The GINA treatment strategy released in 2019 included an important change disrupting a fundamental practice in mild asthma management. Treatment with a short-acting beta 2 agonist (SABA) alone is no longer the preferred treatment for adults and adolescents with asthma. Subsequently, GINA 2021 has two tracks, one with the preferred approach, using an inhaled corticosteroid (ICS)/formoterol as a single maintenance and reliever therapy (SMART), and a second allowing the more traditional approach using a SABA-based reliever with an ICS or an ICS/long-acting beta 2 agonist (LABA) combination. While short-acting bronchodilators may provide symptom relief for patients, they remain at risk for severe exacerbations. In late 2020, a similar update was made to the US National Asthma Education and Prevention Program (NAEPP) guidelines. 

Since launching as the first fixed-dose combinations of an ICS and a LABA, GSK’s Advair and AstraZeneca’s Symbicort have become well-established gold-standard therapies in asthma. However, generic competition in Europe, and more recently in the US, marks the end of this successful history. Lawmakers and regulators have imposed tactics to combat the high price of inhalers by challenging inhaler patents in the Orange Book and urging price cuts.