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Stable Asthma — Long-Term Management

Registrar quick reference · GINA 2025/26 Track 1 · Australian Asthma Handbook 2025
Compiled Jun 2026
Verify doses locally
No SABA-only treatment
Decision support only — not a substitute for GINA, the Australian Asthma Handbook, eTG, or your respiratory team. Confirm asthma with variable expiratory airflow limitation before lifelong therapy. Adults & adolescents (≥12). The single biggest change: the reliever now contains an inhaled corticosteroid — reliever-only SABA is no longer adequate or safe. Verify doses and PBS criteria.
1 GINA Track 1 (preferred) — ICS-formoterol is the reliever throughout
The shiftread this first
Every adult/adolescent needs ICS-containing therapy.
SABA-only is out. The reliever is low-dose ICS-formoterol — fast onset (3–5 min) plus an anti-inflammatory hit with every use.
Steps 1–2 · AIRmild / infrequent
Symptoms up to most days; no daily preventer yet.
As-needed low-dose ICS-formoterol (anti-inflammatory reliever). No maintenance inhaler. Cuts severe exacerbations ~60% vs SABA-only.
Step 3 · MARTsymptoms most days
Symptoms most days, or night waking ≥1/week.
Low-dose maintenance ICS-formoterol + same inhaler as reliever (MART).
Step 4 · MARTuncontrolled on step 3
Still uncontrolled despite low-dose MART (and good adherence/technique).
Medium-dose maintenance ICS-formoterol + as-needed (MART). Add LAMA if still not controlled.
Step 5 · refersevere / specialist
Uncontrolled on optimised medium/high-dose therapy.
Refer for phenotyping + biologic. Add LAMA; treat comorbidities. Avoid maintenance OCS — use it as the last resort, not the plan.
ICS-formoterol must not be the reliever if the maintenance ICS-LABA uses a non-formoterol LABA. Track 2 (alternative) — SABA or ICS-SABA reliever with maintenance ICS — is for when Track 1 isn't feasible, and is riskier if adherence is poor. Action plans for AIR/MART patients say "increase your ICS-formoterol," not "reach for the blue puffer."
2 Confirm it, then grade control

Confirm the diagnosis

  • VariableSymptoms + variable expiratory airflow limitation. Don't commit to lifelong therapy on history alone.
  • SpiroReversibility: FEV₁ ↑≥12% and ≥200 mL post-bronchodilator. Or PEF variability / challenge testing.
  • If on RxAlready treated and diagnosis unclear → consider careful step-down with testing rather than assuming.

Assess control (past 4 weeks)

  • AskDaytime symptoms >2×/wk · any night waking · reliever >2×/wk · any activity limitation.
  • Grade0 = well controlled · 1–2 = partly · 3–4 = uncontrolled.
  • RiskAlso weigh future risk: prior severe exacerbation, low FEV₁, high SABA use, poor adherence.
3 Before you step up — and the SABA problem

Check these first

  • TechniqueWatch them use the device — wrong technique mimics treatment failure.
  • AdherenceAsk non-judgementally; most "uncontrolled" asthma is under-treated, not under-dosed.
  • DiagnosisStill right? Consider VCD, COPD overlap, cardiac, ABPA.
  • TriggersAllergic rhinitis, GORD, obesity, smoking, occupational exposure, anxiety — treat them.

SABA overuse kills

  • Threshold≥3 SABA canisters/year = increased exacerbation and death risk. Flag it on dispensing history.
  • "Mild"Avoid the term "mild asthma." Most asthma deaths occur in people with infrequent symptoms over-relying on SABA.
  • LABANever LABA without ICS — historical mortality signal (SMART).
  • Step downWhen well controlled ≥3 months, reduce to lowest effective dose. Don't stop ICS entirely in adults.
4 Severe asthma & add-ons

Phenotype, then target

  • AllergicRaised IgE + aeroallergen sensitisation → omalizumab (anti-IgE).
  • EosinophilicRaised blood eosinophils → mepolizumab / benralizumab (anti-IL5/5R).
  • Type 2Eos and/or high FeNO, OCS-dependent, atopic → dupilumab (anti-IL4Rα).
  • BroadTezepelumab (anti-TSLP) — works across phenotypes, incl low-T2.

Other add-ons

  • LAMATiotropium add-on for uncontrolled despite ICS-LABA.
  • AzithroAMAZES: 500 mg 3×/week reduces exacerbations. QTc, hearing, resistance, screen NTM.
  • OCSMaintenance OCS is a failure state — refer for biologics before committing someone to it.

Watch

  • MontelukastNeuropsychiatric effects (boxed warning) — counsel; not a first-line preventer.
  • OCS harm4–5 lifetime courses raise osteoporosis, diabetes, cataract risk — track cumulative exposure.
5 The whole patient

Essentials at every review

  • Action planWritten asthma action plan — non-negotiable. Tailor it to AIR/MART vs SABA reliever.
  • Non-pharmSmoking cessation, weight, physical activity, treat allergic rhinitis, vaccinate (flu, COVID, pneumococcal).
  • TriggersIdentify and reduce; consider allergen immunotherapy in selected allergic asthma.

Don't forget

  • MimicsVocal cord dysfunction, ABPA, aspirin-exacerbated respiratory disease, bronchiectasis, COPD overlap.
  • PregnancyKeep asthma controlled — ICS is safe; uncontrolled asthma is the real risk to mother and baby.
  • MonitorControl + reliever use each visit; spirometry periodically; review technique & adherence relentlessly.
Sources. GINA — Global Strategy for Asthma Management and Prevention, 2025 & 2026 updates (Track 1 ICS-formoterol AIR/MART; Track 2 alternative; ≥3 SABA canisters/yr risk; avoid "mild asthma"). National Asthma Council Australia — Australian Asthma Handbook 2025 update (AIR first-line; SABA-alone inadequate for adults/adolescents). eTG; PBS for subsidised inhalers and biologics.   Key trials: SYGMA 1 & 2 and Novel START (as-needed ICS-formoterol vs SABA); AMAZES (azithromycin add-on); biologic programs (omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab).   Caveats: doses depend on the specific budesonide/beclometasone-formoterol product — verify against the device and PBS. Biologic eligibility is governed by PBS phenotype/eosinophil/IgE criteria — confirm before referral promises. Children 6–11 follow a separate GINA pathway not covered here. Companion to the respiratory set; verify all doses.