A 7-year-old with known asthma has nocturnal cough, wheezing on most days of the week, and limitation of activities. Peak expiratory flow (PEF) is 55% predicted. His symptoms persist despite low-dose ICS alone. What GINA step of therapy should be started?

• A Step 2: low-dose ICS monotherapy
• B Step 3: low-dose ICS + long-acting beta-2 agonist (LABA)
• C Step 5: add-on biologic therapy (omalizumab)
• D Step 4: medium/high-dose ICS + LABA ✓

Explanation

This child has moderate persistent asthma (symptoms on most days, nocturnal symptoms, PEF 55% = >40–60% range, activity limitation) that is inadequately controlled on low-dose ICS alone. Per GINA 2023 guidelines, uncontrolled symptoms on Step 2 (low-dose ICS) warrants step-up to Step 3 (low-dose ICS + LABA in ≥5 years), and if moderate-severe uncontrolled as here, direct step-up to Step 4 (medium-to-high dose ICS + LABA) is appropriate. In children <5 years, LABAs are not recommended; leukotriene receptor antagonists are the add-on. Biologics (Step 5) are for severe uncontrolled asthma on maximum Step 4 therapy.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.