Adaptation of the Australian Asthma Handbook stepwise figure, using the same ingredient fingerprint as the inhaler classification sheet. Two changes from the original: the check performed before stepping up is drawn as a gate sitting between the levels rather than tucked into the legend, and each option carries the device it actually arrives in.
ICS–formoterol as reliever
Recommended
SABA as reliever
Alternative
Start hereSuitable initial and long-term treatment for most patients.
1
Budesonide–formoterol as needed
low dose · no separate maintenance inhaler
One device only. Anti-inflammatory reliever — every reliever dose carries a steroid, so there is no SABA in the picture. Usually DPI-R Turbuhaler, Spiromax or Easyhaler; also MDI Rapihaler.
ICS maintenance + SABA reliever as needed
low dose ICS · reliever separate
Two devices, two techniques. The preventer may be MDI or DPI while the reliever is nearly always MDI — check the patient is not applying one breathing pattern to both.
← Consider switching left to reduce severe exacerbation risk
Gate 1 → 2
Are the symptoms actually asthma?
Is inhaler technique correct?
Is adherence adequate?
Or start hereConsider entering at level 2 or 3 if symptoms are frequent or severe, or exacerbation risk is high.
2
ICS–formoterol maintenance-and-reliever therapy
low dose · MART
Still one device, now used two ways. The same inhaler is taken regularly and for symptom relief. The commonest error is the patient keeping an old SABA "for emergencies" — ask directly.
ICS–LABA maintenance + SABA reliever as needed
low dose ICS–LABA · reliever separate
Two devices. Any ICS–LABA may be used here, not only formoterol-containing ones — but a non-formoterol combination cannot double as the reliever.
← Consider switching left to reduce severe exacerbation risk
Gate 2 → 3
Are the symptoms actually asthma?
Is inhaler technique correct?
Is adherence adequate?
Step upGood symptom control not achieved despite adequate adherence and correct technique.
3
ICS–formoterol maintenance-and-reliever therapy
medium dose · MART
Same device, same regimen, higher steroid dose. The change here is strength, not strategy — so a technique fault carried up from level 2 now costs more.
ICS–LABA maintenance + SABA reliever as needed
medium dose ICS–LABA · reliever separate
Two devices. Confirm the medium-dose product is a different strength of the same inhaler, not an additional one — duplicate ICS–LABA is a real dispensing error.
← Consider switching left to reduce severe exacerbation risk
Gate 3 → 4
Are the symptoms actually asthma?
Is inhaler technique correct?
Is adherence adequate?
Specialist territoryConsider add-on LAMA, or a trial of high dose ICS–LABA.
4
Targeted intensive treatment and specialist review
applies to both reliever strategies
The amber segment appears for the first time. A muscarinic antagonist enters the picture only at this level in asthma — either added as a separate LAMA or delivered as a single triple-therapy device. Phenotyping and biologics are considered here. Beyond this level, treatment is individualised rather than stepwise.
Reading the fingerprint
Pale blue — short-acting β2-agonist. Present only in the right-hand track.
Full blue — long-acting β2-agonist, always formoterol where the inhaler doubles as reliever.
Amber — long-acting muscarinic antagonist. Level 4 only in asthma.
Red — inhaled corticosteroid. Present at every level, including level 1 — that is the whole point of the recommended track.
Two fingerprints side by side in a cell means two separate devices. One fingerprint means one.
Movement between levels
- Stepping up — only after the gate. Poor control is far more often technique or adherence than inadequate dose, and stepping up a badly-used inhaler just raises the dose that misses the lungs.
- Stepping down — when asthma has been stable and well controlled for two to three months.
- Sideways, right to left — consider switching a patient from the SABA-reliever track to the ICS–formoterol track to reduce severe exacerbation risk. This is a change of strategy, not of level.
- Which products support MART — only budesonide–formoterol combinations are used this way in the recommended track. An ICS–LABA containing salmeterol or vilanterol cannot be a reliever. Confirm against current product information before advising a patient.
Source and limits. Adapted from the National Asthma Council Australia / Australian Asthma Handbook figure
Asthma treatment levels for adults and adolescents. The content follows the source figure; the gates, fingerprints and device annotations are additions for teaching and technique review. Interpret alongside the full Australian Asthma Handbook at asthmahandbook.org.au.
Not a prescribing tool — dose selection, product choice and PBS criteria sit with the treating prescriber. This sheet does not cover children, pregnancy or acute exacerbation management.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.