In the stepwise management of asthma according to GINA guidelines, at which step is a long-acting beta-2 agonist (LABA) first introduced in combination with an inhaled corticosteroid (ICS)?

Explanation

## GINA Stepwise Asthma Management **Key Point:** ICS/LABA combination therapy is introduced at Step 3 (moderate persistent asthma) when low-to-medium dose ICS monotherapy fails to achieve control. ### GINA Asthma Treatment Steps | Step | Severity | Preferred Controller | Reliever | | --- | --- | --- | --- | | 1 | Intermittent | None (PRN only) | SABA (albuterol/salbutamol) | | 2 | Mild persistent | Low-dose ICS | SABA PRN | | 3 | Moderate persistent | **ICS/LABA combination** | SABA PRN | | 4 | Severe persistent | High-dose ICS/LABA ± LAMA | SABA PRN | | 5 | Severe uncontrolled | High-dose ICS/LABA/LAMA ± biologic | SABA PRN | **High-Yield:** Step 2 uses ICS monotherapy (low-dose), NOT ICS/LABA. The addition of LABA occurs at Step 3 when monotherapy is insufficient. This is a frequently tested distinction in NEET PG. **Clinical Pearl:** Modern GINA 2023 also permits "budesonide–formoterol as needed" (MART regimen) as an alternative to ICS monotherapy at Step 2 in selected patients, but the traditional Step 3 introduction of ICS/LABA remains the standard escalation pathway. **Mnemonic:** **2 = ICS alone; 3 = ICS + LABA** — remember the step number to avoid confusing when LABA is added.