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.
inhaled corticosteroid (ICS): inhaled corticosteroid. short-acting beta-agonist (SABA): short-acting β2-agonist. long-acting beta-agonist (LABA): long-acting β2-agonist. Pharmaceutical Benefits Scheme (PBS): Pharmaceutical Benefits Scheme. The colour key is explained in Inhalers by Ingredient.
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 long-acting muscarinic antagonist (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 colour key
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.
Important: This page is written for health professionals as a summary of published evidence and guidance. It is not medical advice, does not replace the source documents, and does not substitute for clinical judgement or local policy.
Source: 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.