This article is for educational and informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.
If you have asthma, you may have heard different advice about inhalers from your doctor, your pharmacist, and the internet. Guidelines continue to evolve, and the Global Initiative for Asthma (GINA) published its 2026 update in May. This guide explains what changed and what it means for your care. For the basics, see our guide to what asthma is and what triggers it.
What Are the Current Asthma Treatment Guidelines?
Two main sets of guidelines shape asthma care. GINA is a global report updated every year, and its 2026 edition came out in May 2026. In the United States, the 2020 update from the National Heart, Lung, and Blood Institute (NHLBI) is the federal reference. Both agree that people with asthma need inhaled steroid treatment, not a reliever inhaler alone.
Guidelines are written for clinicians and describe how to assess asthma and adjust medicines over time. Your own plan comes from your care team, tailored to your age, symptoms and triggers. Source documents: the GINA 2026 report and the 2020 NHLBI asthma guideline updates.
GINA or NHLBI: Which Guidelines Apply in the US?
The two documents work differently, and US clinicians can draw on both. GINA itself says its report should be read alongside national and local guidelines.
| GINA 2026 | NHLBI 2020 update | |
| Scope | Annual global strategy for asthma management and prevention | NHLBI, part of the National Institutes of Health with US-focused update addressing six selected topics |
| Updates | Every year | Focused update on six topics in 2020 |
| Reliever approach | Prefers a low-dose ICS-formoterol reliever for adults and adolescents. Provides age specific pathways for treatment in children | Recommends SMART for appropriate patients with moderate to severe persistent asthma. Includes recommendations for selected age groups and treatment questions. |
| How to use it | Guides assessment and individualized treatment | Adds recommendations to the existing US guideline framework |
What Changed in the 2026 Update
GINA’s 2026 update added a steroid-containing reliever option to its alternative treatment track, new step-by-step flowcharts for asthma flare-ups, and tighter guidance on oral steroids. It also kept the preferred approach for most adults and adolescents: a low-dose ICS-formoterol reliever. Here are the changes in the update that are different from FDA-recommended treatments relevant to asthma care.
- A new reliever option. GINA’s alternative track now includes a reliever combining an inhaled steroid with a fast-acting medicine (ICS-SABA). In the BATURA study of people with mild asthma, an as-needed inhaler combining an inhaled corticosteroid with albuterol reduced the risk of a first severe exacerbation by approximately 47% compared with albuterol alone. Results vary by study population, so this finding should not be generalized to every asthma treatment regimen.
- New flare-up pathways. Four new flowcharts guide care in primary care and the emergency department, including lung function testing during the visit and before discharge, and more cautious reliever doses.
- A flare-up is a warning. Even one flare-up needing urgent care or oral steroids is a red flag to review your plan.
- Fewer oral steroids. GINA treats reducing oral steroid use as a priority, through better inhaled treatment, biologics where indicated, and limiting dose and duration.
- Know to shake before every puff. Some pressurized metered-dose inhalers must be shaken immediately before each actuation. The correct technique depends on the device and medication. Ask your clinician or pharmacist to demonstrate your specific inhaler.
- New severe asthma options. The report adds a long-acting injection given every 26 weeks (depemokimab) and the first biosimilar anti-IgE medicine.
Asthma Inhaler Types: Reliever, Controller and Combination
Asthma inhalers fall into a few groups. Relievers act within minutes to open the airways. Controllers, mainly inhaled steroids, calm airway inflammation over time. Combination inhalers pair a steroid with a long-acting bronchodilator. One type, ICS-formoterol, can work as both controller and reliever.
| Type | What it does | How guidelines view it |
| Short-acting reliever (SABA, such as albuterol) | Relaxes airway muscles for fast relief | Used for quick relief, but not advised alone |
| Inhaled steroid (ICS) controller | Reduces airway inflammation and the risk of asthma flare-ups. | The recommended regimen depends on age, symptom pattern, asthma severity, and the treatment approach selected by the clinician. |
| ICS-formoterol | One inhaler: a steroid plus a fast-acting, long-acting bronchodilator | GINA’s preferred reliever for adults and adolescents; can serve as controller and reliever |
| ICS-SABA reliever | A steroid plus a fast-acting reliever in one puff | New in GINA 2026’s alternative track but specific medication plan depends on the patient. |
Technique counts as much as the medicine. For a pressurized inhaler with a spacer, GINA prefers a single breath in followed by a breath-hold. Ask your care team to watch you use your inhaler, and do not stop or change prescribed medicines without talking to your clinician, as CDC guidance advises.
SMART and MART Therapy Explained
SMART stands for single maintenance and reliever therapy. One inhaler containing an inhaled steroid and formoterol is used every day and again when symptoms appear. GINA calls the same approach MART. Guidelines report fewer flare-ups with it than with standard separate inhalers, as summarized by American Family Physician.
What this means in the United States:
GINA’s preferred approach and US product labeling are not always identical. Some ICS-formoterol maintenance-and-reliever regimens are guideline-supported but may be used outside the specific rescue indication in a product’s US labeling. Your clinician should explain which inhaler to use, when to use it, your maximum daily dose, and what to do if symptoms worsen. Never change your inhaler routine based on general guideline information alone.
Who may be a candidate
In US guidelines, SMART is recommended for ages 4 and older with moderate to severe persistent asthma. GINA prefers ICS-formoterol reliever therapy for adults and adolescents, and offers MART to children ages 6 to 11 at Steps 3 and 4. Your clinician decides whether it fits.
Why daily limits matter
Your clinician should specify the maximum number of inhalations you can take in 24 hours and when to seek medical care. If you need your reliever more often than directed, or your symptoms are worsening, follow your written asthma action plan and seek prompt medical advice. Severe breathing difficulty is an emergency.
How Stepwise Treatment Works
Stepwise treatment means your medicine is matched to how well your asthma is controlled, then adjusted over time. GINA describes five steps. Treatment moves up when control is poor and may move down after a period of good control. The goal is the lowest treatment that keeps symptoms and flare-ups away.
- Assess. Your clinician reviews symptoms, flare-ups, lung function and risk factors.
- Adjust. Medicine, trigger control and inhaler training change to match.
- Review. You return to check your response. Before stepping up, clinicians look for fixable causes such as technique, missed doses or triggers.
What to Expect at an Asthma Visit
A good asthma visit confirms the diagnosis with lung function testing, looks for your triggers, and ends with a written action plan. After any flare-up, your treatment should be reviewed. At Prime Care of Georgia, spirometry and allergy testing are available within the same practice that manages your asthma treatment.
Confirming the diagnosis with spirometry
GINA advises confirming asthma with objective testing, ideally before treatment starts. It notes that in primary care, asthma cannot be confirmed in about 25 to 35% of people previously diagnosed. Spirometry is a simple breathing test, and Prime Care of Georgia offers it.
Finding your triggers
Allergy testing can help identify sensitization to potential triggers. Your clinician interprets the results alongside your symptoms, exposure history, and asthma pattern to determine which allergens may be clinically relevant. Skin, blood and intradermal allergy tests can identify which ones. Learn how allergies can lead to allergic asthma.
A written action plan
An action plan lists your daily medicines, early warning signs and what to do as symptoms worsen. Many use a green, yellow and red zone format, as Harvard Health Publishing describes.
When Standard Treatment Is Not Enough: Severe Asthma and Biologics
Some people still have symptoms or flare-ups despite well-taken inhaled treatment. Guidelines then call for a closer look at technique, triggers and other conditions. For severe asthma with Type 2 inflammation, add-on biologics may be considered. These are injected medicines that target specific immune pathways, and a specialist decides whether they fit.
Prime Care of Georgia lists biological therapy among its Allergy & Asthma services.
Signs Your Asthma Is Not Well Controlled, and When to Get Emergency Help
Asthma may not be well controlled if you wake at night with symptoms, need your reliever more often than usual, or find that symptoms limit your daily activities. Book an appointment to review your plan. Severe trouble breathing, difficulty speaking, blue or gray lips, or no improvement after your reliever is an emergency. Call 911.
| Book an appointment if:
• You wake at night with asthma symptoms. The American Lung Association lists more than two times a month as a warning sign. • You need your reliever more often than usual. • Symptoms limit your work, exercise or sleep. • You had a flare-up that needed urgent care or oral steroids. |
| Call 911 if:
• You are struggling to breathe or cannot speak in full sentences. • Your lips or fingernails look blue or gray. • Your breathing is getting worse quickly or does not improve after your reliever. • Your action plan’s red zone applies. |
Emergency physicians advise going to the emergency department for severe asthma symptoms.
Asthma Care at Prime Care of Georgia in Pooler and Savannah
Dr. Neha Kharod, an allergy, asthma and immunology specialist, leads the Allergy & Asthma program for children and adults at Prime Care of Georgia. Services include spirometry, allergy testing, allergy shots and drops, and biological therapy, with same-day and next-day appointments. Learn about our Allergy and Asthma care in Pooler and Savannah, or call 912-561-7001.
Frequently Asked Questions
What are the latest asthma treatment guidelines?
The latest global update is GINA 2026, published in May 2026. US clinicians also rely on the 2020 NHLBI focused updates. Both call for inhaled steroid treatment for people with asthma and support combination inhalers that treat inflammation and symptoms together.
What is the difference between GINA and the NHLBI guidelines?
GINA is a global report revised every year. The NHLBI update is a US federal guideline issued in 2020 on six focused topics. They overlap on key points such as SMART, but differ in detail and timing.
What is the difference between a reliever and a controller inhaler?
A reliever works within minutes to ease symptoms. A controller, usually an inhaled steroid, is taken as prescribed to reduce airway inflammation and prevent flare-ups. Some ICS-formoterol inhalers do both jobs. Guidelines advise against relying on a reliever alone.
What is SMART therapy for asthma?
SMART means single maintenance and reliever therapy. One inhaler with an inhaled steroid and formoterol is used daily and when symptoms appear. Guidelines report fewer flare-ups than with separate inhalers. Ask your clinician whether it suits you.
Can asthma be treated without an inhaler?
Inhaled medicine is the foundation of asthma treatment, and no home remedy replaces it. If you have no inhaler and are struggling to breathe, call 911. Talk with a clinician about a prescription and an action plan so you are prepared.
Do the asthma guidelines apply to children?
Yes, with age-specific recommendations. The NHLBI update covers SMART from age 4 for moderate to severe asthma, and GINA has separate sections for ages 6 to 11 and 5 and younger. See the pediatric key points.
When should I see an asthma specialist?
Consider seeing an allergy and asthma specialist if your asthma is not well controlled, you wake at night with symptoms, you had a flare-up needing urgent care or oral steroids, or you want help finding your triggers.
