GINA 2025 Updates

Core Paradigm Shifts

Asthma is fundamentally recognized as a chronic inflammatory disease rather than a disease of acute bronchospasm.
The clinical concept of "mild asthma" is deprecated to prevent complacency among caregivers and adolescents regarding severe exacerbation risks.
Guidelines prioritize exacerbation risk reduction simultaneously with daily symptom control.
Short-Acting Beta2-Agonist (SABA) monotherapy is explicitly condemned for adolescents and strongly discouraged for younger children.
SABA monotherapy masks eosinophilic inflammation, causes beta2-receptor downregulation, triggers pro-inflammatory rebound, and significantly increases mortality risk.

Track 1 utilizes Maintenance and Reliever Therapy (MART) with ICS-Formoterol, ensuring simultaneous bronchospasm relief and anti-inflammatory action.

Step	Track 1: Preferred Strategy (ICS-Formoterol)	Track 2: Alternative Strategy (SABA Reliever + Daily ICS)
Step 1 & 2	As-needed low-dose ICS-Formoterol	Daily low-dose ICS
Step 3	Low-dose maintenance ICS-Formoterol + as-needed	Low-dose ICS-LABA maintenance
Step 4	Medium-dose maintenance ICS-Formoterol + as-needed	Medium/High-dose ICS-LABA maintenance
Step 5	Add Long-Acting Muscarinic Antagonist (LAMA) or Biologics	Add LAMA or Biologics

Step 1: SABA taken alongside low-dose ICS.
Step 2: Daily low-dose ICS.
Step 3: Low-dose ICS-Formoterol MART strongly recommended, or medium-dose ICS/low-dose ICS-LABA.
Step 4: Medium-dose ICS-Formoterol MART or medium-dose ICS-LABA.
Step 5: Add LAMA (Tiotropium) or phenotypic assessment for targeted biologics.

MART strategy is strictly contraindicated due to lacking formoterol safety data in this demographic.
Step 1: As-needed short courses of ICS at viral respiratory infection onset.
Step 2: Daily low-dose ICS.
Step 3: Double low-dose ICS.
Step 4: Continue medium-dose ICS and refer to a pediatric pulmonologist.
Leukotriene Receptor Antagonists (LTRA) like Montelukast require extreme caution due to severe neuropsychiatric side effects.

Biologics replace chronic oral corticosteroid use in severe, therapy-resistant asthma.

Biologic Agent	Target Pathway	Clinical Indication
Omalizumab	Anti-IgE	Severe allergic asthma ( $\geq$ 6 years).
Mepolizumab / Benralizumab	Anti-IL-5 Pathway	Severe eosinophilic phenotypes ( $\geq$ 6 years for Mepolizumab, $\geq$ 12 years for Benralizumab).
Dupilumab	Anti-IL-4R $α$	Comorbid severe atopic dermatitis or chronic rhinosinusitis with nasal polyps ( $\geq$ 6 years).
Tezepelumab	Anti-TSLP	Treats broader spectrum including T2-low (non-eosinophilic) asthma ( $\geq$ 12 years).

FeNO >35 ppb in children supports active IL-13 driven eosinophilic airway inflammation and highly predicts a robust ICS response.
FeNO guides safe ICS step-down and objectively identifies medication non-adherence (e.g., FeNO of 70 ppb while prescribed high-dose ICS).

Pressurized Metered Dose Inhalers (pMDIs) utilize hydrofluorocarbon propellants with extreme global warming potential.
Guidelines advise transitioning capable adolescents to Dry Powder Inhalers (DPIs) or Soft Mist Inhalers (SMIs).
pMDIs with valved holding chambers remain the uncompromised gold standard for infants, preschoolers, and severe acute exacerbations.