Steps of Asthma Management*
Step | Preferred Treatment† | Alternate Treatment |
|---|---|---|
1 (starting point for intermittent asthma) | Low-dose inhaled glucocorticoid plus formoterol as needed†Low-dose inhaled glucocorticoid plus formoterol as needed† Short-acting beta-2 agonist as needed, along with low-dose inhaled glucocorticoid† | — |
2 (starting point for mild persistent asthma) | Daily low-dose inhaled glucocorticoid and as-needed short-acting beta-2 agonist or For ages 12 years and older, as-needed use of concomitant inhaled glucocorticoid and short-acting beta-2 agonist | Mast cell stabilizer, leukotriene receptor antagonist, theophylline, or zileuton (for ages 12 and older), either with as-needed (rescue, or reliever) short-acting beta-2 agonist therapyMast cell stabilizer, leukotriene receptor antagonist, theophylline, or zileuton (for ages 12 and older), either with as-needed (rescue, or reliever) short-acting beta-2 agonist therapy |
3 (starting point for moderate persistent asthma) | Daily and as-needed combination therapy with low-dose inhaled glucocorticoid plus formoterol‡Daily and as-needed combination therapy with low-dose inhaled glucocorticoid plus formoterol‡ | Daily medium-dose inhaled glucocorticoid and as-needed (reliever) short-acting beta-2 agonist or Daily low-dose inhaled glucocorticoid plus one of the following:
Each with as-needed (reliever) short-acting beta-2 agonist therapy or For ages 12 years and older, daily low-dose inhaled glucocorticoid plus a long-acting muscarinic antagonist or zileuton, either with as-needed (reliever) short-acting beta-2 agonist therapyFor ages 12 years and older, daily low-dose inhaled glucocorticoid plus a long-acting muscarinic antagonist or zileuton, either with as-needed (reliever) short-acting beta-2 agonist therapy |
4 | Daily and as-needed combination therapy with medium-dose inhaled glucocorticoid plus formoterol‡Daily and as-needed combination therapy with medium-dose inhaled glucocorticoid plus formoterol‡ | Daily medium-dose inhaled glucocorticoid plus long-acting beta-2 agonist with as-needed (reliever) short-acting beta-2 agonist therapy or For ages 12 years and older, daily medium-dose inhaled glucocorticoid plus long-acting muscarinic antagonist with as-needed (reliever) short-acting beta-2 agonist therapy or Daily medium-dose inhaled glucocorticoid plus one of the following:
Each with as-needed (reliever) short-acting beta-2 agonist therapy |
5 (starting point for severe persistent asthma) | For ages 5–11 years, daily high-dose inhaled glucocorticoid plus long-acting beta-2 agonist combination therapy with as-needed short-acting beta-2 agonist therapy or For ages 12 and older, daily medium-high dose inhaled glucocorticoid plus long-acting beta-2 agonist combination with long-acting muscarinic antagonist and as-needed short-acting beta-2 agonist therapy and Consider adding asthma biologics (includes anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13) | For ages 5–11 years, daily high-dose inhaled glucocorticoid plus leukotriene receptor antagonist or daily high-dose inhaled glucocorticoid plus theophylline, either with as-needed (reliever) short-acting beta-2 agonist therapyFor ages 5–11 years, daily high-dose inhaled glucocorticoid plus leukotriene receptor antagonist or daily high-dose inhaled glucocorticoid plus theophylline, either with as-needed (reliever) short-acting beta-2 agonist therapy or For ages 12 and older, daily medium- to high-dose inhaled glucocorticoid plus long-acting beta-2 agonist or daily high-dose inhaled glucocorticoid plus leukotriene receptor antagonist, either with as-needed (rreliever) short-acting beta-2 agonist therapy and Consider adding asthma biologics (includes anti-IgE, anti-IL5, anti-IL5R, anti-IL-4/IL13) |
6 | Daily high-dose inhaled glucocorticoid plus long-acting beta-2 agonist plus oral glucocorticoid with as-needed short-acting beta-2 agonist therapy and Consider adding asthma biologics (includes anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13) | For ages 5–11 years, daily high-dose inhaled glucocorticoid plus leukotriene receptor antagonist and oral systemic glucocorticoid or daily high-dose inhaled glucocorticoid plus theophylline plus oral glucocorticoid, either with as-needed (reliever) short-acting beta-2 agonist therapyFor ages 5–11 years, daily high-dose inhaled glucocorticoid plus leukotriene receptor antagonist and oral systemic glucocorticoid or daily high-dose inhaled glucocorticoid plus theophylline plus oral glucocorticoid, either with as-needed (reliever) short-acting beta-2 agonist therapy and Consider adding asthma biologics (includes anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13) |
* Before stepping up, adherence, environmental factors (eg, trigger exposure), and comorbid conditions should be reviewed and managed if needed. | ||
† A short-acting beta-2 agonist is indicated to provide quick relief at all steps and to prevent exercise-induced bronchoconstriction. | ||
‡ The updated NAEPP Asthma Management Guidelines' preferred rescue option (also called reliever therapy) for steps 3 and 4 include the use of 1 to 2 puffs of as-needed formoterol in combination with an inhaled glucocorticoid, not to exceed a daily maximum dose of 8 puffs of formoterol (36 mcg) over a 24-hour period for ages 5–11 years, and 12 puffs of formoterol (54 mcg) over a 24-hour period for patients ‡ The updated NAEPP Asthma Management Guidelines' preferred rescue option (also called reliever therapy) for steps 3 and 4 include the use of 1 to 2 puffs of as-needed formoterol in combination with an inhaled glucocorticoid, not to exceed a daily maximum dose of 8 puffs of formoterol (36 mcg) over a 24-hour period for ages 5–11 years, and 12 puffs of formoterol (54 mcg) over a 24-hour period for patients≥ 12 years. | ||
Adapted from the Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 146(6):1217–1270, 2020. doi: 10.1016/j.jaci.2020.10.003 | ||
For additional information, see Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated May 2025. Accessed May 20, 2025. Available from www.ginasthma.org. Note GINA does not recognize a step 6 for the management of severe asthma. Refer to guidelines for comparisons on the management of severe asthma for step 5 and above. | ||