Across randomized trials involving nearly 22,000 participants, single-device maintenance and reliever therapy reduced severe asthma exacerbations by about one-third, a finding that highlights the updated US Department of Veterans Affairs and US Department of Defense recommendations.
The US Department of Veterans Affairs (VA) and US Department of Defense (DoD) have released a 2025 clinical practice guideline for the primary care management of asthma that consolidates emerging evidence into 21 recommendations, streamlines stepwise pharmacotherapy, and reflects a shift away from symptom-driven reliever therapy toward anti-inflammatory strategies.
The 2025 update retains the stepwise treatment framework but no longer recommends short-acting beta-agonist (SABA)-only reliever therapy, instead recommending inhaled corticosteroid (ICS)-containing reliever strategies.
Guideline Development and Scope
The VA/DoD working group convened in 2024 and conducted a systematic review of literature published from July 20, 2018, through May 15, 2024. Using the Grading of Recommendations Assessment, Development and Evaluation framework, the group developed 21 evidence-based recommendations informed by 59 studies and organized around 12 key clinical questions.
The guideline is specifically designed for primary care clinicians managing chronic asthma in patients older than 5 years and doesn't address acute exacerbation management. Biologic therapies are deferred to subspecialists.
Pharmacotherapy: Emphasis on Anti-Inflammatory Reliever Strategies
Asthma affects 8.7% of US adults, with a higher prevalence among women, adults aged 60 years and older, those with a lower household income, and patients with obesity. Historically, management relied on maintenance ICS paired with SABAs for symptom relief. However, greater reliance on SABA use and insufficient use of ICS have been linked to increased asthma-related morbidity and mortality.
The working group strongly recommends ICS for asthma control in all patients, regardless of symptom frequency. Among patients aged 12 years or older with mild asthma, the guideline suggests ICS combined with a rapid-onset long-acting beta-agonist (LABA) such as formoterol for both asthma control and relief . This approach, commonly termed single-device maintenance and reliever therapy (SMART or MART), ensures delivery of anti-inflammatory therapy during symptomatic periods.
In randomized studies involving roughly 22,000 patients, SMART was associated with a reduction of severe exacerbations of approximately one-third.
Among patients with uncontrolled asthma receiving ICS alone, escalation to ICS combined with rapid-onset LABA as both controller and reliever therapy is recommended. In patients whose asthma remains uncontrolled despite medium- or high-dose ICS–LABA therapy, the addition of a long-acting muscarinic antagonist is suggested. Step-down therapy is appropriate after at least 3 months of stable control; however, ICS shouldn't be discontinued.
Comorbidities, Monitoring, and Supportive Care
The guideline highlights management of comorbid conditions that may impair asthma control. Treatment of symptomatic gastroesophageal reflux disease is suggested to improve asthma control and lung function. In adults with asthma and obesity, weight loss is recommended to improve asthma control, particularly among patients achieving more than 5% body weight reduction. The working group advises against routine use of indoor air filtration devices because of limited evidence of clinically meaningful benefit.
A written asthma action plan is suggested to improve asthma control and asthma-related quality of life. The guideline also recommends avoiding routine spirometry for monitoring stable asthma and finds insufficient evidence to advocate for or against routine use of fractional exhaled nitric oxide in primary care settings.
Clinical Implications
In an accompanying editorial, James G. Krings, MD, MSc, of the Division of Pulmonary and Critical Care Medicine in the Department of Medicine at the Washington University School of Medicine and Washington University School of Public Health, stated that the guideline “represents the clearest US-based endorsement to date of ICS-containing reliever therapy across the spectrum of asthma severity.” He noted that formulary limitations for ICS–formoterol inhalers may present implementation challenges despite alignment with evolving evidence.
“The 2025 VA/DoD asthma [clinical practice guideline] update streamlined management of asthma by suggesting a combination of ICS and rapid-onset LABA as both reliever and controller agents and step-up therapy by increasing ICS and/or adding long-acting anticholinergic agents,” noted lead guideline author Amir Sharafkhaneh, MD, PhD, of the Michael E. DeBakey VA Medical Center, and colleagues.
Full disclosures can be found in the synopsis and editorial.