Summary of Updates in Asthma Management According to GINA 2025

Introduction
In May 2025, the GINA 2025 update was published globally, highlighting several key changes in asthma management. These updates focus on shared decision-making in inhaler selection, treatment adjustment options in personalized asthma action plans, and a simplified decision-making algorithm for severe asthma. Notably, fenoterol has been added to the list of bronchodilators that are not recommended due to its high risk of cardiovascular adverse effects and asthma-related mortality.

Similar to previous GINA reports, the 2025 GINA update is based on biannual evidence reviews, forming the foundation for recommendations issued by the GINA Science Committee. The Committee, comprising leading experts in adult and pediatric asthma research, conducted a full-text review of 78 publications, of which 59 were discussed in committee meetings.

Key updates in GINA 2025

1. General Principles for Treatment Decisions

Asthma treatment decisions should be guided both by population-level evidence (for guidelines and policy) and individualized assessment for each patient.When tailoring treatment, clinicians should consider phenotype characteristics, biomarkers, comorbidities, patient preferences, and practical factors. 

2. Treatment Strategies for Adults and Adolescents

GINA 2025 continues to recommend the two-track treatment model:

• Track 1 (Preferred): As-needed ICS–formoterol, if available, as it substantially reduces the risk of severe exacerbations, the need for systemic corticosteroids, hospitalizations, and mortality, while simplifying treatment (single inhaler only).
• Track 2: For patients without access to ICS–formoterol, treatment remains based on SABA, but always in combination with ICS.

Adjustments in Track 2, Step 4:

• Change from medium–high dose ICS–LABA to medium dose ICS–LABA, to minimize exposure to high-dose ICS.
• If high-dose ICS is required, its use should be limited to 3–6 months.

Adjustment of fluticasone furoate dosing:

• Daily doses are reclassified as low–medium (100 mcg) and medium–high (200 mcg), to align with other ICS preparations and reduce confusion.

•  Other controller options:

• May be considered in specific cases (e.g., adding a LAMA at Step 4 when ICS–LABA is insufficient).
• Evidence remains limited, and referral to a specialist for difficult-to-control asthma should not be delayed by repeated trials of additional controllers.

3. Bronchodilators

Fenoterol has been added to the list of non-recommended agents due to its increased risk of cardiovascular adverse events and asthma-related mortality.

4. Inhaler Choice: Emphasis on the order of consideration:
– Select the most appropriate medication for the patient.

– If multiple inhaler types are available for that medication, environmental factors may then be considered—provided the patient can use the device correctly.

5. Action Plan

• For Track 2 (SABA-based): Increase SABA dosing to relieve symptoms. Evidence is modest that doubling or quadrupling the maintenance ICS dose reduces the risk of severe exacerbation requiring oral corticosteroids (OCS).
• For Track 1 (ICS–formoterol as reliever): Patients continue regular maintenance but increase doses as needed to address inflammation and bronchoconstriction. Strong evidence shows this approach significantly reduces the risk of severe exacerbations requiring OCS and urgent care.

6. Management of Severe Asthma Exacerbations (Children 6–11 years, Adolescents, Adults)

• Clarification of initial SABA dosing in emergency and primary care to avoid overuse.
• Nebulized magnesium is no longer recommended.

7. Severe Asthma Decision Tree

• Updated and simplified decision-making algorithm.
• Severe asthma should only be confirmed after excluding comorbidities and following specialist assessment (Stage 5).
• Type 2 biomarkers (eosinophils, FeNO) should be reassessed if the clinical context changes.
• Biologics: efficacy and safety supported for up to 5 years, with no longer-term data currently available.

Conclusion

The GINA 2025 guidelines emphasize prioritizing asthma management through the Track 1 approach (ICS–formoterol), minimizing exposure to high-dose ICS, standardizing action plans, updating the management of acute exacerbations and severe asthma, and reinforcing the principle of individualized treatment. In addition, among short-acting β₂-agonists (SABA), fenoterol is no longer recommended due to its high risk of cardiovascular adverse effects and asthma-related mortality. This highlights the preference for safer SABA options, such as salbutamol or terbutaline, in asthma management.

Reference:

Global Initiative for Asthma. Global strategy for asthma management and prevention (2025 update). Updated May 7, 2025. Available at: https://ginasthma.org/2025-gina-strategy-report/