Annals of Internal MedicineA 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

The updated 2025 VA/DOD clinical practice guideline for primary care asthma management, published in Annals of Internal Medicine, advances ICS combined with rapid-onset LABA as both controller and reliever therapy across all asthma severity levels for patients aged 12 and older. The guideline, based on 59 studies and 21 GRADE-rated recommendations, marks a significant shift away from symptom-driven SABA reliance toward anti-inflammatory maintenance as the foundation of care.

Clinical Considerations

• ICS is now recommended for all asthma patients regardless of severity, eliminating the prior persistent-only indication and acknowledging exacerbation risk even in infrequent symptom patterns
• For uncontrolled asthma on ICS-LABA, adding a long-acting muscarinic antagonist is suggested, supported by 17,000-patient data across 17 RCTs
• Treating symptomatic GERD and obesity (greater than 5% weight loss) each independently improved asthma control in systematic review evidence
• The guideline recommends against indoor air filtration devices, citing no clinically significant improvement in control, exacerbations, or lung function

Practice Applications

• Transition patients using SABA as primary reliever to ICS-formoterol combination as both controller and reliever
• Screen all asthma patients for GERD and obesity as modifiable contributors to poor control
• Counsel patients that air filtration devices are not supported by current evidence and carry out-of-pocket costs
• Refer to subspecialist for biologic therapy consideration; this guideline explicitly defers that decision outside primary care

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