The National Asthma Council Australia has released a landmark update to the Australian Asthma Handbook, marking what experts are calling “a major change of practice” in asthma management. Released on September 16, 2025, the new guidelines represent the biggest shift in asthma treatment in a generation, moving away from reliance on blue puffers (SABA) alone toward anti-inflammatory treatment from day one.

The Major Change: SABA Alone No Longer Adequate

The updated handbook’s most significant recommendation: short-acting beta2 agonists (SABA) alone are now considered inadequate treatment for asthma in adults and adolescents. This affects approximately 2.8 million Australians living with asthma, with about half having poorly controlled asthma at any given time.

Inhaled corticosteroids (ICS) are now indicated for all adults and adolescents with asthma. The guidelines recommend that all patients require ICS as part of their treatment to reduce inflammation and prevent exacerbations.

New First-Line Treatment: Anti-Inflammatory Relievers

Following asthma diagnosis, adults and adolescents should start treatment with low-dose budesonide-formoterol taken as needed when symptoms occur—known as anti-inflammatory reliever (AIR) therapy. Only formoterol-containing combinations are approved for this indication, as formoterol works as quickly as salbutamol (3-5 minutes) while treating underlying inflammation.

Professor Nick Zwar, Chair of the NAC Guidelines Committee, explained: “Research over the last few years has shown that SABA alone has its risks. People who use that alone are more at risk of exacerbations – which are sometimes severe – and their asthma control is sometimes suboptimal.”

The evidence is compelling: AIR therapy reduces the risk of severe exacerbations requiring oral corticosteroids by 55% compared with SABA alone. With more than 31,000 asthma hospitalisations and 474 deaths in 2023 – more than 90% considered potentially preventable – the stakes are high.

MART: The Preferred Step-Up Therapy

For patients requiring daily maintenance treatment, maintenance-and-reliever therapy (MART) is now the preferred pathway. MART uses the same budesonide-formoterol inhaler for both regular prevention and symptom relief, reducing exacerbation rates compared with fixed-dose regimens and simplifying treatment adjustments.

Patients should start at higher intensity (low-dose or medium-dose MART) if they have frequent symptoms, a recent severe exacerbation requiring systemic corticosteroids, or known risk factors for severe exacerbations.

What This Means for General Practice

Professor Zwar noted that asthma patients going to the pharmacist for blue puffers will likely be directed to their GP for anti-inflammatory reliever prescriptions. “That’s a major change in practice.”

Dr. Anita Muñoz, Chair Victoria Faculty RACGP, emphasised the community education challenge: “Many Australians are managing their own asthma just with blue puffers that they buy over the counter, but that is no longer recommended and encourages risky over-reliance.”

Key Implementation Points:

Initial Treatment:

• Start adults and adolescents with low-dose budesonide-formoterol (AIR therapy) as needed
• Low-dose ICS maintenance plus salbutamol remains an alternative for newly diagnosed patients
• Written asthma action plans are essential for all patients prescribed AIR or MART

Specialist Referral: The guidelines lower the threshold for referring difficult-to-control asthma to respiratory physicians, given new biologic therapies that effectively treat severe asthma while avoiding high-dose ICS and recurrent oral steroids. This helps minimise oral steroid use, given clearer evidence of risks to bone health and other adverse effects.

Diagnosis: The handbook emphasises spirometry’s importance, though primary care rates have dropped since COVID-19. Guidelines also include advice on fractional exhaled nitric oxide (FENO) testing referrals to differentiate asthma from other conditions.

Important Age Considerations

These changes apply to adults and adolescents aged 12 and over. Anti-inflammatory relievers are not yet recommended for children under 12, as studies are underway to prove their effectiveness in this age group. Effective preventer options remain available for children to reduce asthma flare-up risk.

The Philosophy Shift

The updated guidelines reflect a fundamental shift in asthma management philosophy, led by GINA (Global Initiative for Asthma) in 2019. Asthma is a chronic inflammatory condition—educating patients that they have it all the time, not just during attacks, helps them understand the rationale for treatment targeting inflammation rather than simply treating symptoms.

Dr. Chris Pearce, Asthma Australia Board Member and GP, explained: “The new anti-inflammatory relievers work just as fast to relieve symptoms but also reduce airway inflammation at the same time. The goal is fewer flare-ups, fewer hospital visits, and more Australians able to live confidently with their asthma.”

With 15 million SABA inhalers dispensed annually in Australia (including for COPD) – more than 4 per person – many patients are at increased risk of exacerbations. The implementation will require significant patient education, practice workflow adjustments, and collaboration between GPs, pharmacists, and other healthcare providers.

Resources and Support

Health Minister Mark Butler stated: “The updated Australian Asthma Handbook will support primary health professionals to better diagnose, treat and manage their patients with the condition, helping those living with asthma to breathe easier and live well.”

The updated Australian Asthma Handbook is available online at www.asthmahandbook.org.au. This includes medication management guidance for acute and long-term control treatment levels for adults and adolescents. A CPD-approved recording of the launch webinar provides detailed implementation guidance. Asthma Australia’s clinical team supports practices in understanding these changes, contact Asthma Educators at 1800 ASTHMA (1800 278 462). 

With approximately one in ten Australians having asthma and 56,600 emergency department visits annually, these evidence-based guidelines offer substantial potential to improve outcomes. Addressing inflammation from day one, rather than masking symptoms, represents the future of asthma management in Australia.

References

1. National Asthma Council Australia. (2025). Australian Asthma Handbook Version 3.0. Retrieved from https://www.asthmahandbook.org.au/
2. Asthma Australia. (2025). Australian Asthma Handbook Update 2025: First Look. Retrieved from https://asthma.org.au/health-professionals/asthma-digest/aah-update-2025/
3. National Asthma Council Australia. (2025). New guidelines state SABA inadequate treatment for asthma. Retrieved from https://www.nationalasthma.org.au/news/2025/new-guidelines-state-saba-inadequate-treatment-for-asthma
4. RACGP newsGP. (2025). ‘Major change of practice’ in asthma advice. Retrieved from https://www1.racgp.org.au/newsgp/clinical/major-change-of-practice-in-asthma-advice
5. Asthma Australia. (2025). Biggest shake-up to asthma treatment in a generation. Retrieved from https://asthma.org.au/about-us/media/biggest-shake-up-to-asthma-treatment-in-a-generation/

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