Table 3.

Steps for confirming the diagnosis of asthma in a patient already taking controller treatment.

Current status	Steps to confirm the diagnosis of asthma
Variable respiratory symptoms and variable airflow limitation	Diagnosis of asthma is confirmed. Assess the level of asthma control (Box 2–2) and review controller treatment (Box 3–5).
Variable respiratory symptoms but no variable airflow limitation	Consider repeating spirometry after withholding BD (4 h for SABA, 24 h for twice-daily ICS-LABA, 36 h for once-daily ICS-LABA) or during symptoms. Check between-visit variability of FEV1, and bronchodilator responsiveness. If still normal, consider other diagnoses (Box 1–5). If FEV1 is >70% predicted: consider stepping down controller treatment (see Box 1–5) and reassess in 2–4 weeks, then consider bronchial provocation test or repeating BD responsiveness. If FEV1 is <70% predicted: consider stepping up controller treatment for 3 months (Box 3–5), then reassess symptoms and lung function. If no response, resume previous treatment and refer patient for diagnosis and investigation.
Few respiratory symptoms, normal lung function, and no variable airflow limitation	Consider repeating BD responsiveness test again after withholding BD as above or during symptoms. If normal, consider alternative diagnoses (Box 1–5). Consider stepping down controller treatment (see Box 1–5): • If symptoms emerge and lung function falls: asthma is confirmed. Step up controller treatment to previous lowest effective dose. • If no change in symptoms or lung function at lowest controller step: consider ceasing controller, and monitor patient closely for at least 12 months (Box 3–7).
Persistent shortness of breath and persistent airflow limitation	Consider stepping up controller treatment for 3 months (Box 3–5), then reassess symptoms and lung function. If no response, resume previous treatment and refer patient for diagnosis and investigation. Consider asthma–COPD overlap (Chapter 5).

“Variable airflow limitation” refers to expiratory airflow. GINA recommendations for confirming the diagnosis in those already started on controller treatment. Source: Box 1–3 in GINA 2022. Box and chapter numbers refer to the GINA 2022 report. Reproduced with permission from ref. ¹¹.

BD bronchodilator, COPD chronic obstructive pulmonary disease, FEV₁ forced expiratory volume in 1 s, ICS inhaled corticosteroid, LABA long-acting beta₂ agonist, SABA short-acting beta₂ agonist.