Journal Update

GINA Track-1 Improves Asthma Control and Reduces Environmental Impact Compared with Track-2

Background

Inhalers are the cornerstone of asthma management but also contribute to healthcare-related carbon emissions, particularly pressurized metered-dose inhalers (pMDIs) that use hydrofluoroalkane propellants. Approximately 22% of primary care’s carbon footprint is attributed to inhaler use. In contrast, dry powder inhalers (DPIs) have a substantially lower environmental impact.

The Global Initiative for Asthma (GINA) recommends:

• Track-1: Low-dose ICS–Formoterol as both maintenance and reliever therapy (SMART).
• Track-2: Maintenance ICS-containing therapy with SABA as the reliever.

This study evaluated the long-term clinical outcomes and environmental impact of these two treatment strategies in Singapore’s primary care setting.

Objective

To compare:

• Asthma control
• Rescue medication use
• Carbon footprint

between adult asthma patients receiving:

• Track-1: Budesonide–Formoterol (BUD/FOR) DPI as maintenance and reliever therapy (SMART)
• Track-2: Budesonide–Formoterol DPI with SABA pMDI as reliever

Study Design

• Retrospective longitudinal study
• Electronic Medical Records (EMR) analysis
• Eight public primary care clinics in Singapore
• Study period: 2018–2023

Study Population

• Adults aged ≥21 years
• Clinical diagnosis of asthma
• At least one Asthma Control Test (ACT) score recorded annually

Methods

Data collected included:

• Inhaler dispensing records
• Asthma Control Test (ACT) scores
• Rescue therapy utilization
• Carbon footprint (based on inhaler canisters dispensed)

Generalized Estimating Equations (GEE) were used to evaluate associations between treatment strategy, asthma control, rescue therapy use, and carbon footprint.

Study Endpoints

• Number of inhalers dispensed
• Asthma control (ACT score)
• Carbon footprint (kgCO₂e)
• Rescue therapy requirement

Key Results

Patient Population

• 5,634 adult asthma patients treated with BUD/FOR DPI

Treatment Trends

• Track-1 use increased markedly:
  • 466 → 2,317 patients
• Track-2 use increased modestly:
  • 628 → 758 patients

Asthma Control

Patients achieving good asthma control (ACT ≥20) in 2023:

• Track-1: 78.5%
• Track-2: 68.7%

Patients receiving Track-1 were:

• 1.5 times more likely to achieve good asthma control (p <0.001)

Rescue Therapy

Compared with Track-2, Track-1 patients had:

• ~30% lower odds of requiring rescue therapy (p <0.001)

Average SABA-pMDI use declined:

• 2.8 → 2.1 canisters/patient/year

Carbon Footprint

Average carbon footprint per patient:

• Track-1: 3.3 kgCO₂e
• Track-2: 62.4 kgCO₂e

Track-1 reduced carbon emissions by approximately 60 kgCO₂e per patient (p <0.001).

Inhaler Utilization

Average annual BUD/FOR inhalers dispensed:

• Track-1: 4.1 inhalers/patient
• Track-2: 5.3 inhalers/patient

Difference:

• 1.2 fewer inhalers per patient per year with Track-1.

Clinical Take-Home Message

✅ GINA Track-1 (ICS–Formoterol SMART) provides:

• Better asthma control
• Reduced need for rescue medication
• Lower inhaler utilization
• Dramatically lower carbon footprint

Adopting Track-1 can improve both patient outcomes and environmental sustainability, supporting a more effective and eco-friendly approach to asthma management.

Reference

J Prim Care Community Health. 2026;17:21501319251411430.
Published online: February 14, 2026.
doi: 10.1177/21501319251411430.

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