Asthma experts explain key asthma topics in quick updates

More than 1 in 10 Australians have asthma, and it is the leading cause of disease burden in children aged 1–9 years.

Each year asthma results in more than 60 000 emergency department presentations. Australian research shows almost half of adults and older adolescents with asthma have poor asthma control, and that most people with asthma could have fuller and more active lives with better asthma management.

Asthma management can be complex, so the National Asthma Council Australia has published a series of short topic updates prepared with panels of asthma experts, to help primary care clinicians follow national guidelines in the Australian Asthma Handbook, updated late 2025:

• Asthma in adults: A quick reference guide
• Overcoming Australia’s over-reliance on ‘blue puffers’ for asthma 
• Anti-inflammatory reliever is the recommended starting treatment for asthma 
• Maintenance-and-reliever therapy for asthma 
• Oral corticosteroid use in asthma: what’s safe and appropriate? 
• Triple therapy for asthma in primary care.

Each information sheet includes a Q&A, dosage guides, and key messages for patients.

Australia has a problem with over-reliance on ‘blue puffers’

Many Australians with asthma are at risk of severe asthma exacerbations due to over-reliance on short-acting beta₂ agonists (SABAs) like salbutamol and terbutaline: they either manage their asthma entirely with over-the-counter salbutamol, or have been prescribed an inhaled corticosteroid (ICS) but don’t use it as intended. Australian research also suggests 70% of adults and late adolescents with asthma use salbutamol more than twice a week on average — enough to be at risk of hospital presentations.

Australian guidelines recommend that no-one aged 12 years or more should manage their asthma solely with a SABA. It is also inadequate asthma treatment for most school-aged children and many preschool children. The message to patients and parents is that a ‘blue puffer’ doesn’t treat the cause of asthma, or prevent symptoms or attacks. 

What’s the alternative to reliance on salbutamol? For school-aged and preschool children, the key message is not to delay prescribing a low daily maintenance dose of ICS, if indicated. For adults and adolescents, asthma treatment based on anti-inflammatory relievers is now recommended. 

Switch to anti-inflammatory reliever

The minimal level of asthma treatment is now budesonide-formoterol taken as needed for symptoms. This ‘anti-inflammatory reliever-only’ therapy is suitable for patients who don’t need daily maintenance treatment, including most adults and adolescents with newly diagnosed asthma.

Symptom-driven dosing lets patients adjust their own treatment level, and overcomes the common problem of poor adherence to daily maintenance ICS treatment. Australian-led research shows that dose-escalation with anti-inflammatory reliever in response to worsening asthma symptoms is much more effective than SABA for preventing progression to severe asthma exacerbations. If the reliever is needed on three or more days per week, a maintenance dose can be added.

Only certain budesonide-formoterol inhalers can be used this way — see the comprehensive list with a dosage guide. Anti-inflammatory reliever use in children under 12 years is currently not approved by the Therapeutic Goods Administration.

The message for patients used to be ‘you must take your asthma preventer every day, forever’. That’s still best for some, but many people can now use a combination inhaler just when they need it, and still get the benefit. Every dose helps relieve inflammation in the airways as well as quickly relieving the symptoms.

Add anti-inflammatory maintenance treatment when indicated

Maintenance-and-reliever therapy (MART) with budesonide-formoterol (patients ≥12 years) or beclometasone-formoterol (patients ≥ 18 years) is now recommended instead of maintenance inhaled corticosteroids plus as-needed SABA. The patient uses their inhaler for daily or twice-daily preventive treatment, and takes extra doses as needed for symptom relief.

This approach reduces severe exacerbations compared with a maintenance dose of ICS in combination with a long-acting beta₂ agonist (LABA) plus a separate SABA reliever: by approximately 32% compared with the same ICS dose, and by 23% compared with a higher ICS dose. 

Only certain combination inhalers can be used as MART — see the comprehensive list and dosage guide.

For difficult asthma, investigate and refer

When good asthma control isn’t achieved despite treatment with medium-dose ICS-LABA in a recommended regimen, take a stepwise approach. First check for common causes: low adherence, incorrect inhaler technique, exposure to cigarette smoke, allergens, or indoor/outdoor air pollution, and any problems interfering with self-management. Consider comorbidities.

If the problem persists, current guidelines recommend blood eosinophil count and spirometry — preferably at an accredited respiratory laboratory that can provide an exhaled nitric oxide (FeNO) test — along with routine referral to a respiratory specialist.

If specialist assessment is not immediately available, consider a short treatment trial with either a high dose of ICS-LABA, or ‘triple therapy’ that includes a long-acting muscarinic antagonist (LAMA). Triple therapy options include tiotropium in a separate inhaler added to any ICS-LABA combination, and single-inhaler triple combinations — see the full list with age restrictions and a dosage guide.

Any patient with a raised eosinophil count or raised FeNO, indicating type 2 airway inflammation, needs specialist assessment for monoclonal antibody therapy to reduce the risk of severe exacerbations.

The key message is that prolonged triple therapy should not replace prompt specialist assessment, because many patients with severe asthma will benefit most from fast-tracking for monoclonal antibody therapy.

Minimise the use of systemic corticosteroids

Short courses of oral prednisone/prednisolone used to be considered fairly harmless, but a longitudinal observational study and large database study have found serious long-term effects in adults after even a few short courses to manage asthma exacerbations. In children, the use of multiple short courses for asthma reduces bone mineral density. ‘Toxic’ doses are frequently dispensed in Australia.

This has led to calls for corticosteroid stewardship from Thoracic Society of Australia and New Zealand. Strategies include using ICS to prevent exacerbations, writing PBS scripts for the required quantity with no repeats, and cautioning patients and parents against casual use of leftover tablets or liquids when asthma symptoms occur.

Update your asthma knowledge

National Asthma Council’s information sheets provide a concise update on all these key asthma topics. Find them and other asthma resources on the website.

Clinical Associate Professor Debbie Rigby, Clinical Executive Lead, National Asthma Council Australia, is an advanced practice pharmacist with over 40 years’ experience across clinical pharmacy practice, interdisciplinary care, policy and advocacy, clinical governance, guidelines development and education. She has a specific interest in respiratory conditions and has been credentialed as an asthma educator. She is also passionate about improving the care and support for people living with asthma through multidisciplinary patient-centred care, shared decision making and evidence-based medicine.

Dr Tim Jones is a Tasmanian GP, rural generalist, GP supervisor, medical educator and PHN board director. He is Chair of Specific Interests, Child and Young Person's Health at the RACGP, Senior Medical Educator & Deputy Faculty Chair of RACGP Tasmania, and a member of the National Asthma Council Australia Guidelines Committee.