Recent updates to the Global Initiative for Asthma (GINA) diagnostic guidelines have substantially improved the accuracy of asthma diagnosis in adults, according to a new diagnostic study. However, researchers found that despite these improvements, the latest criteria may still fail to identify around one-third of adults with asthma.
The findings evaluate how revisions made between the 2023 and 2025 GINA reports have altered the balance between correctly diagnosing asthma and avoiding false-positive diagnoses.
Assessing Three Versions of the GINA Guidelines
The Global Initiative for Asthma regularly updates international recommendations for asthma diagnosis and management. In 2024, the organisation removed airflow limitation as a mandatory diagnostic criterion after evidence suggested it excluded many patients with asthma. The 2025 update further incorporated type 2 inflammatory biomarkers, including fractional exhaled nitric oxide (FeNO) and blood eosinophil counts, when conventional tests are negative or unavailable.
Researchers assessed the diagnostic performance of the 2023, 2024, and 2025 GINA criteria using data from 118 adults with suspected asthma who underwent comprehensive clinical assessment, lung function testing, allergy testing, bronchial challenge testing, and evaluation of treatment response. Diagnoses established by an expert panel served as the reference standard.
Removal of Airflow Limitation Increased Diagnoses
Among the 118 participants, 70 were confirmed to have asthma.
Removing airflow limitation as a mandatory requirement in the 2024 GINA update more than doubled the number of patients meeting the diagnostic criteria, increasing diagnoses from 32 patients under the 2023 criteria to 74 under the 2024 guidance.
The authors note that this change addressed one of the principal reasons asthma cases had previously been missed.
Biomarkers Improved Sensitivity
The addition of type 2 inflammatory biomarkers in the 2025 update identified nine additional asthma cases that would otherwise have remained undiagnosed. However, five of these additional diagnoses were false positives, illustrating the trade-off between improving sensitivity and maintaining diagnostic precision.
The researchers found that elevated FeNO levels and blood eosinophil counts together demonstrated a sensitivity of 57% and a specificity of 88% when used to support asthma diagnosis.
Greater Diagnostic Precision, but Some Cases Still Missed
Overall, changes introduced between the 2023 and 2025 GINA guidelines markedly improved diagnostic specificity, increasing it from 46% to 96%. This means the updated criteria were substantially better at correctly ruling out asthma in people without the disease.
At the same time, sensitivity declined from 100% to 67%, indicating that approximately one-third of patients with asthma could still remain undiagnosed using the latest criteria alone.
The authors suggest that while the revised GINA recommendations represent an important step towards more accurate diagnosis, clinicians should continue to interpret diagnostic test results alongside the patient’s clinical history and consider additional investigations when uncertainty remains.
Reference
Simpson AJ et al. Global Initiative for Asthma Updates for Diagnosing Asthma in Adults. JAMA Netw Open. 2026;9(5):e2611907.
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