Click to Enlarge: Source: Annals of Internal Medicine
WASHINGTON, DC — Asthma affects 8.7% of U.S. adults and is more prevalent among older adults and persons with obesity—clinical characteristics frequently encountered in VA and Department of Defense (DoD) primary care settings. For many veterans and servicemembers, asthma is a chronic respiratory condition requiring structured long-term management to prevent exacerbations and maintain control.
Because of significant advances in the evaluation and treatment of asthma in recent years, the VA and DoD undertook a comprehensive evidence review and issued updated clinical practice guidance in 2025, replacing their previous guideline published in 2019. A synopsis of the revised recommendations was published recently in Annals of Internal Medicine.1
A Paradigm Shift in Treatment
The 2025 update reflected what the authors described as “a notable paradigm shift in the treatment of asthma,” with care transitioning “away from isolated symptom-driven reliever therapies and toward treatments that target airway inflammation to prevent symptoms and promote control.”
Central to that shift is inhaled corticosteroid (ICS) therapy.
The work group “strongly recommended inhaled corticosteroids (ICS) for asthma control,” emphasizing that all patients with asthma should receive anti-inflammatory therapy. The panel noted that “all patients can remain at risk for severe exacerbations,” even those with infrequent symptoms, reinforcing that asthma is fundamentally an inflammatory disease.
Maintenance and Reliever Therapy (MART/SMART)
Click to Enlarge: Source: Annals of Internal Medicine
A major feature of the update is endorsement of maintenance and reliever therapy (MART), also known as SMART. This approach uses a single inhaler containing ICS and a rapid-onset, long-acting beta-agonist (LABA), such as formoterol, for both daily control and symptom relief.
Maintenance and reliever therapy “is a treatment strategy in which patients with asthma are prescribed a single combination inhaler containing an ICS and a long-acting β-agonist (LABA) for use as both maintenance and reliever therapy,” the authors explained. “This strategy aims to improve adherence to inhaled anti-inflammatory therapy each time a reliever medication is administered by the patient.”
For patients age 12 and older, ICS combined with rapid-onset LABA is suggested as the preferred approach. In patients with uncontrolled asthma on ICS alone, escalation to ICS–LABA as both controller and reliever is strongly recommended based on systematic reviews demonstrating reduced exacerbation frequency and severity compared with other step-up options.
If control remains suboptimal despite moderate- or high-dose ICS–LABA therapy, the panel suggests adding a long-acting muscarinic antagonist (LAMA) to further improve symptom control and decrease exacerbation risk.
Evidence-Based Development
The guideline was developed in 2024 under oversight of the VA Evidence-Based Practice Program and the Defense Health Agency. The work group drafted 12 key clinical questions and conducted a systematic review of literature published between July 20, 2018, and May 15, 2024.
Using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, the panel evaluated 59 studies and issued 21 evidence-based recommendations. GRADE requires that recommendations be “evidence-based and not founded on expert opinion alone,” incorporating evidence quality, balance of benefits and harms and patient preferences.
Importantly, the guideline focuses specifically on chronic asthma management in primary care. “Our guideline primarily focuses on primary care providers and not specialists who provide care to more complicated forms of asthma,” the authors wrote. The update does not address acute exacerbation management and defers biologic therapy decisions to subspecialists.
Comorbid Conditions and Nonpharmacologic Care
The updated recommendations also emphasize management of co-occurring conditions common in veteran populations.
The work group suggests treating symptomatic gastroesophageal reflux disease (GERD) in patients with asthma, as evidence supports improvements in asthma control and lung function. Weight loss is recommended in adults with asthma and obesity, with systematic reviews showing clinically meaningful improvements in patient-reported control among those achieving weight reduction.
The guideline also supports multidisciplinary care approaches and regular exercise to improve asthma-related quality of life and adherence.
Interventions Not Recommended
After reviewing available studies, the panel suggested against the use of indoor air filtration devices, such as high-efficiency particulate air and nitric oxide filters, for asthma control. Evidence did not demonstrate clinically significant improvements, and such devices may impose unnecessary financial costs.
The work group also found insufficient evidence to recommend for or against routine use of fractional exhaled nitric oxide monitoring or telemedicine as an alternative to in-person visits in primary care settings.
Tailored to VA/DOD Primary Care
Although the VA/DOD recommendations align in many respects with guidance from the Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program (NAEPP), the VA/DOD guideline is specifically designed for primary care and applies to patients older than 5 years. It focuses exclusively on chronic asthma management within VA and DOD health systems.
By emphasizing consistent anti-inflammatory therapy, streamlined inhaler strategies and evidence-based management of comorbid conditions, the 2025 VA/DOD asthma guideline provides a structured framework for improving long-term asthma control and quality of life for veterans and servicemembers.
- Sharafkhaneh A, Atayde ER, Cho J, Eickhoff D, et al. 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. doi: 10.7326/ANNALS-25-03080. Epub ahead of print. PMID: 41698207.
