What Happens When You Refer
October 15, 2026
A clinical brief for referring providers — week 4 of a 4-part series on severe and difficult-to-control asthma.
Quick question before you read on: According to GINA 2026, at what treatment step should every patient be referred for specialist evaluation?
a) Step 3 b) Step 4 c) Step 5
Over the past three weeks we have covered the diagnostic check, phenotyping, and the cumulative cost of oral steroids. This week: what actually happens when you send someone to us.
When to refer — GINA 2026
Symptoms uncontrolled or frequent exacerbations despite correct technique and good adherence on Step 4
Frequent asthma-related healthcare use — repeated ED or urgent visits
Need for frequent or maintenance OCS
Difficulty confirming the diagnosis
Suspected occupational asthma
Confirmed food allergy or anaphylaxis history — this raises the risk of asthma death
Symptoms suggesting an infective or cardiac cause
Symptoms suggesting bronchiectasis
Significant multimorbidity
Step 5 Every Step 5 patient should be referred.
What the evaluation includes
Confirmation of the diagnosis with objective testing
Comprehensive phenotyping — blood eosinophils, FeNO, total IgE, specific IgE or skin prick testing, sputum analysis where available
Assessment for comorbidities and mimics
Biologic selection and initiation, using the CHEST 2026 framework
Structured OCS taper where the patient is steroid-dependent
Reassessment at 4–6 months, with biologic switching if the response is inadequate
What we will not do: discontinue their ICS. Controllers continue when a biologic starts.
What happens if the first biologic does not work: up to 10% of patients do not respond to their initial agent. There is an evidence-based switching pathway, and a non-response is not the end of the road.
What helps most on the referral: a pre-steroid eosinophil count if you have one, the current controller regimen, and the number of OCS courses in the past twelve months. Those three tell us most of what we need before the patient arrives.
Want the referral pathway walked through with your team?
Dr. Joel Mensing of the Chest & Sleep Team runs a 20-minute clinical briefing covering the GINA 2026 referral triggers, what our evaluation actually includes, and the three pieces of information that move a patient through fastest. Lunch provided. No pitch — just the clinical walkthrough.
Call (847) 860-7250.
The answer
Step 5. All Step 5 patients warrant specialist evaluation for phenotyping and add-on therapy. Step 4 patients warrant referral where symptoms remain uncontrolled despite confirmed adherence and correct technique.