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Explain this please step by step
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Here is a full step-by-step explanation of the GINA Guidelines 2025 chart for adults and adolescents aged 12+.
What is GINA?
GINA = Global Initiative for Asthma. These are internationally accepted guidelines for managing asthma. The 2025 update organizes treatment into two tracks and 5 steps, moving from mild to severe asthma.
The Two Tracks
The chart splits treatment into two parallel pathways depending on what inhaler the patient uses as their reliever (the "rescue" inhaler taken when symptoms hit).
TRACT 1 - Preferred Controller and Reliever (Top Track - PINK/GREEN)
This is the preferred approach. The key idea is that the same inhaler - ICS-formoterol (an inhaled steroid + fast-acting bronchodilator combo) - is used for BOTH daily control AND relief.
Why is it preferred? Using ICS-formoterol as the reliever reduces the risk of serious flare-ups compared to using a plain SABA (like salbutamol) as rescue, and it simplifies the regimen.
Reliever throughout all steps: As-needed low-dose ICS-formoterol
| Step | Treatment |
|---|---|
| Steps 1-2 | "AIR-only" - No daily controller. Just take low-dose ICS-formoterol as needed when symptoms occur. (AIR = Anti-Inflammatory Reliever) |
| Step 3 | MART with low-dose maintenance ICS-formoterol daily, PLUS the same inhaler as reliever. (MART = Maintenance And Reliever Therapy) |
| Step 4 | MART with medium-dose maintenance ICS-formoterol daily, PLUS same inhaler as reliever |
| Step 5 | Add LAMA (long-acting muscarinic antagonist, e.g. tiotropium). Refer for phenotype assessment. Consider high-dose ICS-formoterol. Consider biologics: anti-IgE (omalizumab), anti-IL5/5R (mepolizumab/benralizumab), anti-IL4Rα (dupilumab), anti-TSLP (tezepelumab) |
TRACT 2 - Alternative Controller and Reliever (Bottom Track - PURPLE/GREEN)
This track is for patients who are more likely to adhere to a daily controller but use a SABA (like salbutamol) as their reliever. Before choosing this track, check if the patient will actually take a daily controller pill/inhaler.
Reliever throughout: As-needed ICS-SABA*, or as-needed SABA alone
| Step | Treatment |
|---|---|
| Step 1 | Reliever only. If using SABA, also take an ICS with each SABA dose (to protect the airways) |
| Step 2 | Low-dose maintenance ICS daily (e.g. budesonide, beclomethasone) |
| Step 3 | Low-dose ICS-LABA daily (e.g. budesonide/formoterol or fluticasone/salmeterol) |
| Step 4 | Medium-dose ICS-LABA daily |
| Step 5 | Add LAMA. Refer for phenotype. Consider high-dose ICS-LABA. Consider biologics: anti-IgE, anti-IL5/5R, anti-IL4Rα, anti-TSLP |
Alternative "Other Options" at Each Step
The bottom row of the chart shows alternatives if the main options aren't suitable:
| Step | Alternatives |
|---|---|
| Step 2 | Low-dose ICS whenever SABA is taken; or daily LTRA (e.g. montelukast†); or HDM SLIT (house dust mite sublingual immunotherapy) |
| Step 3 | Medium-dose ICS alone; or add LTRA†; or HDM SLIT |
| Step 4 | Add LAMA; add LTRA†; or switch to high-dose ICS |
| Step 5 | Add azithromycin; add/refer LTRA†; add low-dose oral corticosteroids (OCS) - but only with caution due to side effects |
† When prescribing LTRA (montelukast), warn patients/caregivers about potential neuropsychiatric side effects (this is a specific FDA/regulatory warning).
Key Abbreviations Explained
| Abbreviation | Meaning |
|---|---|
| ICS | Inhaled corticosteroid (reduces airway inflammation) |
| LABA | Long-acting beta₂-agonist (opens airways for 12+ hours) |
| LAMA | Long-acting muscarinic antagonist (another bronchodilator class) |
| SABA | Short-acting beta₂-agonist (quick relief, e.g. salbutamol) |
| MART | Maintenance and Reliever Therapy - one inhaler does both jobs |
| AIR | Anti-Inflammatory Reliever - reliever that also treats inflammation |
| LTRA | Leukotriene receptor antagonist (e.g. montelukast) |
| SLIT | Sublingual immunotherapy |
| TSLP | Thymic stromal lymphopoietin (a cytokine targeted by tezepelumab) |
| OCS | Oral corticosteroid (e.g. prednisolone) |
The Big Picture - How to Use This Chart
- Start by deciding which track fits the patient (Tract 1 preferred for most).
- Assess symptom frequency and severity to pick the starting step.
- Step up if asthma is not controlled after 2-3 months.
- Step down once control is maintained for 3+ months to find the minimum effective treatment.
- At Step 5, the patient has severe/refractory asthma and needs specialist referral for biologic therapy based on their specific inflammatory phenotype (eosinophilic, allergic, etc.).
The 2025 update strongly favors Tract 1 / MART as the default because it automatically delivers an anti-inflammatory dose with every rescue puff, reducing the risk of dangerous exacerbations even in patients with intermittent symptoms.
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