Summary

GINA 2026 is the annual update of the Global Strategy for Asthma Management and Prevention, covering diagnosis, assessment, pharmacologic and non-pharmacologic management, exacerbations, severe asthma, and prevention across all ages. Key 2026 changes include four new exacerbation flowcharts with revised lower oxygen saturation thresholds (≥92%) and more conservative SABA dosing; addition of as-needed ICS-formoterol (AIR) and ICS-SABA options for children 6–11 years (CARE study) and adults (BATURA study); new biologics depemokimab (long-acting anti-IL5, q26-weekly) and biosimilar omalizumab-igec; expanded Step 5 LAMA options including budesonide-formoterol-glycopyrronium; and retention of the ≥12% and ≥200 mL FEV₁ criterion for bronchodilator responsiveness. Track 1 (ICS-formoterol as reliever, with or without maintenance) remains the preferred approach for adults/adolescents.

Key Recommendations

Do NOT treat asthma with SABA alone in any patient ≥6 years; all patients must receive ICS-containing therapy to reduce risk of severe exacerbations and death.
Track 1 (preferred) for adults/adolescents: as-needed low-dose ICS-formoterol at Steps 1–2 (AIR-only) and ICS-formoterol maintenance-and-reliever therapy (MART) at Steps 3–5.
Track 2 (alternative) uses ICS-SABA or SABA reliever with daily maintenance ICS/ICS-LABA; combination ICS-SABA preferred over SABA alone when available.
For children 6–11 years, Step 1–2 options now include as-needed ICS-formoterol or as-needed ICS+SABA (combination or separate inhalers) to reduce exacerbations vs SABA alone; MART is preferred at Steps 3–4.
If patient presents with anaphylaxis and asthma simultaneously, give IM (or intranasal) epinephrine FIRST, then bronchodilator therapy.
For acute exacerbations: give supplemental oxygen only if SpO₂ <92%; target SpO₂ 92–95% (adults/children 6–11) or ≥92% (children ≤5).
Use a validated clinical score (e.g., PRAM) to assess exacerbation severity in children <18 years.
Refer patients with uncontrolled symptoms/exacerbations despite optimized high-dose ICS-LABA for severe asthma assessment, phenotyping, and add-on biologic therapy (anti-IgE, anti-IL5/5R, anti-IL4Rα, or anti-TSLP).
Confirm diagnosis with objective evidence of variable expiratory airflow limitation (BDR: FEV₁ increase ≥12% and ≥200 mL) before starting ICS when possible; retain 2005 ERS/ATS criterion over 2022 >10% predicted criterion.
OCS stewardship: minimize cumulative OCS exposure by optimizing inhaled therapy, using biologics when indicated, and avoiding maintenance OCS except as last resort.
For pregnant women with asthma: do NOT stop ICS-containing therapy; risks of uncontrolled asthma exceed risks of medications.
Provide every patient with a written asthma action plan appropriate to their reliever (ICS-formoterol, ICS-SABA, or SABA) and check inhaler technique and adherence at every visit.

Thresholds & Doses

Bronchodilator responsiveness (adults): increase in FEV₁ or FVC ≥12% AND ≥200 mL from baseline; greater confidence if ≥15% and ≥400 mL.
PEF responsiveness: ≥20% increase post-bronchodilator supports asthma diagnosis.
Diurnal PEF variability: >10% adults, >13% children indicates excessive variability.
FeNO supporting Type 2 asthma: >50 ppb in adults/adolescents; >35 ppb in children.
Supplemental O₂ indicated when SpO₂ <92%; target SpO₂ on oxygen 92–95% adults/children 6–11, ≥92% children ≤5.
AIR-only (adults/adolescents): budesonide-formoterol 160/4.5 mcg (200/6 metered) 1 inhalation as needed; seek care if >12 inhalations/24 hr.
MART Step 3 (adults/adolescents): budesonide-formoterol 160/4.5 mcg 1 inh BID + 1 inh as needed; Step 4: 2 inh BID + 1 inh as needed.
MART for children 6–11 years: budesonide-formoterol 80/4.5 mcg (100/6 metered); seek care if >8 inhalations/24 hr.
SABA over-use threshold: ≥3 canisters (200-dose) per year increases exacerbation risk; ≥12 canisters/year markedly increases mortality risk.
OCS dose for adult exacerbation: prednisone/prednisolone 40–50 mg/day × 5–7 days (no tapering if <2 weeks).
OCS dose for children 6–11: prednisone/prednisolone 1–2 mg/kg/day (max 40 mg) × 3–5 days; OR dexamethasone 0.3–0.6 mg/kg (max 12 mg) × 1–2 days.
OCS dose for children ≤5: prednisolone 1–2 mg/kg max 20 mg (<2 yr) or 30 mg (2–5 yr); dexamethasone 0.3–0.6 mg/kg (max 12 mg) × 1–2 days.
IV magnesium sulfate for severe exacerbation: 40–50 mg/kg (max 2 g) over 20 minutes; for children ≥2 years.
Severe exacerbation criteria: RR >30/min (adults) or >40/min (children ≤5), SpO₂ <92%, PEF <50% predicted, unable to speak in sentences.
Biologic eligibility (severe asthma, typical): BEC ≥150/μL suggests Type 2; ≥300/μL common threshold for anti-IL5/5R; FeNO ≥25 ppb (anti-IL4Rα) or ≥20 ppb.
Depemokimab dose: 100 mg SC every 26 weeks (≥12 years).
Tezepelumab dose: 210 mg SC every 4 weeks (≥12 years).
Dupilumab dose: 200 or 300 mg SC every 2 weeks (≥12 years); weight-based for ages 6–11.
Mepolizumab dose: 100 mg SC q4 weeks (≥12 years); 40 mg SC q4 weeks (6–11 years).
Benralizumab dose: 30 mg SC q4 weeks ×3 doses then q8 weeks (≥12 years).
Low-dose ICS adult/adolescent examples (daily metered): BDP standard particle 200–500 mcg; budesonide 200–400 mcg; fluticasone propionate 100–250 mcg.
Low-dose ICS children 6–11 examples: BDP standard 100–200 mcg; budesonide DPI 100–200 mcg; fluticasone propionate 50–100 mcg.
Vitamin D level associated with reduced wheeze in offspring: maintain 25(OH)D ≥30 ng/mL during pregnancy.

Citations

Section 4, Box 4-6 (p.83) — Track 1/Track 2 personalized management figure for adults/adolescents.
Section 4, Box 4-8 (p.90) — Medications and doses for AIR/MART by age group.
Section 4, Box 4-2 (p.77) — Low, medium, high daily ICS doses (alone or with LABA).
Section 8, Boxes 8-2 through 8-5 (pp.152–155) — Decision tree for difficult-to-treat and severe asthma.
Section 9, Box 9-4 (p.180) and Box 9-6 (p.186) — Primary care and acute care management of exacerbations in adults/adolescents/children 6–11.
Section 10, Box 10-2 (p.195) — Diagnostic criteria for asthma in children 5 years or younger.
Section 12, Box 12-2 (p.218) — PRAM clinical score for children 2–17 years.
What’s new in GINA 2026 (pp.20–23) — Summary of key changes including oxygen saturation targets, SABA dosing, new biologics, and pediatric AIR/MART options.
Appendix A (pp.238–242) — Type 2 biomarkers: thresholds and factors affecting blood eosinophils and FeNO.
Section 2, Box 2-2 (p.41) — Assessment of asthma control: symptom control and risk factors.