MEDICATION OPTIONS FOR CHILDREN 5 YEARS AND YOUNGER

Once the diagnosis of asthma is confirmed, establish the minimal effective dose for each patient that controls their interval symptoms, and in combination with an action plan, reduces the risk of acute episodes and the need for oral corticosteroids. For dosing, consult the summary of product characteristics for each individual product.

In young children with persistent asthma, regular treatment with an LTRA may help to reduce symptoms, but daily ICS has been shown to be more effective in improving symptoms and reducing exacerbations than regular LTRA monotherapy. Parents/carers should be warned about the potential adverse effects on montelukast on sleep and behaviour.

TABLE 4. INHALER DEVICES FOR CHILDREN 5 YEARS AND YOUNGER

Management of asthma exacerbations

A major initiative by GINA this year has been the development of four new flowcharts to simplify and standardise assessment, treatment and follow-up of patients who present with an asthma attack, tailored to the patient’s age group and setting.

Each flowchart provides criteria for mild, moderate, severe and life-threatening presentations, with advice about initial and subsequent treatment and follow-up.

If the patient presents with signs or symptoms of anaphylaxis as well as asthma, a new recommendation is to administer epinephrine (adrenaline) before giving bronchodilators. Epinephrine can be administered as an intramuscular injection or as an intranasal spray, although the intranasal route is not suitable for small children.

Oxygen saturation thresholds and targets have been revised downwards, and supplemental oxygen is not recommended unless saturation is below 92%. The upper limit of the oxygen saturation target is 95% for adults, adolescents and child aged 6–11, and ≥92% for children 5 years and younger.

The recommended doses for short-acting beta2-agonist (SABA) are also lower than in previous GINA reports, because of the increasing evidence of over-treatment during acute exacerbations. High SABA doses increase the risk of SABA toxicity, including lactic acidosis, which may result in hyperventilation that can be misinterpreted as worsening asthma, and lead to further SABA administration.

ICS-formoterol has been added as a treatment option for a mild exacerbation in adults, adolescents and child aged 6–11 presenting in primary care, as an alternative to SABA. This option can also pave the way for patients to commence optimal anti-inflammatory reliever (AIR) treatment or maintenance and reliever therapy (MART) with ICS-formoterol, to reduce the risk of another exacerbation.

Information has also been added about tidal breathing technique with pMDI and spacer to each flowchart, as this is the most common route of administration in acute asthma, but technique is often incorrect.

GINA recommends that the patient’s response should be reviewed after the initial administration of a bronchodilator: ‘This seems obvious, but patients are sometimes written up for multiple administrations of SABA, without any review. If the patient is feeling much better and their symptoms and signs have improved after the initial dose, they may not need to be given more bronchodilator.’ Patients being treated in primary care whose condition is worsening – or not improving – should be transferred to higher level care immediately.

An asthma attack provides an important opportunity to confirm the diagnosis of asthma, by measuring lung function before and after bronchodilator treatment. Results of lung function tests should be documented.

Even a single exacerbation requiring urgent healthcare or oral corticosteroids (OCS) is a red flag alert that the patient’s treatment should be reviewed to help prevent another attack.

Conclusion

The latest GINA report reinforces the need for regular ICS for everyone with a diagnosis, with the possible exception of very young children with infrequent symptoms for whom ICS should be given when symptoms are present. Remember, patients with few or even no asthma symptoms can still have severe or fatal asthma attacks.

The safest and most effective treatment approach for adults and adolescents with asthma is the use of ICS-formoterol across all levels of disease severity. This avoids the risks associated with starting treatment with SABA alone, and offering a combination inhaler means that patients cannot ‘opt out’ of their ICS treatment.

This summary has picked out the main changes in this year’s report – with some repetition of existing recommendations for completeness – but Practice Nurse would urge you to read the full report: it contains a wealth of wisdom to help you improve the management of all your patients living with asthma.

The report is available free of charge (after a short period in 2025 when GINA imposed a paywall) at https://ginasthma.org/2026-gina-strategy-report/.

Reference

Global Initiative for Asthma. Global strategy for asthma management and prevention, 2026. https://ginasthma.org/2026-gina-strategy-report/