Professor Helen Reddel
Updated GINA guidelines drop SABA-only treatment for children aged 6 to 11 and add ICS–formoterol as an option for mild exacerbations in all patients six and older.
The Global Initiative For Asthma published its 2026 Global Strategy for Asthma Management and Prevention in May, accompanied by an online discussion with the European Respiratory Society. A summary appeared in The Lancet Respiratory Medicine this week [link here].
GINA chair Professor Helen Reddel of Macquarie University, Sydney, told the journal the most important changes centred on acute asthma management, anti-inflammatory reliever (AIR) therapy, and inhaler technique.
“The most important changes are about management of acute asthma, reinforcement of the clinical benefits of anti-inflammatory reliever therapy (AIR-only or maintenance and reliever therapy [MART]) for people with asthma aged 6 years and older, and the importance of checking inhaler technique especially if patients have separate reliever and maintenance inhalers,” she said.
ICS–formoterol moves into mild exacerbations
Four new flowcharts cover acute asthma or exacerbations presenting to primary care or acute care facilities. For patients aged 6 years and older presenting with a mild exacerbation, ICS–formoterol is now an option alongside short-acting beta-agonists.
Dr Timothy Hinks of John Radcliffe Hospital, Oxford, welcomed the shift.
“Adding ICS–formoterol as a treatment option for mild exacerbations is a major step forwards in messaging. For many people a mild exacerbation is their first experience of asthma, and this new approach will cement the message early on that the mainstay of their treatment will always be combination ICS–formoterol. Too often the message patients receive at this teachable moment is the gold standard treatment is a SABA: a message which has proven fatal for far too many people,” he said.
SABA doses cut; inhaler technique finding may surprise
Recommended SABA doses are now more conservative, to reduce the risk of overtreatment and toxicity. Professor Reddel said the new flowcharts should “prompt reconsideration of the ultra-high dose SABA treatment used in emergency departments in some countries.”
The guidelines also flag an inhaler technique hazard that may surprise many prescribers. When a salbutamol inhaler is shaken only before a multi-dose burst rather than before each individual puff, “a new salbutamol inhaler will deliver more than three times the expected dose, further increasing the risk of SABA toxicity,” Professor Reddel said.
The guidelines also advise monitoring a patient’s response after an initial bronchodilator dose before administering more, as patients may not require additional doses.
On supplemental oxygen, the updated strategy no longer recommends its use unless saturation falls below 92%. In children aged 5 years or younger with acute wheezing or a severe exacerbation, the threshold is at or below 92%. Patients presenting with both anaphylaxis and asthma should receive adrenaline first, then bronchodilators.
The flowcharts also stress what Professor Reddel called “the need for stronger collaboration with emergency departments to address the persistent disconnect between acute care and long-term asthma management.”
SABA-only out for under-12s
For children aged 6 to 11 years, SABA-only treatment is no longer recommended. The decision draws on the CARE study, published in The Lancet, in which low-dose budesonide–formoterol reduced the risk of moderate to severe exacerbations compared with salbutamol alone in children and adolescents. As-needed ICS–formoterol without maintenance therapy is now a treatment option for this group.
OCS stewardship elevated
Oral corticosteroid stewardship has been made a priority. The guidelines recommend using OCS at the lowest effective dose for the minimum duration required, with optimised inhaled therapy and biologics used where appropriate to prevent reliance on oral steroids.
Dr Hinks said he was pleased to see the change. “I’m delighted to see greater caution with OCS prescribing. In the UK, respiratory physicians are the main prescribers of OCS, and frequently this is without efficacy due to a lack of an eosinophilic phenotype. Using OCS only when clearly indicated could avert much preventable, iatrogenic harm,” he said.
Preferred regimen holds; new step-1 option added
GINA Track 1, a single-inhaler strategy using low-dose ICS–formoterol as anti-inflammatory reliever therapy, remains the preferred approach for adults and adolescents because it substantially reduces the risk of severe exacerbations, OCS exposure, and need for urgent care compared with SABA-based regimens.
GINA Track 2 now includes ICS–SABA as a step-1 option, supported by the BATURA study in the New England Journal of Medicine, which showed this combination reduced exacerbation risk by nearly half compared with SABA alone.
Two new biologics added for severe asthma
Two new biologics have been added for severe asthma: depemokinab, a long-acting IL-5 inhibitor, and omalizumab-igec, a biosimilar anti-IgE. The guidelines advise choosing between biologic therapies based on cost, route of administration, and comorbidities.
On diagnosis, GINA 2026 retains the 2005 ERS/ATS criterion for bronchodilator responsiveness, an FEV1 increase of at least 12% and 200 mL from baseline, rather than the alternative criterion of greater than 10% predicted proposed in 2022, citing the risk of underdiagnosis if the newer threshold were adopted.
The 2026 GINA report is available at ginasthma.org