Asthma — Management (Adults & Adolescents)

Fully rewritten against the Australian Asthma Handbook V3.0 (2025) and its 2026 quick-reference guide, absorbing asthma-adult-assessment.md’s control-classification content (now retired to duplicates/). See Asthma — Diagnosis for the diagnostic work-up, and Asthma — Children for the under-12 approach, where the reliever-therapy change below does not apply. See “View the original” for the pre-rewrite note.

The core change: no more SABA-only reliever therapy

No adult or adolescent should manage their asthma solely with as-needed salbutamol or terbutaline. This is the single biggest shift from the older SABA-first approach this note used to describe. Asthma treatment is now built around inhaled corticosteroid (ICS) — either taken as needed in combination with formoterol, or taken as regular maintenance therapy — plus a rapid-acting bronchodilator for symptom relief.

Two approaches to ICS treatment:

• Recommended: a single inhaler combining ICS and formoterol, taken as needed to relieve symptoms, with or without a daily maintenance dose.
• Alternative: an inhaler containing ICS alone, or ICS + a long-acting beta2 agonist (LABA), taken as daily maintenance, with a separate short-acting beta2 agonist (SABA) inhaler for symptom relief.

Relievers, similarly, are recommended as ICS-formoterol (an “anti-inflammatory reliever”, AIR) rather than SABA alone — regimens using ICS-formoterol as reliever reduce the risk of severe exacerbations requiring oral corticosteroids, compared with SABA-only reliever regimens.

Starting treatment after diagnosis

The recommended initial treatment for most patients — including those with infrequent symptoms — is anti-inflammatory reliever (AIR)-only therapy: low-dose budesonide-formoterol, taken as needed when symptoms occur, with no daily maintenance dose. This markedly reduces the risk of severe exacerbations requiring oral corticosteroids compared with as-needed SABA.

Start treatment with a regimen that includes maintenance ICS if the patient has frequent symptoms, a previous severe exacerbation, or other known risk factors for severe exacerbations (see below). Arrange follow-up within 2–3 months of starting treatment to reassess control, adherence, and inhaler technique.

Treatment levels (stepped therapy)

Level	ICS-formoterol as reliever (recommended)	SABA as reliever (alternative)
1 — suitable initial treatment for most patients	Budesonide-formoterol (low dose) as needed	ICS maintenance (low dose) + SABA reliever as needed
2	ICS-formoterol maintenance-and-reliever therapy (low dose)	ICS-LABA maintenance (low dose) + SABA reliever as needed
3	ICS-formoterol maintenance-and-reliever therapy (medium dose)	ICS-LABA maintenance (medium dose) + SABA reliever as needed
4	Targeted intensive treatment & specialist review — consider add-on LAMA or a trial of high-dose ICS-LABA	—

Consider starting at level 2 or 3 for frequent/severe symptoms or a high risk of exacerbation. Before stepping up, confirm symptoms are actually due to asthma, inhaler technique is correct, and adherence is adequate. Consider stepping up if good control isn’t achieved despite adherence and correct technique. When stable and well-controlled for 2–3 months, consider stepping down — but the least intensive appropriate treatment is low-dose budesonide-formoterol taken as needed; do not withdraw ICS completely.

Maintenance-and-reliever therapy (MART) — ICS-formoterol taken twice daily plus extra as-needed doses — is recommended for patients who need maintenance treatment to control symptoms. For patients already on maintenance ICS-LABA with SABA reliever, consider switching to MART rather than stepping up the ICS-LABA dose.

Risk factors for exacerbations (checklist)

Increased exacerbation risk: poor symptom control; any exacerbation in the past 12 months; high SABA use (≥3 canisters/year); other chronic lung disease; poor lung function even with few symptoms; difficulty perceiving airflow limitation/exacerbation severity; blood eosinophils ≥300/µL despite medium-dose ICS; smoke/vape exposure; socioeconomic disadvantage; mental illness.

Increased risk of life-threatening asthma: history of intubation/ICU admission for asthma (ever); ≥2 hospitalisations or ≥3 ED visits for asthma in the past year; hospitalisation/ED visit in the past month; history of sudden-onset acute asthma; delayed presentation during a moderate–severe exacerbation; high SABA use (≥12 canisters/year); cardiovascular comorbidity; sensitivity/exposure to an unavoidable allergen (e.g. mould); no written action plan; social isolation.

Assessing recent control

Good control (all of, over past 4 weeks)	Poor control (any of)
Daytime symptoms ≤2 days/week	Daytime symptoms >2 days/week
No limitation of activities	Any limitation of activities
No symptoms during night or on waking	Any symptoms during night or on waking
Reliever use ≤2 days/week*	Reliever use >2 days/week*

*Excludes prophylactic pre-exercise SABA doses, and excludes reliever use entirely for patients using an anti-inflammatory reliever (budesonide- or beclometasone-formoterol) — record and interpret these separately.

Inhaler technique and self-management

Choose an inhaler type the patient can use correctly and involve them in the choice. Advise pMDI users to use a spacer. Demonstrate technique with a placebo inhaler and reassess regularly, along with adherence.

Develop an individualised written asthma action plan for every patient, covering their usual medicines, how to adjust treatment (including reliever dose and when/how to start oral corticosteroids) when symptoms worsen, and when/how to get medical care including in an emergency.

Managing worsening symptoms: instruct patients to use their reliever as often as needed. Prescribe a short course of oral corticosteroid if symptoms recur within 4 hours of reliever use, or don’t resolve promptly.

Difficult-to-treat and severe asthma

If asthma isn’t well controlled on medium-dose ICS-LABA (medium-dose MART, or maintenance medium-dose ICS-LABA plus SABA as needed), investigate the cause before stepping up or assuming severe asthma — poor adherence, incorrect technique, trigger exposure, poor self-management, SABA overuse, and comorbid/alternative diagnoses are all more common explanations.

If control remains poor on medium-dose ICS despite correct technique and adherence, refer for spirometry + FeNO testing, blood eosinophil assessment, and specialist referral. While awaiting referral, consider a short (3–6 month) trial of high-dose ICS-LABA, or ICS-LABA-LAMA at medium/high ICS dose.

Avoid long-term high-dose ICS unless unavoidable — systemic effects include reduced bone mineral density, cataracts, and diabetes.

Monoclonal antibody therapy is now first-choice treatment for patients with severe allergic or eosinophilic asthma not adequately controlled by ICS and LABA. Some require specialist initiation or co-management; all are PBS-reimbursed only under specialist care.

Acute asthma emergencies in primary care

Rapidly assess severity by observation and pulse oximetry while starting bronchodilator and supplemental oxygen. Call an ambulance for any signs of severe or life-threatening acute asthma.

	Mild–moderately severe (all of)	Severe (any of)	Life-threatening (any of)
Speech/posture	Can walk, speak whole sentences in one breath	Unable to complete sentences in one breath due to breathlessness	Reduced consciousness/collapse, exhaustion, poor respiratory effort
SpO2 (room air)	>94%	92–96%, target on treatment	<92%
Other	—	Accessory muscle use, obvious distress	Cyanosis, silent chest/poor air entry

Immediate treatment: salbutamol 4–12 actuations (mild–moderate) or 12 actuations (severe) via pMDI + spacer using the tidal breathing method if too breathless for a single breath; if a nebuliser is unavoidable, 5 mg for a severe exacerbation or 2×5 mg nebules for life-threatening (continuous nebulisation, oxygen-driven, SpO2 target 92–96%). Start oxygen if SpO2 <92%; titrate to 92–96%, using the lower target range 88–92% for patients at hypercapnoea risk (COPD, obesity, obesity hypoventilation syndrome, bronchiectasis, cystic fibrosis, neuromuscular disease, severe kyphoscoliosis) — over-oxygenation increases hypercapnoea risk. Repeat bronchodilator every 20–30 minutes for the first hour if needed.

Start systemic corticosteroids regardless of severity, unless contraindicated:

• Adults: prednisone/prednisolone 37.5–50 mg orally, then repeat each morning on subsequent days (5–10 days total).
• Adolescents: prednisone/prednisolone 1 mg/kg (max 50 mg) orally once daily for 3–5 days.

If dyspnoea/increased work of breathing isn’t relieved within 5 minutes, repeat the bronchodilator dose and arrange transfer to emergency department. If manifest anaphylaxis or respiratory peri-arrest, give adrenaline before salbutamol (IM 0.01 mg/kg up to 0.5 mg/dose).

After resolution: observe ≥4 hours, arrange follow-up within 3–5 days (check symptom resolution and adherence to any prescribed OCS/ICS) and a comprehensive asthma review 2 weeks later — identify the trigger, review the action plan and reliever use, adjust the ICS-containing regimen (e.g. switch a SABA-reliever regimen to MART), check inhaler technique, and offer specialist review if there’s been more than one emergency presentation for asthma in the past 12 months.