VA/DoD Guideline Recommends ICS/Formoterol-Based Therapy for Asthma Management
USA: The 2025 U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) clinical practice guideline updates asthma management in primary care and aligns its treatment approach with the Global Initiative for Asthma (GINA). The guidance emphasizes inhaled corticosteroid (ICS)-containing reliever therapy and maintenance-and-reliever therapy (MART) rather than short-acting beta-agonist (SABA) monotherapy. The guideline, published in Annals of Internal Medicine, focuses on primary care management and does not cover biologic therapies for severe asthma, which generally require specialist care.
A central recommendation is to use an ICS combined with a rapid-onset long-acting beta-agonist, such as formoterol, instead of albuterol alone as the preferred reliever strategy for adolescents and adults with asthma. In mild asthma, patients may use ICS/formoterol as needed for symptom relief, while those with moderate to severe disease can use the same combination for both daily maintenance and symptom relief, with ICS doses adjusted according to treatment needs.
Key Recommendations:
- Prefer ICS/formoterol over albuterol alone as reliever therapy for adolescents and adults with asthma.
- Mild asthma: As-needed ICS/formoterol can be used for symptom relief.
- Moderate to severe asthma: ICS/formoterol can serve as both maintenance and reliever therapy through the MART approach, with ICS dosing adjusted as needed.
- Uncontrolled asthma: If symptoms remain inadequately controlled despite medium- to high-dose MART, adding a long-acting muscarinic antagonist (LAMA) should be considered.
- Step-down therapy: For patients whose asthma remains well controlled for at least 3 months, clinicians should consider reducing treatment intensity while continuing to monitor control.
- Address comorbidities: Management should include obesity and symptomatic gastroesophageal reflux disease when present, as these may contribute to poor asthma control.
- Exercise-induced bronchoconstriction: A short-acting beta-agonist can be used before exercise; ICS/formoterol may also be appropriate in patients already using this combination.
- Alternative when ICS/formoterol is unavailable: An ICS-containing rescue approach, such as ICS/albuterol, is preferred over albuterol monotherapy.
The updated guidance reinforces a shift away from treating asthma symptoms with bronchodilator-only rescue therapy. Using an ICS-containing reliever provides anti-inflammatory treatment at the time symptoms occur, while MART allows the same inhaler to provide both maintenance and rapid symptom relief.
The guideline also highlights the importance of reassessing patients regularly rather than maintaining treatment intensity indefinitely. Once asthma has remained controlled for 3 months, treatment can be cautiously stepped down to the lowest effective regimen. Patients whose asthma remains difficult to control despite optimized MART may require additional therapy and specialist assessment.
Overall, the VA/DoD guideline strengthens the evidence-based move toward ICS/formoterol-based reliever and maintenance strategies, while discouraging reliance on albuterol alone. Its recommendations provide a practical framework for primary care clinicians managing adolescents and adults with mild to moderate persistent asthma, while recognizing that severe asthma requiring biologic therapy falls outside the scope of primary care management.
Reference:
Sharafkhaneh A, et al. A synopsis of the 2025 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the primary care management of asthma. Ann Intern Med 2026 Feb 17; [e-pub]. DOI: 10.7326/ANNALS-25-03080.
Krings JG. A new approach to reliever therapy in asthma: Implications of the U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med 2026 Feb 17; [e-pub]. DOI: 10.7326/ANNALS-25-05637.
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