GINA 2019 recommendations about reliever medications in Steps 3-5

We have become aware that the GINA 2019 recommendation for ‘Preferred reliever’ in Steps 3-5 is sometimes being misinterpreted. Please note the following important information.

In the GINA 2019 treatment figure for adults and adolescents (Box 3-5A), Steps 3-5 show the medication options for patients with moderate to severe asthma in whom modifiable causes of symptoms or exacerbations have been addressed.!In these patients, low-dose ICS-formoterol is the preferred reliever only for patients who are prescribed maintenance and reliever therapy with ICS-formoterol. GINA does not recommend use of ICS-formoterol as the reliever for patients taking combination ICS-LABA medications with a different LABA. For these patients,
their as-needed reliever inhaler should be a short-acting b2-agonist (SABA).

To help clarify this issue, an extra slide (#12) has been added to the ‘What’s new in GINA 2019?’ slide set on the GINA website. The slide set can be downloaded from

The maintenance and reliever regimen (sometimes called ‘MART’ or ‘SMART’) is approved in many countries for use with low dose beclometasone-formoterol or low dose budesonide-formoterol. With this regimen, the patient receives ICS-formoterol as their regular twice-daily or once-daily maintenance treatment, and takes additional doses of a low-dose ICS-formoterol for relief of symptoms, instead of as-needed short-acting b2-agonist.

About the maintenance and reliever regimen (GINA 2019, page 52): “In adult and adolescent patients with ≥1 exacerbation in the previous year, the ICS-formoterol maintenance and reliever regimen significantly reduces exacerbations and provides similar levels of asthma control at relatively low doses of ICS, compared with a fixed dose of ICS-LABA as maintenance treatment or a higher dose of ICS, both with as-needed SABA [GINA 2019 references 202-207] (Evidence A). Low dose ICS-formoterol is the preferred reliever for patients prescribed the maintenance and reliever treatment regimen. It should not be used as the reliever for patients taking combination ICS-LABA medications with a different LABA.”