Global Initiative for Asthma (GINA) 2025: A Revolutionary Document for Management of Asthma in Children

Global Initiative for Asthma (GINA) 2025 guidelines were released in May 2025.[1] These are evidence based guidelines, made using proper methodology, and are much awaited by pediatricians and pulmonologists to get updated about newer developments in asthma. The report is based on a twice annual update of the evidence, which forms the basis for the recommendations made by the GINA Science Committee. The committee, which is comprised of leaders in adult and pediatric asthma research, performed a full-text review for 78 publications by at least two members of the Science Committee, of which 59 full-text publications were discussed at committee meetings. GINA 2024 advocated a “probability” based approach to diagnose asthma below 5 years.[2] On basis of history patients were divided into low, some and high probability of asthma. Although easy to use clinically, it did create problems for clinicians in counselling parents where the word “probability” was understood differently by different people leading to lot of confusion and dissatisfaction. GINA 2025 has major updates in diagnosis of asthma in children below 5 years.[1] The report includes clear and pragmatic guidance on diagnosing asthma in children aged 5 years and younger. The three main criteria are: (i) recurrent acute wheezing episodes; (ii) no likely alternative cause for the respiratory symptoms; and (iii) respiratory symptoms or signs showing a timely clinical response to the administration of asthma medications. All three criteria are required for diagnosing asthma in young children. A step-wise treatment approach for asthma is recommended in patients aged 5 years and younger. Treatment involves long-term, daily low-dose inhaled corticosteroids (ICS) to keep asthma well controlled, and short-acting beta-2 agonist (SABA) as reliever for as-needed symptom relief, using a pressurized metered-dose inhaler (pMDI) with a mouthpiece or facemask as appropriate. When symptoms are not well controlled after 2–3 months on initial treatment with low-dose ICS, or if there are continued exacerbations, clinicians may consider doubling the low daily ICS dose. If asthma symptoms are still not well controlled, the patient’s inhaler technique and medication adherence should be reassessed, along with environmental factors, and the patient can be referred to a specialist. For managing children aged 5 years and younger with worsening asthma and exacerbations in primary care or an acute care facility, the report recommends assessing severity of the exacerbation while initiating the following treatment with bronchodilator and oxygen if needed: SABA, 4 to 6 puffs of salbutamol 100 mcg/actuation by pMDI with spacer or 0.25 mg by nebulizer, given once for mild exacerbations and every 20 min for three total doses during the first hour, if needed, for moderate or severe exacerbations; and oxygen, if needed, to maintain saturation at least 94%. As initial emergency department management within or after the initial hour of treatment, intravenous isotonic magnesium sulfate may be considered in those at least 2 years of age with severe exacerbations. The 2025 GINA strategy report includes a new appendix with expanded information on the role of type 2 biomarkers—most notably blood eosinophil count (BEC) and fractional exhaled nitric oxide (FeNO)—in the diagnosis, assessment, management and prognosis of asthma. Additionally, more information on type 2 biomarkers has been included throughout the report. This expanded biomarker information includes criteria for defining high BEC and FeNO in adults and adolescents. General criteria provided for defining high BEC is a level that is, greater or equal to the upper limit of normal for the given population, based on regional or national laboratory reference values. Among patients with severe asthma using high-dose ICS, a BEC of at least 150/µL suggests type 2 inflammation, and a BEC of at least 300/µL is a typical threshold for type 2–targeted biologics. The criteria provided for defining high FeNO levels are as follows: FeNO greater than 50 ppb in individuals who are ICS-naïve; FeNO at least 25 ppb in individuals using medium dose ICS; and FeNO at least 20 ppb in individuals using high-dose ICS. The report noted that BEC and FeNO levels should be interpreted with caution in clinical practice. Because clinicians need to be mindful of factors contributing to variability in BEC and FeNO, information on these factors has been added to the 2025 report. This information may be highly relevant when clinicians are assessing a patient’s eligibility for type-2 targeted biologic therapy in clinical practice. In patients with severe asthma who are being considered for type 2-directed biologics, BEC and FeNO should be measured at least three times if they are not initially above the target threshold. The report noted that recent research on the Oxford Asthma Attack Risk Scale 2 supports GINA’s longstanding recommendation that “multiple factors, including type 2 biomarkers, should be considered in the assessment of patients’ risk of future exacerbations.”[3] Also new to this year’s GINA update is a brief section on extreme weather and asthma. Climate change impacts asthma primarily in two ways: catastrophic weather events affect infrastructure and disrupt care for patients with asthma; and climate change also contributes to higher air pollution levels (e.g., from wildfires), better survival of respiratory viruses, and increased allergens such as mold and pollen, which—along with extreme heat and cold—may worsen asthma morbidity.[4] Recommended mitigation strategies include using face masks during wildfires and sheltering in temperature controlled environments. The diagnostic flowchart for asthma in adults and adolescents has been updated, with assessment of lung function continuing to be the first option for confirming a diagnosis. The flowchart now includes the limited role of biomarkers. The committee has replaced the phrase “variable expiratory airflow limitation” in the previous version with “variable expiratory airflow,” as airflow limitation may be present sometimes and not at other times in patients with untreated asthma. Apart from above there are more minor changes which the reader can access by going through the whole report in details. We are sure that the updates included in the GINA2025 reports will go a long way in making treatment of asthma more evidence based, targeted and with better outcomes. Author contribution SSR conceived the idea, reviewed the literature, drafted the manuscript, and submitted for publication. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.