🫁 GINA Step-Up/Step-Down Treatment Ladder Simulator

As-Needed Low-Dose ICS-Formoterol

Infrequent symptoms treated with reliever-only low-dose ICS-formoterol.

• ICS-Formoterol: Preferred reliever (anti-inflammatory reliever)
• <2: Symptom days/wk (typical entry threshold)
• Low: Exacerbation risk (with as-needed use)
• None: Maintenance dose (no daily controller)

Why ICS-formoterol replaces SABA-only

SABA-only relievers leave airway inflammation untreated.

GINA no longer recommends SABA-only reliever therapy for any step.

Who fits Step 1

Patients with symptoms fewer than twice per week.

Monitoring at Step 1

Reliever overuse signals a need to step up.

Low-Dose Maintenance ICS-LABA or ICS

Regular symptoms trigger a daily low-dose controller inhaler.

• 2: Controller options (ICS-LABA or ICS alone)
• 2–4: Symptom days/wk (typical entry range)
• 0–1: Exacerbations/yr (usually mild history)
• High: Adherence impact (daily dosing needed)

Adding a daily controller

Low-dose ICS reduces airway inflammation continuously.

ICS-LABA vs ICS alone

ICS-LABA combines faster symptom relief with control.

Low-dose maintenance ICS-formoterol also serves as the reliever.

Step-down consideration

Three months of control allow cautious step-down.

Low-Dose Maintenance ICS-LABA, Standard

Persistent symptoms move patients onto standard ICS-LABA dosing.

• ICS-LABA: Preferred regimen (maintenance and reliever)
• 5–6: Symptom days/wk (near-daily symptoms)
• 1–2: Exacerbations/yr (moderate risk history)
• MART: Reliever strategy (maintenance and reliever therapy)

MART regimen explained

One inhaler serves both daily control and relief.

MART lowers severe exacerbation risk versus fixed dosing.

Assessing inadequate control

Night waking and activity limits flag treatment failure.

Ruling out other causes

Inhaler technique and adherence are checked first.

Medium/High-Dose ICS-LABA

Repeated exacerbations call for a higher ICS-LABA dose.

• Medium–High: ICS dose tier (stepped up from Step 3)
• 7: Symptom days/wk (daily symptoms common)
• 2–3: Exacerbations/yr (recurrent flare history)
• LAMA: Add-on options (triple therapy considered)

Escalating the ICS dose

Higher inhaled steroid dose targets persistent inflammation.

Triple therapy option

A LAMA is added when control still fails.

Triple ICS-LABA-LAMA therapy cuts exacerbations in severe cases.

Specialist referral trigger

Poor response here prompts specialist assessment.

Add-On Biologic or Oral Corticosteroid

Severe uncontrolled asthma is referred for biologic add-on therapy.

• 5+: Biologic classes (anti-IgE, anti-IL5, anti-TSLP)
• 7: Symptom days/wk (continuous symptoms)
• 4+: Exacerbations/yr (frequent severe flares)
• Minimize: OCS goal (lowest effective dose)

Phenotyping before biologics

Eosinophil count and IgE guide biologic selection.

Biologics cut long-term oral corticosteroid exposure and side effects.

Oral corticosteroids as last resort

OCS is minimized due to cumulative toxicity.

Specialist center referral

Severe asthma clinics confirm diagnosis and phenotype.