Asthma Treatment – Adults & Adolescents
Key Points – from RCH and Asthma guidelines 3.0
Background
- Medications and Delivery Devices:
- Inhaled Corticosteroid (ICS): Reduces inflammation in the airways.
- Short-acting β-agonist (SABA): Provides quick relief by relaxing the muscles around the airways.
- Long-acting β-agonist (LABA): Provides prolonged bronchodilation, reducing asthma symptoms and exacerbations.
- Metered Dose Inhaler (MDI): Delivers a specific amount of medication to the lungs in aerosol form.
- Dry Powder Inhaler (DPI), including the Turbuhaler®: Delivers medication in powder form, requiring adequate inhalation technique.
- Risks of SABA Alone: High use of SABA alone (>3 MDI canisters per year) and low use of ICS is associated with more severe asthma exacerbations and death.
- Combination Therapy (ICS/LABA): Ensures use of anti-inflammatory with every reliever dose (anti-inflammatory reliever-based regimen). Currently, budesonide/formoterol is the only combination prescribed as a reliever.
- Traditional Management: Daily ICS as a preventer and SABA as needed is effective and may be preferred for those already on a working regimen or with difficulties using DPI/Turbuhaler®.
- Environmental Impact: MDI has a larger carbon footprint. Achieving good asthma control to reduce SABA need or switching to DPI can help reduce environmental impact.
Assessment
- History:
- Daytime Symptoms: Frequency and severity.
- Need for Reliever: Number of doses per week.
- Limitation of Activities: Impact on daily life.
- Night or Morning Symptoms: Frequency and severity of symptoms at night or on waking.
- Examination:
- Inhaler Technique: Ensure correct usage of inhalers.
- Comorbidities: Look for signs of allergic rhinitis and eczema.
Management
- Investigations:
- Most adolescents can be diagnosed clinically based on symptoms and response to treatment.
- Investigations are necessary if other diagnoses are considered or if treatment needs to be stepped up beyond Step 3.
- Spirometry should be performed in an accredited respiratory function laboratory, including bronchodilator response and possibly exercise or challenge tests.
- Initiating Treatment:
- Anti-inflammatory reliever-based regimen (budesonide/formoterol 200 mcg/6 mcg) can be started following an acute presentation or routine review.
- If the adolescent is already on a traditional regimen, discuss changes with their long-term care provider.
Asthma treatment levels for adults and adolescents
Asthma treatment is adjusted to maintain good symptom control, reduce exacerbation risk, and minimise side-effects. The best treatment level may change over time depending on control, exacerbation history, adherence, inhaler technique, and patient preference.
Key principles
- All adults and adolescents with asthma require ICS-containing treatment
- Do not prescribe or recommend SABA-only treatment
- Start with low-dose budesonide–formoterol as needed when symptoms occur
- Advise patients to carry their reliever at all times
- Reliever may be used:
- when breathless/wheezy/tight-chested
- before exercise
- before unavoidable trigger exposure
- Prescribe asthma medicines via inhalers, not nebulisers, unless there is a specific clinical indication
AIR and MART in Asthma
AIR – Anti-Inflammatory Reliever
What it is
- A reliever-only strategy
- Uses low-dose ICS–formoterol as needed (PRN)
- No regular maintenance therapy
How it works
- Formoterol → rapid bronchodilation (like SABA)
- ICS (e.g. budesonide) → treats airway inflammation
- Both delivered together when symptoms occur
Typical regimen
- 1 inhalation when symptomatic
- Repeat after a few minutes if needed
- Max:
- Usually ≤8 inhalations/day
- Up to 12 inhalations/day (short term)
Indications
- Mild asthma
- Infrequent symptoms
- First-line option in Australian guidelines (instead of SABA-only)
Common inhalers
- Budesonide/formoterol combinations (e.g. Symbicort, DuoResp, Fobumix)
MART – Maintenance and Reliever Therapy
- Single inhaler used for BOTH:
- Daily maintenance (preventer)
- Symptom relief (reliever)
How it works
- Regular ICS controls baseline inflammation
- Extra PRN doses increase ICS automatically during worsening asthma
Typical regimen
- Maintenance: 1–2 inhalations BD
- Reliever: 1 inhalation PRN
- Max:
- Usually ≤8 inhalations/day
- Up to 12/day short-term if needed
Indications
- Persistent asthma
- Frequent symptoms / night waking
- Poor control on AIR or ICS alone
Key requirement
- Must use formoterol-containing ICS–LABA
- (rapid onset → acts as reliever)
Common inhalers
- Budesonide/formoterol (e.g. Symbicort, DuoResp, Fobumix)
- Beclomethasone/formoterol (e.g. Fostair – ≥18 yrs)
🔥 Key Differences
| Feature | AIR | MART |
|---|---|---|
| Daily preventer | ❌ No | ✅ Yes |
| Reliever | ICS–formoterol PRN | Same inhaler |
| ICS exposure | Only when symptomatic | Daily + PRN |
| Best for | Mild asthma | Persistent asthma |
| SABA needed | ❌ No | ❌ No |
Recommended treatment levels
| Level | Preferred treatment | Description |
|---|---|---|
| Level 1 | Low-dose budesonide–formoterol as needed | AIR-only therapy. Used when symptoms occur. |
| Level 2 | Low-dose MART | Maintenance low-dose ICS–formoterol plus extra doses from the same inhaler as needed. |
| Level 3 | Medium-dose MART | Medium-dose ICS–formoterol maintenance, usually by increasing inhalations from a low-dose inhaler, plus extra doses as needed. |
| Level 4 | Targeted intensive treatment | Specialist-level or more intensive treatment, usually ICS–LABA based, sometimes with LAMA, biologics, azithromycin, or other add-ons. |
Alternative options at Levels 1–3
| Level | Alternative option |
|---|---|
| Level 1 | Maintenance low-dose ICS plus SABA as needed |
| Level 2 | Maintenance low-dose ICS–LABA plus SABA as needed |
| Level 3 | Maintenance medium-dose ICS–LABA plus SABA as needed |
1. AIR-only (Level 1)
As-needed low-dose ICS–formoterol
Options
| Drug | Brand (AU) | Strength | Dose | Max |
|---|---|---|---|---|
| Budesonide–formoterol (pMDI) | Symbicort Rapihaler, Rilast Rapihaler | 100/3 mcg | 1–2 puffs PRN | 12 per occasion, ≤16/day (up to 24 temporarily) |
| Budesonide–formoterol (DPI) | Symbicort Turbuhaler, Rilast Turbuhaler | 200/6 mcg | 1 puff PRN | 6 per occasion, ≤8/day (up to 12 temporarily) |
| Budesonide–formoterol (DPI) | Bufomix Easyhaler | 200/6 mcg | 1 puff PRN | similar to Turbuhaler limits |
👉 Key: this replaces SABA; patient uses it whenever symptomatic.
2. MART (Levels 2–3)
Maintenance + reliever using same inhaler
Low-dose MART (Level 2)
| Drug | Brand | Maintenance | Reliever | Max total |
|---|---|---|---|---|
| Budesonide–formoterol 100/3 (pMDI) | Symbicort / Rilast Rapihaler | 2 puffs BD | 1–2 puffs PRN | ≤16/day (up to 24 short-term) |
| Budesonide–formoterol 200/6 (DPI) | Symbicort / Rilast Turbuhaler, Bufomix Easyhaler | 1 puff BD | 1 puff PRN | ≤8/day (up to 12 short-term) |
Medium-dose MART (Level 3)
👉 achieved by increasing maintenance dose
| Drug | Brand | Maintenance | Reliever | Max |
|---|---|---|---|---|
| Budesonide–formoterol 100/3 (pMDI) | Symbicort / Rilast Rapihaler | up to 4 puffs BD | PRN | ≤16/day |
| Budesonide–formoterol 200/6 (DPI) | Symbicort / Rilast / Bufomix | 2 puffs BD | PRN | ≤8/day |
3. Alternative (non-MART) regimens
ICS alone (Level 1 alternative)
| Drug | Brand | Low dose |
|---|---|---|
| Budesonide | Pulmicort Turbuhaler | 200–400 mcg/day |
| Fluticasone propionate | Flixotide | 100–200 mcg/day |
| Beclometasone (extra-fine) | Qvar | 100–200 mcg/day |
- SABA PRN (salbutamol e.g. Ventolin)
ICS–LABA + SABA (Levels 2–3 alternative)
| Drug | Brand | Dose |
|---|---|---|
| Fluticasone–salmeterol | Seretide | 100/50 to 250/50 BD |
| Budesonide–formoterol | Symbicort (non-MART use) | 1–2 puffs BD |
| Fluticasone furoate–vilanterol | Breo Ellipta | 100/25 OD |
- SABA PRN
Level 4: Targeted intensive asthma treatment
High-dose ICS–LABA
Short-term 3–6 month trial while assessing persistent symptoms/severe exacerbations or awaiting biologic eligibility. Specialist care recommended if not controlled on medium-dose ICS–LABA.
| Drug | Example | Dose |
|---|---|---|
| Symbicort 200/6 | DPI | up to 2 puffs BD |
| Seretide 500/50 | Accuhaler | 1 puff BD |
Add-on LAMA
| Drug | Brand | Dose |
|---|---|---|
| Tiotropium | Spiriva Respimat | 2.5 mcg, 2 puffs OD |
| Triple therapy (ICS–LABA–LAMA) | Trelegy Ellipta | 100/62.5/25 OD |
Trial option for patients with normal eosinophils/FeNO, persistent symptoms or severe exacerbations, or while awaiting biologic assessment. May be long-term if clear benefit.
Add-on oral / other
| Drug | Notes |
|---|---|
| Montelukast (Singulair) – May be considered as add-on therapy, especially in aspirin-exacerbated respiratory disease. – Limited role in severe asthma. – Counsel about neuropsychiatric adverse effects. | 10 mg nocte (caution: neuropsychiatric effects) |
| Azithromycin – Specialist add-on option for persistent exacerbations despite medium-dose ICS–LABA. – Requires screening and caution | 250–500 mg 3x/week (specialist use) |
Biologics (specialist)
Targeted anti-inflammatory therapy based on allergic status and inflammatory phenotype. Used under specialist care.
| Drug | Target |
|---|---|
| Omalizumab (Xolair) | IgE |
| Mepolizumab (Nucala) | IL-5 |
| Benralizumab (Fasenra) | IL-5 receptor |
| Dupilumab (Dupixent) | IL-4/13 |
Important alert
SABA-only treatment is not recommended for adults or adolescents with asthma, even if symptoms are infrequent.
All treatment levels should include an inhaled corticosteroid-containing regimen.
- Symptom Control Indicators:
| Control Level | Daytime Symptoms | Need for Reliever | Limitation to Activity | Nighttime Symptoms |
|---|---|---|---|---|
| Good Control | ≤2 days per week | ≤2 days per week | None | None |
| Partial Control | >2 days per week | >2 days per week | Present | Present |
| Poor Control | >2 days per week | >2 days per week | Present | Present |
- Action Based on Control:
- Good Control: Maintain current treatment. If good control is sustained for approximately 3 months, consider stepping down preventer treatment.
- Partial Control: Review adherence and technique, then consider stepping up treatment.
- Poor Control: Step up preventer medication and reassess. Ensure correct technique and adherence. Consider alternative diagnoses if control remains poor.
- Severe Exacerbations: Review and step up treatment if a severe exacerbation occurs.
Additional Treatment Considerations
- For Severe, Uncontrolled Asthma (Step 3 and Beyond):
- Referral: Refer to a respiratory physician or specialist asthma service for further evaluation and management.
- Additional Treatments:
- Oral Prednisolone: 1 mg/kg (max 50 mg) daily for 2 weeks.
- Tiotropium: 2.5 mcg 2 puffs daily.
- Montelukast: 5 mg daily.
Inhaled Corticosteroids (ICS)
- Common ICS and Starting Doses:
- Fluticasone: Start at 125 mcg twice daily, can increase up to a total daily dose of 500 mcg.
- Ciclesonide: Start at 80 mcg once daily, can increase up to 320 mcg as required.
Anti-inflammatory Reliever-based Asthma Action Plan
- Written Action Plan: A core part of asthma management, detailing steps to take in case of worsening symptoms.
- Indicators for Seeking Medical Attention:
- DPI: Total of 12 actuations of budesonide/formoterol in a day.
- MDI: Total of 24 inhalations of budesonide/formoterol in a day.
Management in Hospital
- For Exacerbations:
- Treat with SABA as per standard practice (see acute asthma guidelines).
- Use SABA at home while waiting for ambulance if needed.
- On discharge, resume budesonide/formoterol for symptom relief.
Approach to Asthma Not Responding to Treatment
- Review the Following:
- Correct asthma diagnosis.
- Adherence to treatment.
- Inhaler technique.
- Contributing factors like
- allergic rhinitis
- obesity
- obstructive sleep apnea
- gastro-oesophageal reflux
- dysfunctional breathing
- depression/anxiety
- smoking/vaping
- environmental factors.
- Socioeconomic factors affecting access to healthcare.
- Poor adherence to treatment
- Denying or disregarding asthma symptoms
- Avoiding regular review appointments
- Life events (new school, moving house, family disruption, absent parent)
- Family problems (e.g. family conflict, family dysfunctions
- Psychological distress (e.g. feelings of hopelessness, bereavement or recent loss)
- Mental health problems (e.g. depression, emerging mood disorders
- Risky use of alcohol/other substances
- Communication problems
- Consultation:
- Consult respiratory/specialist asthma services if asthma control remains inadequate at Step 3 or if diagnosis is unclear.
Conditions that Confuse with Asthma
Conditions Characterised by Cough
- Pertussis (whooping cough)
- Gastro-oesophageal reflux
- Rhinosinusitis/upper airway cough syndrome
- Adverse effect of medicines (e.g. ACE inhibitors)
- Bronchiectasis
- Chronic obstructive pulmonary disease (COPD)
- Pulmonary fibrosis
- Large airway stenosis
- Habit-cough syndrome
- Inhaled foreign body
Conditions Characterised by Wheezing
- Respiratory infections
- Chronic obstructive pulmonary disease (COPD)
- Upper airway dysfunction
Conditions Characterised by Difficulty Breathing
- Breathlessness on exertion due to poor cardiopulmonary fitness
- Hyperventilation
- Anxiety
- Chronic heart failure
- Pulmonary hypertension
- Lung cancer
Additional Resources
- Green Prescribing: Strategies to reduce the environmental impact of asthma treatments.
- Educational Materials: Information on inhaler techniques, asthma action plans, and environmental control measures.
Stepping Down in Adulthood for Asthma Management
Main Aim
- Achieve good asthma control and minimize risks with the lowest effective dose of preventer medicines.
When to Consider Stepping Down
- Consider stepping down when the patient has experienced good asthma control for 2-3 months and is at low risk of flare-ups.
General Tips
- Confirm the patient’s actual treatment regimen before stepping down.
- Address concerns about inhaled corticosteroids and propose a lower dose with an action plan for flare-ups.
- Plan steps down before the patient finishes their current inhaler to resume the previous dose if control deteriorates.
- Advise patients to step back up if asthma worsens, based on agreed criteria.
- Monitor peak flow for 2 weeks before and 3-4 weeks after dose reduction to detect early deterioration.
Stepping Down Inhaled Corticosteroid Dose
- Gradually reduce the dose for patients with well-controlled asthma on ICS/LABA combinations or ICS alone.
- Reduce dose by stepping down through available formulations.
- Note: Fluticasone furoate/vilanterol combinations contain moderate-to-high doses (100/25 mcg and 200/25 mcg).
Ceasing Inhaled Corticosteroid
- Patients stopping regular low-dose ICS have an increased risk of flare-ups.
- Stopping treatment may be necessary to confirm asthma diagnosis; close monitoring is needed.
Ceasing Long-acting Beta2 Agonist
- Patients well controlled on ICS/LABA can continue the regimen long-term, reducing dose through available formulations.
- Switching from ICS/LABA to ICS alone can lead to deterioration; advise patients to restart combination inhaler if asthma worsens after switching.
- For fluticasone furoate/vilanterol, step down by switching to a lower dose ICS/LABA combination or ICS alone, with clear written instructions to avoid confusion.
Additional Considerations
- Some patients may prefer to stay on high doses; monitor peak flow closely.
- Ensure patients understand the changes and provide written instructions for new inhaler devices and dosing frequencies.