Considering all of the available data, what should physicians do? First, it is important to follow current guidelines that emphasize the use of inhaled corticosteroids as the first line of treatment for patients with mild to moderate persistent asthma symptoms (12). Physicians should not use LABAs as initial therapy for any asthmatic patient. Second, physicians caring for patients who do not achieve at least good control (defined by recent guidelines (13) as minimal daily or nocturnal symptoms and infrequent exacerbations requiring systemic corticosteroids or emergency department visits) should use an approach based on the recent Gaining Optimum Asthma controL (GOAL) study (3). This randomized, double-blind clinical trial of more than 3000 patients with uncontrolled mild to moderate asthma stratified by corticosteroid use sought to achieve asthma control by escalating the dose of inhaled corticosteroids alone or combined with salmeterol. The GOAL investigators found that the combination of inhaled corticosteroids plus a LABA resulted in a greater rate and level of control and a lower dose of inhaled corticosteroids than did inhaled corticosteroids alone. However, on the basis of all available data, including the analysis by Salpeter and colleagues, it seems prudent to first escalate the dose of inhaled corticosteroids to achieve asthma control. If satisfactory control is not attained at maximal doses of inhaled corticosteroids, then a LABA should be added. The report by Salpeter and colleagues reminds us of the critical importance of careful monitoring to identify patients who are not responsive or whose condition deteriorates in response to LABA therapy. If LABA therapy fails, the physician should withdraw the drug, either abruptly or by tapering it over a period of days or weeks, a point of some uncertainty (14). As suggested by Salpeter and colleagues, physicians should be prepared to provide an alternative medication for patients in whom LABA therapy fails. Adding an inhaled anticholinergic agent has theoretical appeal, based on limited data suggesting that patients with the Arg/Arg genotype, who may constitute a substantial proportion of LABA-unresponsive patients, have a particularly favorable response to anticholinergics (14). An especially vexing problem is the African-American patient whose asthma is not adequately controlled by inhaled corticosteroids alone, even with maximal doses. On the basis of available information ((8), (11)), it appears reasonable to add an inhaled anticholinergic agent (since African-American persons have a higher prevalence of the Arg/Arg genotype) and to avoid LABAs if possible.