GINA · 2026

Bronchial Asthma — Management Guideline

Source: Global Initiative for Asthma (GINA), Global Strategy for Asthma Management and Prevention, 2026 update (May 2026)

✓ Edition checked 3 Oct 2026 — GINA 2026 is the current edition as of this date.

View the official source ↗

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Based on a history of typical variable respiratory symptoms (wheeze, shortness of breath, chest tightness, cough) plus confirmed variable expiratory airflow. In adults a positive bronchodilator response is an increase in FEV1 (or FVC) of at least 12% and at least 200 mL from baseline, or a PEF increase of at least 20% if spirometry is unavailable. GINA 2026 kept this criterion because the >10%-of-predicted criterion proposed in 2022 would underdiagnose asthma, particularly in younger males. Test before treating: confirm the diagnosis before starting ICS-containing treatment whenever possible.

⚠ Alarm features (investigate before diagnosing)

Sudden severe breathlessness with cyanosis or a silent chest (impending respiratory failure)
Poor response to reliever inhaler during an acute exacerbation
Oxygen saturation below 92% on room air
Features of anaphylaxis alongside asthma (give epinephrine first, then bronchodilators)
Worsening or no improvement after the initial bronchodilator in primary care (transfer to a higher level of care immediately)
Signs suggesting an alternative diagnosis: unilateral wheeze, clubbing, significant weight loss, hemoptysis

Initial workup

Test	When to order
Spirometry with bronchodilator responsiveness	At initial diagnosis, ideally before ICS-containing treatment is started. Also strongly recommended for every patient presenting with an exacerbation (except life-threatening presentations) and again before discharge.
Peak expiratory flow (PEF) diary	When spirometry is unavailable or the diagnosis is uncertain; average daily diurnal PEF variability above 10% in adults supports the diagnosis. Use the best of 3 readings and the same meter each time.
FeNO or blood eosinophils	Can support a diagnosis of Type 2 asthma when spirometry/PEF is unavailable or normal (FeNO above 50 ppb in adults and adolescents), but may be raised in non-asthma conditions and lower levels do not rule out asthma.
Objective confirmation in patients already taking ICS-containing treatment	If the diagnosis was never objectively documented: repeat spirometry/PEF, and if needed step down the ICS dose by 25-50% with close supervision and review at 2-4 weeks. In primary care the diagnosis cannot be confirmed in about 25-35% of patients previously labeled as having asthma.
Inhaler technique and adherence check	Before escalating therapy for poor control.

✕ Tests the guideline advises against

Using the >10%-of-predicted bronchodilator-response criterion alone to exclude asthma: GINA 2026 retained the criterion of an FEV1 increase of at least 12% and at least 200 mL; people with physician-diagnosed asthma who were negative by the >10%-of-predicted criterion had a high respiratory burden, so using it alone risks underdiagnosis.

Treatment

Steps 1-2 (Track 1, preferred: mild or infrequent symptoms)

1 As-needed low-dose ICS-formoterol as an anti-inflammatory reliever (e.g., budesonide-formoterol) Strong (Guideline recommendation) — Track 1 is preferred; preferred over a SABA-only reliever at any severity

Dose: 1 inhalation as needed for symptoms (budesonide-formoterol 160/4.5 mcg delivered, i.e. 200/6 mcg metered); no separate maintenance dosing. Patients should seek medical care if they need more than the number of inhalations specified in their action plan within 24 hours
Duration: Ongoing, reassess control regularly
Evidence level: High
Avoid if: Known hypersensitivity to formoterol or budesonide
If no response ClinicoQ pathway: Move to Step 3 (maintenance ICS-formoterol) after checking technique and adherence

Step 3 (Track 1: more frequent symptoms)

1 Maintenance and reliever therapy (MART): low-dose ICS-formoterol maintenance plus as-needed for relief Strong (Guideline recommendation) — preferred over separate ICS + SABA reliever

Dose: 1 inhalation twice daily maintenance, plus 1 as-needed for symptoms
Duration: Ongoing, reassess at 2-3 months
Evidence level: High
Avoid if: Same hypersensitivity precaution as above
If no response ClinicoQ pathway: Increase to medium-dose MART (Step 4) after checking technique and adherence

Steps 4-5 (persistent symptoms despite Step 3)

1 Medium-dose ICS-formoterol MART Strong (Guideline recommendation)

Dose: Increase maintenance inhalations (e.g., 2 inhalations twice daily plus as-needed)
Duration: Ongoing, reassess at 2-3 months
Evidence level: Moderate
Avoid if: Same as above
If no response ClinicoQ pathway: Add-on LAMA (Step 5) and refer for specialist assessment

2 Add-on LAMA at Step 5 (including the triple ICS-LABA-LAMA budesonide-formoterol-glycopyrronium if not controlled on medium-dose ICS-LABA) Guideline option — the reduction in severe exacerbations is far smaller than with biologics, but triple therapy may help patients who do not qualify for biologics

Dose: Per product labeling
Duration: Ongoing, reassess
Evidence level: Evidence updated in GINA 2026
Avoid if: Known hypersensitivity; per individual product labeling
If no response ClinicoQ pathway: Specialist assessment for severe asthma phenotyping and biologic therapy

3 Referral for specialist assessment (severe asthma phenotyping, Type 2-targeted biologic candidacy) Strong (Guideline recommendation)

Dose: Biologic choice depends on payer criteria, Type 2 markers, comorbidities, route, dosing frequency, and patient preference. New in 2026: depemokimab (injection every 26 weeks, severe eosinophilic asthma from age 12) and the first generic anti-IgE (omalizumab-igec)
Duration: —
Evidence level: Moderate
Avoid if: —

Alternative: Track 2 (ICS-SABA or SABA reliever)

1 Anti-inflammatory reliever (AIR) with combination ICS-SABA (new at Step 1 in GINA 2026) Alternative to Track 1 (GINA Track 2) — Track 1 remains preferred where ICS-formoterol is available

Dose: Per product labeling: as the only reliever at Step 1, or as the reliever on top of daily ICS or a leukotriene receptor antagonist at Steps 2-5. Requires two inhalers from Step 2
Duration: Ongoing, reassess control regularly
Evidence level: Trial evidence (BATURA): about a 50% lower risk of severe exacerbations than a SABA-only reliever in poorly controlled asthma
Avoid if: Patient cannot be trained to distinguish the two inhalers; known hypersensitivity to a component
If no response ClinicoQ pathway: Consider switching to Track 1 where ICS-formoterol is available

Acute exacerbation (GINA 2026 flowcharts)

1 Standardized assessment with lung function and severity grading (mild, moderate, severe, life-threatening) Strong (Guideline recommendation) — spirometry (or PEF if unavailable) for all except life-threatening presentations; a validated clinical score (e.g., PRAM) for patients under 18

Dose: —
Duration: At presentation, and again before discharge
Evidence level: —
Avoid if: —
If no response: Treat according to severity; in primary care, transfer to a higher level of care immediately if worsening or not improving

2 Mild exacerbation: inhaled salbutamol by pMDI with spacer, or ICS-formoterol as an alternative Guideline recommendation (GINA 2026 primary care flowchart); SABA doses are now more conservative

Dose: Salbutamol 4 puffs by pMDI with spacer (shake the inhaler immediately before each actuation), or budesonide-formoterol 160/4.5 mcg 2 puffs. Review the response after the initial dose before giving more bronchodilator
Duration: Single initial dose, then reassess
Evidence level: —
Avoid if: Over-treatment with SABA (risk of lactic acidosis with compensatory hyperventilation that can be mistaken for worsening asthma)
If no response: Transfer to a higher level of care immediately

3 Supplemental oxygen only if saturation is below 92% Guideline recommendation — oxygen thresholds and targets were revised down in 2026

Dose: If oxygen is given, the upper limit of the saturation target is 95% (adults, adolescents, children 6-11 years)
Duration: Until saturation target reached
Evidence level: —
Avoid if: —

4 Epinephrine first when anaphylaxis features accompany asthma Guideline recommendation (added to each flowchart in 2026)

Dose: Intramuscular or intranasal (the intranasal route is not suitable for small children); then give bronchodilators
Duration: Immediate
Evidence level: —
Avoid if: —

5 Discharge planning and follow-up Guideline recommendation — even a single exacerbation needing urgent care or OCS is a red flag to review treatment

Dose: Review and optimize maintenance treatment, preferably starting an anti-inflammatory reliever (MART with ICS-formoterol) before discharge; arrange follow-up
Duration: At discharge
Evidence level: —
Avoid if: —

✕ Treatments the guideline advises against

SABA as sole/monotherapy at any severity: Guideline recommends against this — SABA-only use increases the risk of severe exacerbations and death; ICS-containing treatment is needed for all adults and adolescents.

Oral salbutamol or oral theophylline: Guideline does not recommend either agent.

Routine supplemental oxygen during an exacerbation when saturation is 92% or higher: GINA 2026 revised the thresholds down: supplemental oxygen is not recommended unless saturation is below 92%.

Repeated or high-dose SABA administration during an exacerbation without reviewing the response: GINA 2026 advises more conservative SABA doses because of evidence of over-treatment, which risks lactic acidosis and compensatory hyperventilation misread as worsening asthma.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.