Guideline	Step 1	Step 2	Step 3	Step 4	Step 5
GINA 2025	Low dose ICS-LABA (budesonide-formoterol) as needed	Low-dose ICS-LABA (budesonide-formoterol) as needed	Low dose ICS-LABA daily and as needed (MART*)	Medium dose ICS-LABA daily and as needed (MART*)	Refer to pulm. Add-on LAMA; can trial high dose maintenance ICS-LABA; consider biologics.
Reliever: as needed low-dose ICS-formoterol

Asthma

Background

Definition: chronic airway inflammation, with episodic respiratory symptoms and variable expiratory airflow
Risk factors: allergies, atopic dermatitis, family history of asthma, low SES

Recurrent wheezing, difficulty breathing, chest tightness, and cough that vary over time and in intensity
Symptoms occur or worsen at night or in early morning. Triggers can include exercise, viral infection, exposure to allergens and irritants, changes in weather, laughter, etc.
Ddx: upper airway obstruction, foreign body, COPD, ILD, vocal cord dysfunction, CHF, ACE-i induced cough, OSA

Characteristic respiratory symptoms AND variable expiratory airflow confirmed with lung function testing (order spirometry pre/post bronchodilator)
Spirometry shows positive bronchodilator responsiveness (increase in FEV1 ≥12% and ≥200L 10- 15 min after rapid-acting bronchodilator administration)
Consider methacholine challenge test (sensitive, not specific) if spirometry normal
CBC with diff may show eosinophilia in Type 2 asthma, eosinophilic asthma
If concerned for allergic asthma or allergic bronchopulmonary aspergillosis, consider measuring total serum IgE levels

SABA over-use, inadequate ICS (due to poor adherence or not being prescribed), exposures to allergens or irritants, psychosocial problems, poor lung function (FEV1 <60% predicted), high type 2 inflammatory markers (blood eos), and hx of severe exacerbation

Use the lowest possible step to maintain control. Step down therapy if pt has been well-controlled for 2-3 months.
Prior to escalating therapy, consider adherence (including inhaler technique), uncontrolled comorbidities (allergies, GERD, OSA, obesity), and alternative diagnoses
Ensure pts receive MDI and spacer teaching
Avoid SABA-only therapy due to increased risk of exacerbation, lower lung func, and asthmarelated death. Per guidelines ICS-containing medication is recommended for all patients, though may be insurance barriers.

Assessment	Questions	Interpretation
Assess for Symptom Control (GINA 2025)	In the past four weeks, has the patient had: Daytime asthma symptoms more than twice/week? Any nighttime waking due to asthma? Use of SABA inhaler for symptoms more than twice/week? Any limits to activity due to asthma?	Well controlled: none of these Partly controlled: 1-2 of these Uncontrolled: 3-4 of these

*MART: maintenance and reliever therapy
Suggested Initial Treatment Step (GINA 2025)

Infrequent symptoms <1-2 days/wk: Step 1
Symptoms <3-5 days/wk, with normal or mildly reduced lung func: Step 2
Symptoms most days, ≥1 nighttime awakening per week, or low lung func: Step 3
Daily symptoms, ≥1 nighttime awakening per week, low lung func, or current smokers: Step 4

Defined retrospectively based intensity of therapy which achieves symptom control for 2-3mo. Severe asthma is uncontrolled on high-dose ICS-LABA
Mild asthma is controlled on Step 1-2 therapy. Moderate controlled with Step 3-4. Severe controlled with Step 5 or remains uncontrolled despite Step 5.

Wixela (fluticasone-salmeterol) is the formulary ICS/LABA. See local policies for most updated information.