Step 1 as-required therapy for asthma in adults and adolescents

Step 1 as-required therapy is indicated for patients with symptoms less than twice per month and without risk factors for exacerbations—few patients with asthma can be managed with Step 1 therapy.

Step 1 therapy consists of one of the following:

  • as-required short-acting beta2 agonist (SABA)
  • as-required low-dose budesonide+formoterol.

For Step 1 as-required therapy, use:

1 budesonide+formoterol 200+6 micrograms by inhalation via pMDI with spacer or via DPI, as required (see Table 9.3 for regimen expressed as number of inhalations) asthma, Step 1 as-required therapy (adult, adolescent) budesonide + formoterol budesonide+formoterol budesonide+formoterol

OR

1 salbutamol 200 micrograms by inhalation via pMDI with spacer, as required (see Non–ICS inhalers available in Australia for asthma for formulations) asthma, Step 1 therapy (adult, adolescent) salbutamol salbutamol salbutamol

OR

2 terbutaline 500 micrograms by inhalation via DPI, as required (see Non–ICS inhalers available in Australia for asthma for formulations). asthma, Step 1 therapy (adult, adolescent) terbutaline terbutalineterbutaline

There is no direct evidence from clinical trials to support as-required low-dose budesonide+formoterol in patients with symptoms less than twice per month and no waking due to asthma, and without risk factors for exacerbations (eg flare ups that required oral corticosteroids in the previous 12 months). However, the use of as-required budesonide+formoterol has a low risk of harm and may reduce the occurrence of acute severe asthma exacerbations, which can still occur in these patients. At the time of writing, other combination products (eg beclometasone+formoterol) are not approved by the Australian Therapeutic Goods Administration (TGA) for use as Step 1 as-required therapy.

SABA therapy effectively reduces acute symptoms. The requirement for SABA on two or more days per month is an indication that the patient requires Step 2 therapy. Frequent use or use as monotherapy is associated with poor asthma outcomes, even if asthma appears well controlled. See Choice of reliever therapy for information about the effects of over-reliance on SABA.