Ann Intern Med
New VA/DoD guidance streamlines asthma care in primary practice
A 2025 update to the joint VA/DOD clinical practice guideline outlines 21 evidence-based recommendations for asthma management in primary care, informed by a systematic literature review and GRADE methodology. The guideline strongly supports inhaled corticosteroids (ICS) as foundational therapy and recommends an ICS plus rapid-onset long-acting β‑agonist (LABA) regimen that can be used as both controller and reliever. Step-up options include increasing ICS dose and/or adding a long-acting anticholinergic agent (LAMA). The panel also highlights addressing comorbid symptomatic GERD and obesity as part of asthma control, advises against indoor air filtration devices, and clarifies referral points for subspecialty care.
Recommendations (strength of recommendation)
Diagnosis & Assessment
- Identify known risk factors for developing asthma and asthma‑associated conditions (e.g., deployment exposures, smoking, depression, anxiety). (Weak for)
- Identify risk factors for adverse asthma outcomes (e.g., overweight/obesity, atopy, air quality, secondhand smoke exposure, prior lower respiratory infection) and screen for anxiety or depression. (Weak for)
Asthma Education
- Offer a written asthma action plan to improve asthma control and quality of life. (Weak for)
- No recommendation for or against use of patient‑oriented technology (apps, devices) to augment usual care. (Neither for nor against)
Pharmacotherapy
- Use inhaled corticosteroids (ICS) for asthma control in all patients. (Strong for)
- For patients ≥12 years, consider ICS + rapid‑onset LABA (e.g., formoterol) for both control and relief. (Weak for)
- For uncontrolled asthma on ICS alone, use ICS–formoterol as both controller and reliever (SMART). (Strong for)
- For patients uncontrolled on ICS+LABA who are still using SABA, switch to ICS–formoterol for controller and reliever. (Weak for)
- Add a long‑acting muscarinic antagonist (LAMA) for patients ≥12 years uncontrolled on medium/high‑dose ICS+LABA. (Weak for)
- Use pre‑exertional SABA for exercise‑induced bronchoconstriction. (Weak for)
- In controlled asthma, consider stepping down ICS dose (not stopping) or discontinuing LABA. (Weak for)
- Treat symptomatic GERD in patients with asthma and GERD to improve control and lung function. (Weak for)
Non‑Pharmacologic Interventions
- Promote weight loss in adults with asthma and obesity to improve control. (Weak for)
- Do not use indoor air filtration devices (e.g., HEPA, NO₂ filters) for asthma control. (Weak against)
- Use a multidisciplinary care approach to improve control, adherence, and quality of life. (Weak for)
- Encourage regular exercise to improve asthma control and quality of life. (Weak for)
- Offer cognitive behavioral therapy to improve asthma‑related quality of life and self‑reported control in adults. (Weak for)
Monitoring & Follow‑up
- Do not use routine spirometry for monitoring stable asthma. (Weak against)
- No recommendation for or against routine use of fractional exhaled nitric oxide (FeNO) in primary care monitoring. (Neither for nor against)
- No recommendation for or against telemedicine as a substitute for in‑person asthma care. (Neither for nor against)
- Leverage electronic health record tools (e.g., reminders, trackers) in asthma care. (Weak for)
Source:
Sharafkhaneh A, et al. (2026, February 17). Ann Intern Med. A 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. https://pubmed.ncbi.nlm.nih.gov/41698207/
