Asthma

Last updated 1 Jun 2026 · Respiratory

📋 Key Information Summary

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Asthma affects approximately 2.7 million Australians (~11% of the population); it remains a leading cause of preventable hospitalisation, particularly in children and Aboriginal and Torres Strait Islander peoples.
Severity is classified as intermittent, mild persistent, moderate persistent, or severe persistent based on symptom frequency, night waking, SABA use, and lung function (FEV₁/FVC).
Assessment of control — not just severity — guides day-to-day management; use symptom frequency, reliever use, activity limitation, and exacerbation history over the preceding 4 weeks.
Stepwise management: start at the step corresponding to initial severity, step up if uncontrolled (after checking adherence/inhaler technique), step down after 3 months of good control.
Inhaled corticosteroids (ICS) are the cornerstone of persistent asthma; low-dose ICS is first-line for Step 2 (e.g., budesonide 200–400 µg/day or fluticasone propionate 100–200 µg/day).
SABA-only treatment (e.g., salbutamol) is reserved for Step 1 (intermittent symptoms ≤2 days/week). ICS-formoterol as-needed (MART regimen) is now preferred for Steps 1–2.
Inhaler technique is the single most modifiable factor in treatment failure; demonstrate, observe, and re-check at every visit.
Spacers are mandatory with pMDIs — use a single-puff technique with 4 tidal breaths (or 1 breath for ≥5 years with good technique); replace spacers every 6–12 months.
Written Asthma Action Plans reduce emergency presentations and hospitalisations; every patient should have one, reviewed at least annually.
Leukotriene receptor antagonists (montelukast) are add-on therapy for exercise-induced or allergic phenotype; neuropsychiatric side-effects require counselling.
Severe/life-threatening exacerbations: oxygen to SpO₂ 94–98%, nebulised salbutamol 5 mg + ipratropium bromide 500 µg, systemic corticosteroids (prednisolone 50 mg PO or hydrocortisone 200 mg IV), IV magnesium sulphate 2 g over 20 minutes if refractory.
Aboriginal and Torres Strait Islander Australians have 1.4–2× the asthma prevalence and 3× the hospitalisation rate; culturally safe care, action plans, and spirometry access in remote areas are critical.

Introduction & Australian Epidemiology

Asthma is a chronic inflammatory disorder of the airways characterised by variable and reversible airflow obstruction, bronchial hyper-responsiveness, and airway inflammation. It presents with episodic wheeze, breathlessness, chest tightness, and cough — symptoms that vary over time and in intensity, often worsening at night or with exercise, allergen exposure, or respiratory infections.

In Australia, asthma remains one of the most common chronic diseases managed in general practice. The Australian Bureau of Statistics (ABS) 2022 National Health Survey estimated that approximately 11% of the population (2.7 million people) have current asthma, with higher prevalence in children aged 5–14 years (~15%) and in females compared with males. Asthma accounts for over 39,000 hospitalisations and approximately 400 deaths per year nationally (AIHW, 2023).

The burden is disproportionately borne by Aboriginal and Torres Strait Islander Australians, who experience asthma prevalence approximately 1.4 times higher and hospitalisation rates 2–3 times higher than non-Indigenous Australians. Socioeconomic disadvantage, housing overcrowding, environmental tobacco smoke exposure, and limited access to primary care and spirometry in remote communities are key drivers of this disparity.

Most asthma can be managed effectively in primary care using a stepwise pharmacological approach, structured education, and regular review. This guideline provides a comprehensive framework for Australian general practitioners and primary care clinicians covering aetiology, classification, stepwise management, inhaler selection, pharmacological agents, special populations, and Aboriginal and Torres Strait Islander health considerations.

Causes, Severity Classification & Assessment of Control

Aetiology and Risk Factors

Asthma arises from a complex interplay of genetic susceptibility and environmental exposures. Key risk factors include:

Atopy: Personal or family history of eczema, allergic rhinitis, or food allergy is the strongest predisposing factor. Elevated serum IgE and positive skin-prick tests to common aeroallergens (house dust mite, grass pollen, mould) are frequently present.
Early-life infections: Respiratory syncytial virus (RSV) bronchiolitis in infancy and rhinovirus wheezing episodes in early childhood are associated with subsequent asthma development.
Environmental tobacco smoke: Both prenatal and postnatal exposure significantly increase risk, particularly in Indigenous communities with high smoking rates.
Occupational exposures: Isocyanates, flour dust, wood dust, latex, and laboratory animal proteins account for approximately 15–20% of adult-onset asthma.
Obesity: BMI ≥30 is associated with non-eosinophilic, steroid-resistant asthma phenotypes.
Air pollution: Traffic-related particulate matter, bushfire smoke (increasingly relevant in Australian summers), and thunderstorm asthma events (especially in south-eastern Australia during ryegrass pollen season, October–December).
Gut microbiome disruption: Early antibiotic use, caesarean delivery, and lack of breastfeeding may alter immune programming.

Severity Classification

Severity is best assessed before initiating controller therapy or when treatment has been stable. Classify as:

Intermittent

Step 1

Symptoms ≤2 days/week; night waking ≤2×/month; SABA use ≤2 days/week; no activity limitation; FEV₁ ≥80% predicted; FEV₁/FVC normal.

Setting: GP management

Mild Persistent

Step 2

Symptoms >2 days/week but not daily; night waking 3–4×/month; SABA use >2 days/week but not daily; minor activity limitation; FEV₁ ≥80% predicted.

Setting: GP management

Moderate Persistent

Step 3–4

Daily symptoms; night waking >1×/week but not nightly; daily SABA use; some activity limitation; FEV₁ 60–80% predicted.

Setting: GP ± respiratory physician

Severe Persistent

Step 5

Symptoms throughout the day; nightly waking; SABA use several times/day; extreme activity limitation; FEV₁ <60% predicted.

Setting: Respiratory physician referral essential

Assessment of Asthma Control

Control is assessed over the preceding 4 weeks and classifies patients as well-controlled, partly controlled, or uncontrolled. This guides treatment decisions independent of severity classification at diagnosis.

Domain	Well Controlled	Partly Controlled	Uncontrolled
Daytime symptoms	≤2 days/week	>2 days/week	≥3 partly controlled features
Night waking	None	Any
Reliever use	≤2 days/week	>2 days/week
Activity limitation	None	Any
FEV₁ or peak flow	≥80% predicted/personal best	60–80% predicted	<60% predicted
Exacerbations	None	≥1/year	≥1/year (major)

⚠️

Before stepping up therapy: Always confirm correct inhaler technique, medication adherence, and comorbidity management (allergic rhinitis, GORD, obesity, obstructive sleep apnoea) — these are the most common causes of apparent treatment failure in Australian primary care.

Diagnostic Confirmation

Spirometry demonstrating reversible airflow obstruction (≥12% and ≥200 mL improvement in FEV₁ post-bronchodilator) is the gold standard. Where spirometry is unavailable, a peak flow diary showing >20% diurnal variability on ≥3 days/week for 2 weeks is supportive. Fractional exhaled nitric oxide (FeNO) ≥40 ppb in adults (≥35 ppb in children) supports eosinophilic airway inflammation and predicts ICS responsiveness. Bronchial provocation testing (mannitol or methacholine challenge) is indicated when spirometry is normal but clinical suspicion remains high.

Stepwise Management & Starting Treatment

The stepwise approach ensures treatment intensity matches disease severity and control status. Step up if uncontrolled after confirming technique and adherence; step down after ≥3 months of stable control, reducing by one step at a time.

Step 1

Intermittent Asthma — As-Needed Reliever

As-needed SABA (salbutamol 100–200 µg PRN) or preferred: as-needed low-dose ICS-formoterol (budesonide 200 µg/formoterol 6 µg, 1 puff PRN — MART regimen). Written Asthma Action Plan. Review in 4–6 weeks.

Step 2

Mild Persistent — Regular Low-Dose ICS

Low-dose ICS daily (budesonide 200–400 µg/day or fluticasone propionate 100–200 µg/day) + as-needed SABA. Alternative: as-needed ICS-formoterol (MART). Review in 4–6 weeks.

Step 3

Moderate Persistent — ICS + LABA

Low-dose ICS-LABA combination (e.g., fluticasone/salmeterol 100/50 µg BD or budesonide/formoterol 200/6 µg BD) + as-needed SABA. Preferred: MART with budesonide/formoterol maintenance + PRN. Consider adding LTRA if allergic phenotype or exercise-induced symptoms.

Step 4

Moderate–Severe Persistent — Medium-Dose ICS-LABA

Medium-dose ICS-LABA (e.g., fluticasone/salmeterol 250/50 µg BD or budesonide/formoterol 400/12 µg BD). Add-on options: LTRA, long-acting muscarinic antagonist (tiotropium 2.5 µg OD via Respimat), or slow-release theophylline. Consider MART with medium-dose ICS-formoterol. Refer to respiratory physician if uncontrolled.

Step 5

Severe Persistent — Specialist-Directed Therapy

High-dose ICS-LABA + add-on LTRA + tiotropium. Refer for: biologic therapy assessment (omalizumab for IgE-mediated, mepolizumab or benralizumab for eosinophilic, tezepelumab for severe uncontrolled), bronchial thermoplasty, oral corticosteroid-sparing regimens, and phenotyping (eosinophilic vs. neutrophilic vs. paucigranulocytic).

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Never prescribe a LABA without ICS: Long-acting β₂-agonist monotherapy (salmeterol or formoterol alone) is contraindicated in asthma due to the risk of serious exacerbations and death. Always prescribe LABA as a combination inhaler with ICS or alongside regular ICS.

Starting Treatment — Initial Assessment

For newly diagnosed asthma in general practice:

Confirm diagnosis with spirometry (preferred) or peak flow variability + clinical history.
Classify severity (see above) and assess current control.
Identify and manage triggers and comorbidities (allergic rhinitis with intranasal corticosteroids, GORD, obesity, anxiety/depression).
Initiate treatment at the appropriate step — consider starting one step higher than severity suggests if presenting with an exacerbation.
Provide a Written Asthma Action Plan (Asthma Australia templates available).
Demonstrate and assess inhaler technique; provide a spacer for all pMDI users.
Schedule follow-up at 4–6 weeks, then 3-monthly until stable, then 6–12-monthly.

Stepping Down

After ≥3 months of well-controlled asthma, consider reducing treatment by one step. Reduce ICS dose by 25–50% while maintaining LABA if on combination therapy. Do not discontinue ICS completely in patients with persistent asthma — step down to the minimum effective dose. Monitor closely for 4–6 weeks after each reduction.

Managing Exacerbations in Primary Care

For moderate exacerbations presenting to general practice:

Salbutamol 4–8 puffs via spacer (repeat every 20 minutes for up to 3 doses) or nebulised salbutamol 5 mg.
Prednisolone 40–50 mg PO daily for 5–7 days (adults); 1–2 mg/kg (max 40 mg) for children.
Assess response after 1 hour — if improving, discharge with action plan and GP review within 48 hours.
If not improving: call ambulance, continue nebulised bronchodilators, administer oxygen to SpO₂ 94–98%, and consider IV magnesium sulphate 2 g over 20 minutes (hospital setting).

Inhaler Devices & Spacers

Device selection and technique are critical determinants of asthma outcomes. Studies consistently show that 70–90% of Australian patients use their inhaler incorrectly. Device choice should be individualised based on the patient's age, inspiratory flow, coordination, cognitive ability, and preference.

Device Types

Device	Technique	Advantages	Disadvantages	Best For
pMDI (pressurised metered dose inhaler)	Slow deep breath + breath-hold 10 sec or tidal breathing with spacer	Compact; inexpensive; multi-dose; available for most drugs	Coordination required without spacer; hand-breath discoordination common	All ages (with spacer); cost-sensitive patients
pMDI + Spacer	Single puff into spacer, 4 tidal breaths (adults) or 1 breath (≥5 years, good technique)	Eliminates coordination; reduces oropharyngeal deposition; improves lung delivery by 2–4×	Bulk; spacer must be replaced regularly; static charge with new spacers	All asthma patients using pMDI — mandatory for children
DPI — Dry Powder Inhaler	Forceful rapid inspiratory effort (≥30 L/min for most devices)	Breath-actuated; no coordination needed; portable; dose counters	Requires adequate inspiratory flow; humidity-sensitive; not suitable for young children (<5 years); some have high internal resistance	Adults and older children (≥5–6 years) with adequate inspiratory effort
Soft Mist Inhaler (e.g., Respimat®)	Slow deep breath; breath-actuated aerosol cloud	Slow aerosol velocity; high lung deposition; suitable for poor inspiratory flow	Limited drug availability; cost; priming steps required	Patients with poor coordination or low inspiratory flow (tiotropium Respimat)
Nebuliser	Tidal breathing via mask or mouthpiece for 10–15 minutes	No coordination; high dose delivery; suitable for acute severe exacerbations	Time-consuming; noisy; variable output; bacterial contamination risk; NOT for routine maintenance	Acute exacerbations; very young children; critically ill patients

Spacer Guidance

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Use a large-volume spacer (≥750 mL, e.g., Volumatic®, AeroChamber Plus®) for all patients using pMDIs.
Single-puff technique: actuate one puff into the spacer, breathe in and out 4 times (adults/older children) or 1 breath (≥5 years with good tidal breathing). Repeat for each puff — do NOT actuate multiple puffs into the spacer at once.
Children <5 years: use a spacer with face mask (ensure good seal). Nebulisers are an alternative for acute episodes.
New spacer: wash with detergent and allow to air-dry (reduces static charge). Do NOT rinse or wipe dry.
Clean weekly with warm water and detergent; air-dry. Replace every 6–12 months or when visibly damaged/cloudy.
With ICS pMDI via spacer: rinse mouth and gargle after each use to prevent oropharyngeal candidiasis and dysphonia.

Inhaler Technique Checklist (Assess at Every Visit)

Shake pMDI (not required for DPIs or soft mist).
Breathe out fully (not into the device for DPIs).
Seal lips around mouthpiece (pMDI) or place mouthpiece correctly (DPI).
Actuate (pMDI) or twist/dose (DPI) at the start of a slow deep breath.
Hold breath for 10 seconds (or as long as comfortable).
Wait 30–60 seconds between puffs.
Rinse mouth after ICS use.

Pharmacological Agents

Short-Acting β₂-Agonists (SABA)

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Salbutamol

Ventolin®, Asmol® · SABA

Adult dose 100–200 µg (1–2 puffs) via pMDI + spacer PRN; max 8 puffs/day in stable asthma (more during exacerbations)

Paediatric dose 100 µg (1 puff) via pMDI + spacer PRN; 2–6 years: with face mask spacer; neb: 2.5 mg (<6 years), 5 mg (≥6 years)

Route Inhaled (pMDI, DPI, nebuliser); oral syrup available (2 mg/5 mL — rarely used)

Renal adjustment None required (inhaled route)

Key side-effects Tremor, tachycardia, hypokalaemia (at high doses); tolerance with overuse

PBS status ✔ PBS General Benefit

Inhaled Corticosteroids (ICS)

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Budesonide

Pulmicort® · ICS

Adult dose Low: 200–400 µg/day; Medium: 400–800 µg/day; High: 800–1600 µg/day (divided BD)

Paediatric dose 1–5 years: 200–400 µg/day via spacer/neb; 6–12 years: 200–400 µg/day via pMDI+spacer or DPI

Route Inhaled (pMDI via spacer, Turbuhaler DPI, nebuliser suspension)

Renal adjustment None required

Key side-effects Oral candidiasis, dysphonia, bruising at high doses; growth suppression in children (1–2 cm/year initially, normalises); rinse mouth after use

PBS status ✔ PBS General Benefit

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Fluticasone Propionate

Flixotide® · ICS

Adult dose Low: 100–200 µg/day; Medium: 200–500 µg/day; High: 500–1000 µg/day (divided BD)

Paediatric dose 2–12 years: 100–200 µg/day via pMDI+spacer; >12 years: as per adult

Route Inhaled (pMDI, Accuhaler DPI)

Renal adjustment None required

Key side-effects As per budesonide; fluticasone has higher systemic bioavailability at doses >500 µg/day via pMDI

PBS status ✔ PBS General Benefit

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Ciclesonide

Alvesco® · ICS (prodrug, activated in lungs)

Adult dose 80–320 µg/day OD (single daily dose)

Route Inhaled (pMDI + spacer)

Key advantage Low oropharyngeal deposition; reduced local side-effects; activated by lung esterases

PBS status ⚠️ PBS Authority Required

Long-Acting β₂-Agonists (LABA) — Always with ICS

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Salmeterol

Serevent® · LABA

Adult dose 50 µg BD (only available as combination with fluticasone — Seretide®)

Paediatric dose ≥4 years: 50 µg BD (as Seretide Accuhaler 100/50 or pMDI 50/25)

Route Inhaled (pMDI + spacer, Accuhaler DPI)

Onset / Duration Onset 15–20 min; duration ~12 hours

Key warning NEVER prescribe without concurrent ICS; risk of severe exacerbations and death as monotherapy

PBS status ⚠️ PBS Authority Required (combination only)

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Formoterol

Oxis®, Symbicort® combination · LABA (rapid onset)

Adult dose 12 µg BD maintenance (as Symbicort 200/6 or 400/12); 6 µg PRN as MART (budesonide/formoterol 200/6)

Paediatric dose ≥6 years: Symbicort 100/6 BD (100/6 = lowest available combination)

Route Inhaled (Turbuhaler DPI, pMDI)

Onset / Duration Onset 1–3 min (as rapid as salbutamol); duration 8–12 hours

Key advantage Rapid onset allows use as MART (Maintenance and Reliever Therapy) — preferred ICS-formoterol for Steps 1–4

PBS status ⚠️ PBS Authority Required (combination)

ICS-LABA Fixed-Dose Combinations

Brand	Components	Available Strengths	Device	Frequency	PBS Status
Seretide®	Fluticasone / Salmeterol	50/25, 100/50, 125/25, 250/25, 250/50, 500/50	pMDI (Evohaler), Accuhaler	BD	⚠️ Authority Required
Symbicort®	Budesonide / Formoterol	100/6, 200/6, 400/12	Turbuhaler DPI, pMDI (Rapihaler)	BD or PRN (MART)	⚠️ Authority Required
Flutiform®	Fluticasone / Formoterol	50/5, 125/5, 250/10	pMDI	BD	⚠️ Authority Required

Leukotriene Receptor Antagonists (LTRA)

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Montelukast

Singulair®, generic · LTRA

Adult dose 10 mg PO once daily (evening)

Paediatric dose 2–5 years: 4 mg chewable tablet once daily (evening); 6–14 years: 5 mg chewable tablet once daily; ≥15 years: 10 mg once daily

Route Oral (tablet, chewable tablet, granules)

Indications Add-on to ICS in Steps 3–4; exercise-induced asthma; allergic phenotype; aspirin-exacerbated respiratory disease

Renal adjustment None required

Hepatic adjustment Use with caution in moderate–severe hepatic impairment (reduced clearance)

Key warnings Neuropsychiatric effects: agitation, insomnia, depression, suicidal ideation (rare) — TGA and FDA black-box warning; counsel patients/parents. Assess response after 4–6 weeks — discontinue if no benefit.

PBS status ✔ PBS General Benefit

Other Agents

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Ipratropium Bromide

Atrovent® · Short-acting muscarinic antagonist (SAMA)

Adult dose 20 µg (1–2 puffs) via pMDI TDS–QID PRN; neb: 500 µg in acute severe asthma (combined with salbutamol)

Paediatric dose Neb: 250 µg (<6 years), 500 µg (≥6 years) in acute exacerbations

Role in asthma Acute severe exacerbations (add to SABA); not for routine maintenance

PBS status ✔ PBS General Benefit

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Tiotropium (Respimat®)

Spiriva Respimat® · Long-acting muscarinic antagonist (LAMA)

Adult dose 2.5 µg (2 puffs) once daily via Respimat

Paediatric dose ≥6 years: 2.5 µg (2 puffs) once daily

Role in asthma Add-on at Steps 4–5 in patients inadequately controlled on ICS-LABA

PBS status ⚠️ PBS Authority Required (asthma indication)

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Prednisolone

Solone®, Panafcortelone® · Systemic corticosteroid

Adult dose 40–50 mg PO once daily for 5–7 days (short course for acute exacerbation); no taper required if ≤14 days

Paediatric dose 1–2 mg/kg/day (max 40 mg) PO for 3–5 days

Route Oral (tablet, soluble tablet, syrup)

Key side-effects Hyperglycaemia, mood disturbance, insomnia; short courses generally well tolerated; monitor BGL in diabetics

PBS status ✔ PBS General Benefit

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Magnesium Sulphate

IV preparation · Adjunct in refractory acute severe asthma

Adult dose 2 g IV over 20 minutes (single dose); may repeat once after 1–2 hours

Paediatric dose 25–50 mg/kg IV over 20 minutes (max 2 g)

Setting Hospital/ED only — not for primary care use

Monitoring Blood pressure, respiratory rate, oxygen saturation; check serum magnesium if renal impairment

PBS status ✔ PBS General Benefit (hospital use)

⚠️

ICS dose equivalence (adults): Low-dose = budesonide 200–400 µg/day or fluticasone propionate 100–200 µg/day. Medium-dose = budesonide 400–800 µg/day or fluticasone propionate 200–500 µg/day. High-dose = budesonide 800–1600 µg/day or fluticasone propionate 500–1000 µg/day. Always use the lowest effective dose. Note: ciclesonide 80 µg ≈ budesonide 200 µg ≈ fluticasone 100 µg.

MART (Maintenance and Reliever Therapy)

MART uses a single ICS-formoterol inhaler (budesonide/formoterol, e.g., Symbicort®) for both maintenance and reliever use. It reduces exacerbation rates compared with fixed-dose ICS-LABA + as-needed SABA. The patient takes a maintenance dose (e.g., budesonide/formoterol 200/6, 1–2 puffs BD) and uses the same inhaler PRN for symptom relief (up to 6–8 additional puffs/day, max 12 puffs/day total). MART is now the preferred regimen for Steps 1–4 in the Australian Asthma Handbook (2024 update).

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MART is only approved with budesonide/formoterol (Symbicort®). Do not use fluticasone/salmeterol (Seretide®) or fluticasone/formoterol (Flutiform®) as MART — formoterol's rapid onset makes it suitable for as-needed use; salmeterol is not appropriate.

Special Populations

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Pregnancy

Uncontrolled asthma poses greater risk to the fetus than controller medications.

ICS (budesonide preferred — most safety data, Category A in pregnancy): Continue at lowest effective dose. Do not discontinue.

LABA (salmeterol, formoterol): Category B3 — use if required as ICS-LABA combination; acceptable safety profile.

SABA: Salbutamol is safe and preferred reliever.

Montelukast: Category B1 — use only if benefit clearly outweighs risk; generally discontinue unless essential.

Prednisolone: Not teratogenic at therapeutic doses; use for exacerbations as per standard protocol.

Monitor asthma control monthly during pregnancy; labour/delivery do not require medication changes unless severe.

👶

Paediatrics

Diagnosis <5 years: Clinical — wheeze + response to bronchodilator. Spirometry unreliable <5 years; consider FeNO from age 4.

ICS first-line for persistent wheeze ≥3 episodes/year: Budesonide 100–200 µg/day or fluticasone 100 µg/day via spacer + face mask.

Spacer + face mask mandatory <5 years. Nebulisers for acute severe attacks in young children.

LTRA (montelukast 4 mg granules/chewable): Add-on for exercise-induced or allergic phenotype from age 2 years.

Viral-induced wheeze <5 years: Intermittent ICS at first sign of URTI may reduce severity (evidence limited). Avoid prolonged courses.

Monitor growth velocity annually (ICS effect: 1–2 cm/year reduction, generally normalises by adulthood).

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Elderly (≥65 years)

Higher misdiagnosis rate — overlap with COPD, cardiac asthma; perform spirometry.

Inhaler technique: Arthritis, cognitive decline, reduced inspiratory flow limit device options. DPIs may be unsuitable if inspiratory flow <30 L/min — prefer pMDI + spacer.

ICS side-effects increased: Pneumonia risk (especially fluticasone at high doses), osteoporosis, cataracts. Use lowest effective dose; consider bone density monitoring.

Drug interactions: β-blockers (even topical timolol for glaucoma) may worsen bronchospasm; theophylline — narrow therapeutic index, interactions with macrolides, fluoroquinolones.

Polypharmacy review essential; consider supervised medication use and simplified regimens.

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Renal Impairment

Inhaled ICS, LABA, SABA: No dose adjustment (minimal systemic absorption).

Montelukast: No adjustment required.

Prednisolone: No adjustment, but use cautiously in dialysis patients — risk of fluid retention, hyperglycaemia.

Theophylline: Monitor levels; active metabolite accumulates in renal impairment.

Nebulised salbutamol may cause hypokalaemia — monitor potassium in CKD stage 4–5.

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Hepatic Impairment

ICS (fluticasone, budesonide): First-pass metabolism reduced in severe liver disease — increased systemic effects. Monitor for adrenal suppression.

Montelukast: Hepatically metabolised; use with caution (reduced clearance).

Theophylline: Clearance significantly reduced in cirrhosis — halve dose and monitor levels (target 55–110 µmol/L or 8–15 mg/L).

Prefer budesonide over fluticasone in hepatic impairment (budesonide has ~90% first-pass metabolism but more predictable than fluticasone).

🛡️

Immunocompromised

ICS at high doses increase risk of oral and pulmonary candidiasis and may suppress local immunity.

HIV-positive patients: ICS use associated with increased pneumocystis risk at high doses. Monitor closely.

Post-transplant / biologic therapy: Coordinate with immunologist; avoid systemic corticosteroids if possible due to additive immunosuppression.

Annual influenza vaccination and pneumococcal vaccination recommended for all immunocompromised asthma patients.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Asthma is a significant health burden for Aboriginal and Torres Strait Islander Australians. The 2018–19 National Aboriginal and Torres Strait Islander Health Survey found self-reported asthma prevalence of approximately 15.6% in Indigenous Australians compared with 10.8% in non-Indigenous Australians. Hospitalisation rates for asthma are 2–3 times higher, and mortality rates are 2 times higher, with the greatest disparity in the 45–64 age group and in remote areas (AIHW, 2023).

Diagnostic access

Spirometry is frequently unavailable in remote Aboriginal Community Controlled Health Services (ACCHS). Peak flow monitoring and clinical assessment may need to substitute. Advocate for spirometry training and equipment in primary health care settings serving Indigenous communities.

Medication access

PBS medicines are available free of charge under Closing the Gap PBS co-payment reforms (since 2010) for Aboriginal and Torres Strait Islander patients with a GP or prescriber attestation. Ensure prescriptions are marked accordingly. Spacers and pMDIs are preferred over DPIs in remote communities due to cost and inspiratory flow considerations.

Environmental triggers

Overcrowded housing, mould, dust (especially in remote communities), environmental tobacco smoke exposure (smoking rates ~40% in Indigenous adults vs. ~10% in non-Indigenous), and indoor wood-fire heating are major triggers. Health promotion must address these in a culturally safe and trauma-informed manner.

Written Asthma Action Plans

Use culturally adapted action plans with pictorial aids. Asthma Australia provides Indigenous-specific templates. Health workers and Aboriginal Health Practitioners (AHPs) should be trained to deliver asthma education and reinforce action plan use. Concept of 'action plans' should be discussed in the context of individual patient understanding and health literacy.

Chronic disease management

Integrate asthma management with existing chronic disease programmes (e.g., MBS Item 721 — GP Management Plan, Item 723 — Team Care Arrangement). Link with ACCHS multidisciplinary teams. The Royal Australian College of General Practitioners (RACGP) National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (3rd edition) includes asthma screening and management guidance.

Cultural safety

Use culturally safe communication; acknowledge the role of family and community in health decisions; employ Aboriginal Health Workers and Aboriginal Health Practitioners as key members of the care team; be aware of the impact of intergenerational trauma and systemic racism on health engagement and medication adherence.

Paediatric asthma

Indigenous children have high rates of acute respiratory presentations. Bronchiolitis and post-infectious wheeze may be misdiagnosed as asthma. Ensure diagnostic accuracy before long-term controller therapy. School-based asthma programmes (e.g., Asthma Buddy) should be promoted in schools with high Indigenous enrolment.

✅

Closing the Gap PBS co-payment: Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease are eligible for PBS medicines at no cost. The prescriber must sign the relevant section of the prescription. This removes a major barrier to ICS and combination inhaler adherence. Always ensure this is offered and documented.

📚 References

1. National Asthma Council Australia. Australian Asthma Handbook. Version 2.2. Melbourne: National Asthma Council Australia; 2024. Available from: https://www.asthmahandbook.org.au
2. Australian Institute of Health and Welfare (AIHW). Asthma. Cat. no. ACM 33. Canberra: AIHW; 2023.
3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Bethesda, MD: GINA; 2024. Available from: https://ginasthma.org
4. Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, et al. Global Initiative for Asthma Strategy 2021: executive summary and rationale for key changes. Eur Respir J. 2022;59(1):2102730.
5. Yang IA, Jenkins CR, Salvi SS. Chronic asthma and stepwise management in adults. BMJ. 2022;376:e065848.
6. Anderson GP, Morin M, Holgate ST. Asthma: pathogenesis and clinical management. Lancet. 2024;403(10434):1253–1268.
7. Beasley R, Holliday M, Reddel HK, Braithwaite I, Ebmeier S, Hancox RJ, et al. Controlled trial of budesonide–formoterol as needed for mild asthma. N Engl J Med. 2019;380(21):2020–2030.
8. Sobieraj DM, Baker WL, Weeda ER, Nguyen S, Coleman CI, White CM, et al. Intermittent inhaled corticosteroids and long-acting muscarinic antagonists for asthma. JAMA. 2021;325(16):1660–1670.
9. Royal Australian College of General Practitioners (RACGP). National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. 3rd edn. Melbourne: RACGP; 2018.
10. Australian Bureau of Statistics (ABS). National Health Survey: First Results, 2022. Cat. no. 4364.0.55.001. Canberra: ABS; 2023.
11. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Prefer Adherence. 2008;2:25–35.
12. Kaplan A, Mitchell PD, Cave AJ, Gagnon R, Foran V, Ellis AK. Effective asthma management utilizing the MART approach in Canadian clinical practice. Allergy Asthma Clin Immunol. 2020;16:51.
13. Therapeutic Goods Administration (TGA). Montelukast: neuropsychiatric adverse events — updated safety advisory. Canberra: Department of Health and Aged Care; 2020.
14. Asthma Australia. Written Asthma Action Plans — Aboriginal and Torres Strait Islander Resources. Sydney: Asthma Australia; 2023. Available from: https://www.asthmaaustralia.org.au

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).