A 30-year-old woman with asthma has daytime symptoms on most days and wakes with cough once a week. She uses only albuterol as needed, with good inhaler technique, and has had no exacerbations. Spirometry shows an FEV₁ of 76% predicted with significant bronchodilator reversibility. According to GINA 2025/2026, which regimen is most appropriate to start?

Budesonide-formoterol maintenance and reliever

High-dose fluticasone plus albuterol as needed

Montelukast 10 mg daily plus albuterol as needed

Albuterol as needed, with no controller

A 66-year-old man with COPD (post-bronchodilator FEV₁ 45% predicted) has persistent exertional dyspnea (mMRC grade 2) while taking salmeterol 50 mcg twice daily with good technique. He has had no exacerbations in the past year, and blood eosinophils are 150 cells/µL. Which change is most appropriate?

Add tiotropium (LAMA) to the LABA

Add fluticasone (ICS) to the LABA

A 28-year-old woman with moderate persistent asthma is started on budesonide/formoterol 160/4.5 mcg, 2 inhalations twice daily, plus 1 inhalation as needed for symptoms (maintenance-and-reliever therapy). Which counseling point is correct?

Use 1 extra puff for symptoms, up to 12 puffs a day

Take 4 extra inhalations at once if symptoms start

Use albuterol, not this inhaler, for any sudden symptoms

Skip the maintenance doses on days with no symptoms

A 30-year-old woman with asthma uses budesonide 180 mcg 2 inhalations twice daily and albuterol as needed. Over the past 4 weeks she has had daytime symptoms 3 times a week, woke at night once with cough, and used albuterol 3 times a week (not for exercise); she has no activity limitation. Inhaler technique and adherence are confirmed. Which assessment and plan are most appropriate?

Uncontrolled; step up her controller therapy

Well controlled; step down the budesonide

Uncontrolled; prescribe a 5-day prednisone burst

Partly controlled; continue current therapy

A 28-year-old woman with asthma has used fluticasone/salmeterol 250/50 mcg one inhalation twice daily for a year. For the past 4 months she has had no daytime symptoms, night waking, reliever use, or exacerbations, and her FEV1 is 92% of predicted. She asks to cut back her medication. Which change is most appropriate?

Reduce to fluticasone/salmeterol 100/50 twice daily

Stop all controllers and use albuterol as needed

Stop fluticasone and continue salmeterol alone

Continue the current dose for at least 5 more years

BCPS Asthma vs COPD: GINA and GOLD Inhaler Steps

1Two diseases, opposite starting points

Asthma is an inflammatory disease first, and the airway narrowing follows from the inflammation. That is why GINA treats a bronchodilator without an ICS as unsafe at any step: it relieves the symptom and leaves the inflammation untreated. COPD is driven mainly by fixed airflow limitation and airway remodeling, and an ICS adds little for most patients while raising the risk of pneumonia. So the first long-acting drug is an ICS in one disease and a bronchodilator in the other.

The two mistakes that follow are mirror images. Giving an ICS alone to a patient with COPD is wrong under GOLD 2026, and giving a LABA without an ICS to a patient with asthma is wrong under GINA 2026. Either regimen looks reasonable until you check which disease the patient has. The exacerbation side of both diseases is in the pulmonology and gastroenterology monograph.

1.1Inhaled steroids and the CYP3A4 problem

Fluticasone and budesonide are cleared through CYP3A4. Strong inhibitors such as ritonavir and cobicistat raise systemic steroid exposure enough to cause Cushing syndrome and adrenal suppression, as the fluticasone labeling warns. Inhibitor and inducer timing is covered in CYP450 inducers and inhibitors.

2GINA 2026 and GOLD 2026 side by side

≠ marks rows where the two differ.

Inhaler strategy in asthma and in COPD per the 2026 GINA and GOLD reports
Point of comparison	Asthma (GINA 2026)	COPD (GOLD 2026)
Differs: First long-acting therapy	An ICS at every step, as needed ICS-formoterol at the lowest steps	LAMA plus LABA for most symptomatic patients; one long-acting bronchodilator when symptoms are few
Differs: Place of the ICS	Always present; a LABA is never given without it	Added for exacerbators with raised eosinophils; never alone
Differs: Preferred reliever	Low-dose ICS-formoterol (Track 1)	Short-acting bronchodilator as needed
Differs: Who counts as high risk	Patients with exacerbation risk factors, assessed at every visit	One or more moderate or severe exacerbations in the past year; earlier reports required two moderate or one leading to hospitalization
Differs: Biologics	Several classes for severe asthma, chosen by phenotype	Dupilumab and mepolizumab for eosinophilic exacerbators
Differs: Stepping down	Built in once control is sustained, keeping the ICS	ICS can be withdrawn when it was not indicated or pneumonia occurs

Doses, eosinophil cut-points and device lists are in the GINA and GOLD reports; see the references below.

3How the guidance moved

2017
FDA removes the boxed warning from ICS-LABA combination inhalers
Safety trials showed no excess serious asthma events when the LABA comes with an ICS.
2019
GINA stops recommending SABA-only treatment
Adults and adolescents get an ICS-containing regimen from the first step.
2023
GOLD regroups patients into A, B and E
Group E gathers the exacerbators, whatever their symptom score.
November 2025
GOLD 2026 report
One moderate or severe exacerbation in a year now makes a patient an exacerbator, after data linking a single event to further exacerbations and death; biologics gain ground for eosinophilic disease.
May 2026
GINA 2026 report
Track 1 with ICS-formoterol stays the preferred path.

4Counseling a patient on maintenance-and-reliever therapy

One inhaler does both jobs: the scheduled doses and the extra puffs for symptoms.
Only formoterol combinations qualify, because formoterol works within minutes; salmeterol combinations cannot be used as a reliever.
Know the maximum total puffs per day set by GINA and written into the action plan (US labels do not describe this regimen), and seek care if you need more.
Rinse and spit after use to limit oral thrush.
Check technique at every visit before deciding the regimen has failed.

5Asthma or COPD? Decide, then step

Decide asthma or COPD first, then the step. Watch for regimens that would be right in the other disease.

Study cases written by our editors, not BPS items. The real BCPS exam is computer-based multiple choice, answered in order with no going back.

Case 1 of 6 · 0 answered

How case rounds work

Pick an option to see the verdict and a note on every option. Keys while the round has focus: 1–5 or A–E answer, ← → move between cases. Nothing is saved or sent anywhere.

Case 01
A 30-year-old woman with asthma has daytime symptoms on most days and wakes with cough once a week. She uses only albuterol as needed, with good inhaler technique, and has had no exacerbations. Spirometry shows an FEV₁ of 76% predicted with significant bronchodilator reversibility. According to GINA 2025/2026, which regimen is most appropriate to start?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
Symptoms most days with weekly night waking correspond to GINA Step 3, where the preferred Track 1 regimen is low-dose budesonide-formoterol as both maintenance and reliever (MART), which reduces severe exacerbations compared with SABA-based regimens. GINA no longer recommends SABA-only treatment at any step. High-dose ICS exposes her to more adverse effects without matching MART’s exacerbation benefit, and montelukast is less effective than ICS and carries a boxed warning for neuropsychiatric events.
A
High-dose ICS adds adverse effects without matching the exacerbation benefit of low-dose ICS-formoterol MART.
B
Montelukast is less effective than an ICS and carries a boxed warning for neuropsychiatric events.
C
GINA no longer recommends SABA-only treatment at any step.
D
Correct. Symptoms most days with weekly night waking put her at GINA Step 3, where Track 1 is budesonide-formoterol MART.
Case 02
A 66-year-old man with COPD (post-bronchodilator FEV₁ 45% predicted) has persistent exertional dyspnea (mMRC grade 2) while taking salmeterol 50 mcg twice daily with good technique. He has had no exacerbations in the past year, and blood eosinophils are 150 cells/µL. Which change is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: B.
GOLD 2026 recommends dual LAMA+LABA bronchodilation for persistent dyspnea, and adding a LAMA improves symptoms and lung function. Adding an ICS is the outdated answer: LABA+ICS without a LAMA is not recommended in COPD, and an ICS is considered only for exacerbations with eosinophils of 100 cells/µL or more (300 or more at initiation in Group E). Roflumilast is for exacerbations in chronic bronchitis with FEV₁ below 50%, and montelukast has no role in COPD.
A
Montelukast has no role in COPD.
B
Correct. Persistent dyspnea on a LABA calls for dual bronchodilation; adding a LAMA improves symptoms and lung function.
C
Roflumilast is for repeated exacerbations in chronic bronchitis with FEV₁ below 50%, and he has had none.
D
LABA plus ICS without a LAMA is not recommended in COPD, and he has no exacerbations or high eosinophils to justify an ICS.
Case 03
A 28-year-old woman with moderate persistent asthma is started on budesonide/formoterol 160/4.5 mcg, 2 inhalations twice daily, plus 1 inhalation as needed for symptoms (maintenance-and-reliever therapy). Which counseling point is correct?
Pick an option: the verdict and a note on every option open here.
Best answer: D.
With MART the same ICS-formoterol inhaler is both controller and reliever: one inhalation is taken as needed (repeated after a few minutes if necessary), up to 12 inhalations (72 mcg formoterol) per day in total, and she should rinse her mouth after use. Using albuterol as the reliever abandons the regimen whose as-needed ICS doses reduce severe exacerbations. Maintenance doses continue daily, and taking several inhalations at once exceeds the per-occasion dosing.
A
With MART each reliever use is one inhalation, repeated after a few minutes if needed, not four at once.
B
Switching to albuterol for sudden symptoms abandons the as-needed ICS doses that prevent severe exacerbations.
C
The maintenance doses continue every day, whether or not she has symptoms.
D
Correct. With MART one extra inhalation is taken for symptoms, up to 12 inhalations a day in total.
Case 04
A 62-year-old man with COPD (post-bronchodilator FEV₁ 35% predicted) and chronic productive cough had two moderate exacerbations in the past year despite good adherence and technique with tiotropium/olodaterol. He still smokes 10 cigarettes per day despite counseling. Blood eosinophils are 60 cells/µL on two occasions. Which medication should be added?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
GOLD 2026 escalates exacerbations on LABA+LAMA by eosinophils: with eosinophils below 100 cells/µL an ICS adds little benefit and raises pneumonia risk, so roflumilast is preferred when FEV₁ is below 50% with chronic bronchitis. Azithromycin is the other option at low eosinophils but is preferentially used in former smokers, as it is less effective in current smokers. Montelukast has no role in COPD.
A
Montelukast has no established role in COPD.
B
With eosinophils below 100 cells/µL an ICS adds little benefit and raises pneumonia risk.
C
Correct. Exacerbations on LABA+LAMA with eosinophils under 100, FEV₁ below 50% and chronic bronchitis point to roflumilast.
D
Azithromycin is the other low-eosinophil option, but it works less well in current smokers and is favored in former smokers.
Case 05
A 30-year-old woman with asthma uses budesonide 180 mcg 2 inhalations twice daily and albuterol as needed. Over the past 4 weeks she has had daytime symptoms 3 times a week, woke at night once with cough, and used albuterol 3 times a week (not for exercise); she has no activity limitation. Inhaler technique and adherence are confirmed. Which assessment and plan are most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: A.
GINA symptom control asks four questions about the past 4 weeks—daytime symptoms more than twice weekly, any night waking, reliever need more than twice weekly, and any activity limitation; she answers yes to three, so her asthma is uncontrolled and, with technique and adherence confirmed, controller therapy should be stepped up (for example to ICS-formoterol maintenance-and-reliever therapy). One or two yes answers define partly controlled. A prednisone burst treats an exacerbation, which she is not having, and does not fix poor control.
A
Correct. Three of four GINA control criteria are positive, so asthma is uncontrolled; with technique and adherence confirmed, step up.
B
Symptoms, night waking and reliever use all exceed control limits, so a step-down is the wrong direction.
C
A prednisone burst treats an exacerbation, which she is not having, and does not fix ongoing poor control.
D
Partly controlled means one or two positive criteria; she has three.
Case 06
A 28-year-old woman with asthma has used fluticasone/salmeterol 250/50 mcg one inhalation twice daily for a year. For the past 4 months she has had no daytime symptoms, night waking, reliever use, or exacerbations, and her FEV1 is 92% of predicted. She asks to cut back her medication. Which change is most appropriate?
Pick an option: the verdict and a note on every option open here.
Best answer: C.
GINA advises stepping down once asthma has been well controlled for about 3 months, typically by reducing the ICS dose by 25–50% while keeping the combination, then reassessing control. LABA monotherapy without an ICS increases the risk of severe exacerbations and asthma death. SABA-only treatment is not recommended at any step, and continuing an unnecessarily high ICS dose for years adds adverse effects without benefit.
A
Dropping to SABA-only is not recommended at any GINA step.
B
LABA without an ICS raises the risk of severe exacerbations and asthma death.
C
Correct. After about 3 months of good control, GINA steps down by cutting the ICS dose by 25–50% and keeping the combination.
D
Holding a higher-than-needed ICS dose for years adds adverse effects without benefit.

6Inhaler questions, both diseases

What if a patient has features of both asthma and COPD?

GINA and GOLD agree that an ICS must be part of the regimen whenever asthma features are present, so long-acting bronchodilators without an ICS are avoided.

Where does montelukast fit?

It is a less effective controller than an ICS in asthma and carries a boxed warning for neuropsychiatric events, so GINA places it as an alternative rather than a preferred option.

Which COPD patients are candidates for a biologic?

GOLD 2026 names dupilumab and mepolizumab for patients who keep having exacerbations on inhaled maintenance therapy and have eosinophilic disease. The eosinophil cut-points are in the GOLD report.

Why does GOLD now count a single exacerbation?

Large real-world data sets showed that one moderate exacerbation already raises the risk of the next one and of death within a year, so GOLD 2026 moved the line from two events to one.

7References

Global Initiative for Asthma (GINA), Global Strategy for Asthma Management and Prevention, 2026 update. As of October 27, 2026.
Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2026 report. As of October 27, 2026.

Next step

Study where the shift leaves you time

The iPhone app fits the gaps; the practice set on this site works in any browser.

Get the app Practice free on this site

Pharmacotherapy Exam Prep 2026 is an app for iPhone and iPad only; there is no Android version. On any other phone or a computer, use the free practice set on this site in your browser.