Chloe Hava
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[post_content] => The Australian Technical Advisory Group on Immunisation (ATAGI) 2025 statement paints a mixed picture.
While Australia has made important gains with new vaccines and national immunisation reforms, rising cases of pertussis, measles and mpox reveal how fragile protection can be when coverage falters.
Australian Pharmacist explores where progress has been made and where urgent focus is required.
1. Vaccination rates are declining across the board
An ongoing decline in vaccination rates has been identified among all children, adolescents and adults. The steepest and most troubling drop is in childhood vaccination rates at 12 months of age – reducing 3.2 percentage points since 2020. Coverage for children aged 24 months has also dipped below 90% for the first time since 2016. Coverage at 60 months is the highest milestone (92.7%) – indicating that catch-up vaccination is occurring.
Adolescent human papillomavirus (HPV) vaccination rates are also on a downward trend, sitting well below the 90% target at 81.1% in females and 77.9% in males for at least one dose of the vaccine at 15 years of age. Concerningly, the rates are even lower among Aboriginal and Torres Strait Islander people, sitting at 76.7% in females and 69.2% in males.
Uptake of COVID-19 vaccines fell sharply in 2024 across all adult age groups, with only a fraction (2.3%) of younger adults aged 18 to <50 receiving at least one dose of the vaccine. Among those most vulnerable to severe complications, patients aged 75 and older, the vaccination rate dropped from 52.3% to 36.5%.
ATAGI will track declining coverage for selected vaccines to inform additional control strategies, and monitor the effects of schedule changes on coverage and disease – such as the shift to a 1-dose HPV schedule in 2023.
2. Australia’s RSV vaccination campaign is world leading
In 2024, Australia became the first country to put a combined maternal and infant respiratory syncytial virus (RSV) immunisation program in place. Pregnant women were given free access to Abrysvo under the National Immunisation Program (NIP)
from 28 weeks gestation ahead of the 2025 RSV season. Monoclonal antibody nirsevimab is funded for infants under various state and territory arrangements to ensure protection for at-risk infants and/or those whose mother did not receive the vaccine during pregnancy.
These arrangements include:
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[post_content] => PSA has announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education offerings and professional and practice support for members and the pharmacy profession.
PSA’s Board announced negotiations had successfully concluded. While there are still steps to be completed before the settlement, PSA is focused on how the acquisition will strengthen its leadership in education and training for pharmacists, pharmacy assistants, and technicians.
The acquisition allows PSA to grow its industry-leading education and workforce development programs. The PSA Board is confident this is the right path forward for PSA, its members and the broader profession.
National President and Chair of the PSA Board Associate Professor Fei Sim FPS said the agreement was a transformational opportunity for the future of pharmacy education.
‘This agreement is a major milestone in our journey to strengthen and unify pharmacy education in Australia,’ A/Prof Sim said.
‘As the custodian for standards and guidelines for professional practice, the acquisition of the College by the PSA is a further strategic step toward building scale, capability, and capacity for pharmacy education in Australia, amidst the fast-evolving practice landscape.
‘This agreement reflects our shared intent and commitment to invest in the future of the profession and ensure pharmacists, pharmacy assistants, and technicians are supported at every stage of their careers. The acquisition aligns with PSA’s broader strategy to support the profession through a period of significant transformation, including the expansion of scope of practice and increasing demands on the healthcare system.
‘This is about building a stronger, more sustainable future for pharmacy education, so we can do more for our members. As the peak body representing all pharmacists in Australia, PSA continues to represent pharmacists across the profession and their interests, while continuing our commitment to uphold and support high standards of practice.
‘We are proud to lead this work and look forward to continuing to support our members with the highest quality education and professional development.’
PSA will continue to engage with stakeholders throughout the transition process, with a focus on continuity, quality and innovation in education delivery.
[post_title] => PSA to lead unified future for pharmacy education
[post_excerpt] => PSA announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education.
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[post_content] => Serious adverse events in infants prompted the Therapeutic Goods Administration (TGA) to issue a safety alert about prilocaine/lidocaine cream.
The anaesthetic cream, sold under the brand name Emla and various other generics, is typically used for topical anaesthesia of the skin before various minor procedures. It is commonly used prior to circumcision, insertion of catheters and vaccination.
What are the signs and symptoms of overdose?
Prilocaine/lidocaine overdose can lead to methaemoglobinaemia, disrupting haemoglobin’s capacity to carry oxygen. Common symptoms include:
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[post_content] => Case scenario
Amir, a 35-year-old male, presents to the pharmacy requesting a salbutamol inhaler. Upon questioning, he informs you he needs salbutamol for his asthma and has ‘used it since he was a kid’. Amir says his asthma has been well controlled of late and that it only flares with a chest infection and when he gets hay fever. He states he would like to have the salbutamol as he is going away and wants to have one on hand. He is on no other asthma medicines and has only used salbutamol twice in the past month.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
The Global Initiative for Asthma (GINA) strategy defines asthma as ‘a heterogeneous disease, usually characterised by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation’.1
In 2019, GINA comprehensively revised its recommendations for asthma management. This was based on its committee of asthma experts reviewing the evidence. Asthma guidelines from the National Asthma Council Australia (NAC) have now followed suit, and the NAC’s updated Australian Asthma Handbook states that short-acting beta2-agonists (SABA), such as salbutamol, are no longer recommended as sole therapy for asthma in adults and adolescents. The NAC now recommends anti-inflammatory reliever (AIR) therapy as needed from day one when it comes to asthma treatment in adults and adolescents.2 AIR-only therapy refers to the as-needed use of a low-dose inhaled corticosteroid (ICS)–formoterol combination, budesonide–formoterol, to provide both symptom relief and anti-inflammatory action.1
According to Asthma Australia, over 90% of asthma-related hospitalisations in 2022–23 were potentially preventable with optimised care in the community.3,4 This powerful statistic underscores the critical role pharmacists can play in reducing asthma morbidity through education, medicines management, and promoting adherence to treatment.
Asthma is a significant health concern in Australia, reported to affect nearly 2.8 million individuals (1 in 9 Australians) as at 2022.5 The prevalence of asthma is higher in certain demographic groups, such as Aboriginal and Torres Strait Islander peoples, who report asthma rates of 16%.6
Hospitalisation rates related to asthma have increased in recent years, with over 31,000 hospital admissions recorded in 2022–2023.3 Additionally, asthma exacerbations often lead to emergency department visits, with approximately 97,000 Australians presenting with asthma in 2022–2023.7
Asthma-related mortality remains a major concern. In 2023, 474 Australians died from asthma, with females, particularly those aged 75 and over, accounting for 43% of these deaths.8,9
Asthma is a chronic inflammatory airway disorder influenced by both genetic and environmental factors. A family history of asthma significantly increases risk, particularly where first-degree relatives are affected. Genetic variations in interleukin-4, -5, -13, and the beta-adrenergic receptor contribute to Th2-mediated immune responses, leading to eosinophilic inflammation and heightened bronchial reactivity.10
Environmental triggers include allergens (e.g. dust mites, pollen, animal dander) and irritants (e.g. tobacco smoke, air pollution). Infectious triggers commonly include viral respiratory tract infections.1 Urban living and socioeconomic disadvantage, often associated with poor air quality and reduced healthcare access, also contribute to asthma risk.11,12 In utero and childhood exposure to second-hand smoke is an established risk factor for asthma development.13
Asthma is increasingly recognised as a heterogeneous disease, with several phenotypes defined by clinical and inflammatory characteristics. Common phenotypes include allergic (eosinophilic, IgE-mediated), non-allergic (often neutrophilic or paucigranulocytic), late-onset adult asthma, obesity-associated asthma, and asthma with persistent airflow limitation.14 Identifying phenotypes supports individualised treatment strategies, particularly in those with severe asthma, and better long-term outcomes.
The hallmark pathophysiological process is chronic airway inflammation. Upon allergen or irritant exposure, mast cells, eosinophils and T-helper cells release mediators, including histamine, leukotrienes and cytokines. These drive bronchoconstriction, mucus hypersecretion and airway oedema. Long-standing inflammation may lead to structural changes (airway remodelling), including basement membrane thickening and smooth muscle hypertrophy, sustaining airway hyperresponsiveness and fixed airflow obstruction, increasing the risk of asthma-COPD overlap (ACO), particularly among older adults and those with a history of smoking.14–16
Asthma presents with variable symptoms, including wheezing, chest tightness, breathlessness and cough, particularly at night or early morning; however, not all patients with asthma experience all of the above symptoms. Symptoms reflect underlying airway hyperresponsiveness and inflammation and can vary in frequency and severity. Acute exacerbations may involve tachypnoea, prolonged expiration and accessory muscle use.2
Persistent, poorly controlled asthma can result in airway remodelling and progressive lung function decline, underscoring the importance of early diagnosis and proactive management.1,2,15
Atopy is commonly associated with asthma, particularly in childhood-onset disease, and may coexist with other allergic conditions, including eczema and allergic rhinitis.2,10
Thunderstorm asthma refers to the sudden onset of severe asthma symptoms triggered by a combination of high pollen counts, humidity and storm activity, which can cause pollen grains to rupture into smaller particles that are easily inhaled into the lower airways.17
Exercise-induced bronchoconstriction (EIB) is the temporary narrowing of the airways during or after exercise, causing cough, wheeze or breathlessness. It is more common in people with poorly controlled asthma.17 Management includes optimising asthma control with ICS, with low-dose ICS–formoterol now preferred as an AIR or maintenance and reliever therapy (MART) approach. A SABA may be taken 5–15 minutes before exercise but is often no longer needed after several weeks of consistent ICS use.2
Asthma diagnosis relies on a comprehensive assessment, including a detailed history of variable respiratory symptoms along with relevant family history, response to therapy, and objective confirmation of variable airflow limitation.2 Spirometry is the preferred initial test for confirming variable airflow obstruction and reversibility, with an improvement in FEV₁ of ≥12% and ≥200 mL post-bronchodilator supporting the diagnosis.18 However, normal spirometry does not exclude asthma, particularly if the patient is asymptomatic at the time of testing. In such cases, additional tests such as peak expiratory flow (PEF) variability or fractional exhaled nitric oxide (FeNO) may provide further diagnostic evidence.2
Differential diagnoses must be considered, especially in older adults, and include chronic obstructive pulmonary disease (COPD), bronchiectasis, vocal cord dysfunction, cardiac failure and inducible laryngeal obstruction. Accurate diagnosis is critical to ensure appropriate management and avoid misclassification, particularly where ACO is suspected.19
Prognosis is highly variable and depends on factors such as severity, trigger exposure, comorbidities, and medication device technique and adherence. With timely diagnosis, evidence-based treatment and regular review, most patients can achieve good asthma control and a significant reduction in symptoms and exacerbations.20
The 2025 approach to asthma management in adults and adolescents, as outlined by the Australian Asthma Handbook, represents a significant shift from symptom-only treatment to proactive, anti-inflammatory care. The use of SABAs alone is no longer recommended. Instead, all adults and adolescents should receive treatment that includes ICS to target underlying airway inflammation from the outset.2
Step 1: Initial and long-term treatment
The recommended starting point for most patients is as-needed low-dose budesonide–formoterol, a combination ICS–long-acting beta2-agonist (LABA) inhaler used in AIR-only therapy. This dual-purpose inhaler provides both rapid symptom relief and anti-inflammatory action. Formoterol is uniquely suitable for this role due to its rapid onset of action, making it the only LABA approved for use as-needed (PRN).2
Steps 2 and 3: Maintenance and reliever therapy (MART)
If symptoms are more frequent or severe, or the patient is at high risk of exacerbations, treatment should escalate to MART. This involves using a low- or medium-dose ICS–formoterol inhaler for both daily maintenance and as-needed relief (Steps 2 and 3). This simplified regimen improves adherence and ensures consistent anti-inflammatory treatment. Recommended formulations include budesonide–formoterol or beclometasone–formoterol.2
Step 4: Specialist review and targeted therapy
For patients with persistent symptoms despite medium-dose MART, Step 4 involves targeted intensive treatment and specialist referral. Options may include high-dose ICS–LABA, the addition of a long-acting muscarinic antagonist (LAMA), such as tiotropium, or other advanced therapies, including biologics. This level is reserved for those with severe asthma who may benefit from specialist input and a personalised treatment plan.2
Alternative: SABA as reliever
While the recommended approach is the use of ICS–formoterol as both maintenance and reliever, an alternative pathway allows for low-dose ICS (Step 1) or low- to medium-dose ICS–LABA (Steps 2 and 3) maintenance therapy with SABA as the reliever. However, this is less favoured due to delayed anti-inflammatory action during a worsening of symptoms.2
MART with ICS–formoterol reduces the risk of severe exacerbations requiring oral corticosteroids (OCS), hospitalisation or emergency department visit, compared with the same or higher dose of ICS or ICS–LABA.21
Treatment is guided by a stepwise approach. Stepwise medicines adjustment should be carried out under supervision of the prescriber. Before stepping up treatment, clinicians must confirm that2:
Conversely, stepping down should be considered when asthma is well-controlled for 2–3 months, to minimise medication exposure while maintaining control.2
Severe asthma
In cases where asthma remains uncontrolled despite optimal inhaled therapy, or requires frequent OCS, early specialist referral is critical. Patients may be eligible for monoclonal antibody therapies, such as mepolizumab, benralizumab, dupilumab, or omalizumab. These patients must continue inhaled preventer medicines alongside biologics to maintain baseline control.2,17
Oral corticosteroids are reserved for managing acute exacerbations or as a last resort due to their adverse effects.2,17
Effective asthma management relies on timely intervention, ongoing assessment and alignment with current clinical guidelines. Management goals should be tailored in collaboration with the patient, based on recent symptom burden, risk factors and individual preferences.17
Asthma can develop at any age, and a formal diagnosis is essential to guide appropriate management.2
Validated tools such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) can support structured assessment of asthma control.22 According to the Australian Asthma Handbook, well-controlled asthma is defined as having2:
Failure to meet any of these criteria may indicate poor control, warranting further investigation or therapeutic intervention.2,17
Effective self-management is crucial for long-term symptom control. Inhaler technique remains a common barrier, with up to 94% of patients using their devices incorrectly.23 Patients should carry a reliever (budesonide–formoterol or SABA, depending on management) at all times for prompt symptom relief in the event of worsening symptoms or acute episodes.
Comorbid conditions can complicate asthma management. Assess for and help address factors such as allergic rhinitis, which affects up to 80% of people with asthma,24 as well as gastro-oesophageal reflux disease (GORD), anxiety, depression, obstructive sleep apnoea and smoking.
Individuals with asthma are recommended to receive annual influenza and COVID-19 vaccinations, to reduce the risk of respiratory infections that can trigger asthma exacerbations and lead to serious complications. Pneumococcal and RSV vaccines should be considered depending on asthma severity and age of the patient.25,26
Pharmacists should initiate and support informed conversations with patients about changes to asthma management in light of the updated guidelines.
Patients presenting to a pharmacy who use SABA should be referred to their GP or nurse practitioner (NP) for review2; however, they may still access SABAs as a Pharmacist Only medicine when required, especially for acute symptom relief. Reviewing a patient’s dispensing history can help to identify patients in need of a referral to their GP or NP.27 Red flags include frequent SABA use or irregular preventer use, potentially indicating poor adherence or sub-optimal therapy.27 Where practicable, patients should be referred to their GP or NP for a written asthma action plan. Patients should be supported in understanding and using the plan and educated on identifying and avoiding individual triggers.28
Pharmacists should educate patients on correct use of devices, recommend spacers with pressurised metered dose inhalers (pMDIs), and apply ancillary labels, such as Label 130: INHALE SLOW and STEADY or Label 131: INHALE QUICK and DEEP, to prompt regular device checks.27 Simplifying regimens through daily dosing or single-inhaler strategies like MART may enhance adherence.
All patients with asthma should receive asthma first-aid education.29 Pharmacists can also provide balanced information about thunderstorm asthma risks without causing undue alarm.30
Other pharmacy services such as vaccinations, MedsChecks, Home Medicines Reviews (HMRs) and smoking cessation can support asthma management. Structured fee-for-service in-pharmacy clinics like sleep apnoea screening, weight loss programs and allergic rhinitis clinics can address associated broader health needs.
Pharmacists should encourage responsible disposal of expired or unused inhalers through pharmacy return schemes to reduce environmental harm.31 Where clinically appropriate, pharmacists can raise awareness of the environmental impact of pMDIs and suggest that patients discuss the option of switching to a dry powder inhaler (DPI) with their doctor. DPIs generally have a significantly lower carbon footprint.32
These interventions help optimise medicine use, identify barriers to asthma control, and improve clinical outcomes across all age groups.
The updated Australian Asthma Handbook recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation that is the hallmark of asthma.
Patients requesting a SABA in the pharmacy may still access it as a Pharmacist Only medicine. If the SABA is being used as their sole therapy, the patient should be referred to their GP or NP for review and initiation of AIR-only therapy or MART where appropriate. Reliever therapy should not be withheld if required for acute symptom relief, and pharmacists should apply careful clinical judgement in such interactions.
Pharmacists are uniquely positioned to bridge gaps in asthma care, advise on the updated guidelines, particularly at the community level, and reduce asthma morbidity through education and by promoting the quality use of medicines.
Case scenario continuedYou explain to Amir that he should always have a reliever on hand and that he can have salbutamol today. You also explain that the Australian asthma guidelines have recently changed in line with best available evidence. You refer Amir to his GP to ask about anti-inflammatory reliever (AIR) therapy, an asthma review and an asthma action plan. You check Amir’s inhaler technique and recommend a spacer. You also provide education on asthma first aid should Amir experience an episode while he is away. Amir is grateful for your advice. |
Sherri Barden BPharm, FANZCAP (Resp/CommPharm), MPS is a pharmacist and asthma educator with over 30 years of experience in community pharmacy. She founded APLUS Pharmacy Education in 2023 to support pharmacies across Australia in managing asthma, hay fever, eczema and COPD, with an emphasis on improving respiratory health outcomes in the community.
Debbie Rigby BPharm, GradDipClinPharm, AdvPracPharm, AdvDipNutrPharm, FASCP, FPS, CredPharm (MMR), FACP, FAICD, FSHP, FANZCAP
Debbie Rigby is the Clinical Executive Lead of the National Asthma Council Australia. She has received honorariums for presentations, publications, conferences, travel and advisory groups with AstraZeneca, Mundipharma, MSD, Teva, GSK, Menarini, Boehringer Ingelheim, Care Pharmaceuticals, Respiri, Chiesi, Viatris, Moderna and Trudell. She has received honorariums for webinars with HealthEd, ThinkGP and Praxhub education organisations.
[post_title] => Time to vent: changes to asthma management in adults and adolescents [post_excerpt] => The updated Australian Asthma Handbook now recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => time-to-vent-changes-to-asthma-management-in-adults-and-adolescents [to_ping] => [pinged] => [post_modified] => 2025-10-20 15:22:20 [post_modified_gmt] => 2025-10-20 04:22:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30337 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Time to vent: changes to asthma management in adults and adolescents [title] => Time to vent: changes to asthma management in adults and adolescents [href] => https://www.australianpharmacist.com.au/time-to-vent-changes-to-asthma-management-in-adults-and-adolescents/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30649 [authorType] => )
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[post_content] => Half the country has funded the roll out of the intranasal influenza vaccine in 2026.
With a new formulation of the most-administered vaccine by pharmacists on the horizon, pharmacists need to update their vaccination knowledge.
Why introduce an intranasal vaccine?
Needlephobia is a significant deterrent to childhood vaccination. The Royal Children's Hospital (RCH) Melbourne's Child Health Poll found that one in four children aged 4 years or more (27%) has an intense fear of needles, often preventing them from being vaccinated.
The intranasal vaccine, FluMist, also has a higher vaccine coverage rate than traditional injectable flu vaccines, said community pharmacist and PSA’s Vaccination Ambassador Anna Theophilos MPS.
‘Data indicates that [it provides] all-year coverage, as opposed to weaning off after a few months,’ Ms Theophilos said.
Who is the vaccine indicated for?
The intranasal influenza vaccine has been approved by the Therapeutic Goods Administration for children and adolescents between 2–18 years of age.
‘However, it is assumed [the manufacturer] will keep petitioning for greater expansion of the vaccine,’ Ms Theophilos said.
Which jurisdictions have approved it?
At this stage, three states have provided funding to cover the costs of the vaccine for children aged 2 to under 5 from 2026, including:
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[post_content] => The Australian Technical Advisory Group on Immunisation (ATAGI) 2025 statement paints a mixed picture.
While Australia has made important gains with new vaccines and national immunisation reforms, rising cases of pertussis, measles and mpox reveal how fragile protection can be when coverage falters.
Australian Pharmacist explores where progress has been made and where urgent focus is required.
1. Vaccination rates are declining across the board
An ongoing decline in vaccination rates has been identified among all children, adolescents and adults. The steepest and most troubling drop is in childhood vaccination rates at 12 months of age – reducing 3.2 percentage points since 2020. Coverage for children aged 24 months has also dipped below 90% for the first time since 2016. Coverage at 60 months is the highest milestone (92.7%) – indicating that catch-up vaccination is occurring.
Adolescent human papillomavirus (HPV) vaccination rates are also on a downward trend, sitting well below the 90% target at 81.1% in females and 77.9% in males for at least one dose of the vaccine at 15 years of age. Concerningly, the rates are even lower among Aboriginal and Torres Strait Islander people, sitting at 76.7% in females and 69.2% in males.
Uptake of COVID-19 vaccines fell sharply in 2024 across all adult age groups, with only a fraction (2.3%) of younger adults aged 18 to <50 receiving at least one dose of the vaccine. Among those most vulnerable to severe complications, patients aged 75 and older, the vaccination rate dropped from 52.3% to 36.5%.
ATAGI will track declining coverage for selected vaccines to inform additional control strategies, and monitor the effects of schedule changes on coverage and disease – such as the shift to a 1-dose HPV schedule in 2023.
2. Australia’s RSV vaccination campaign is world leading
In 2024, Australia became the first country to put a combined maternal and infant respiratory syncytial virus (RSV) immunisation program in place. Pregnant women were given free access to Abrysvo under the National Immunisation Program (NIP)
from 28 weeks gestation ahead of the 2025 RSV season. Monoclonal antibody nirsevimab is funded for infants under various state and territory arrangements to ensure protection for at-risk infants and/or those whose mother did not receive the vaccine during pregnancy.
These arrangements include:
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[post_content] => PSA has announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education offerings and professional and practice support for members and the pharmacy profession.
PSA’s Board announced negotiations had successfully concluded. While there are still steps to be completed before the settlement, PSA is focused on how the acquisition will strengthen its leadership in education and training for pharmacists, pharmacy assistants, and technicians.
The acquisition allows PSA to grow its industry-leading education and workforce development programs. The PSA Board is confident this is the right path forward for PSA, its members and the broader profession.
National President and Chair of the PSA Board Associate Professor Fei Sim FPS said the agreement was a transformational opportunity for the future of pharmacy education.
‘This agreement is a major milestone in our journey to strengthen and unify pharmacy education in Australia,’ A/Prof Sim said.
‘As the custodian for standards and guidelines for professional practice, the acquisition of the College by the PSA is a further strategic step toward building scale, capability, and capacity for pharmacy education in Australia, amidst the fast-evolving practice landscape.
‘This agreement reflects our shared intent and commitment to invest in the future of the profession and ensure pharmacists, pharmacy assistants, and technicians are supported at every stage of their careers. The acquisition aligns with PSA’s broader strategy to support the profession through a period of significant transformation, including the expansion of scope of practice and increasing demands on the healthcare system.
‘This is about building a stronger, more sustainable future for pharmacy education, so we can do more for our members. As the peak body representing all pharmacists in Australia, PSA continues to represent pharmacists across the profession and their interests, while continuing our commitment to uphold and support high standards of practice.
‘We are proud to lead this work and look forward to continuing to support our members with the highest quality education and professional development.’
PSA will continue to engage with stakeholders throughout the transition process, with a focus on continuity, quality and innovation in education delivery.
[post_title] => PSA to lead unified future for pharmacy education
[post_excerpt] => PSA announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education.
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[post_content] => Serious adverse events in infants prompted the Therapeutic Goods Administration (TGA) to issue a safety alert about prilocaine/lidocaine cream.
The anaesthetic cream, sold under the brand name Emla and various other generics, is typically used for topical anaesthesia of the skin before various minor procedures. It is commonly used prior to circumcision, insertion of catheters and vaccination.
What are the signs and symptoms of overdose?
Prilocaine/lidocaine overdose can lead to methaemoglobinaemia, disrupting haemoglobin’s capacity to carry oxygen. Common symptoms include:
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[post_date_gmt] => 2025-10-12 23:55:03
[post_content] => Case scenario
Amir, a 35-year-old male, presents to the pharmacy requesting a salbutamol inhaler. Upon questioning, he informs you he needs salbutamol for his asthma and has ‘used it since he was a kid’. Amir says his asthma has been well controlled of late and that it only flares with a chest infection and when he gets hay fever. He states he would like to have the salbutamol as he is going away and wants to have one on hand. He is on no other asthma medicines and has only used salbutamol twice in the past month.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
The Global Initiative for Asthma (GINA) strategy defines asthma as ‘a heterogeneous disease, usually characterised by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation’.1
In 2019, GINA comprehensively revised its recommendations for asthma management. This was based on its committee of asthma experts reviewing the evidence. Asthma guidelines from the National Asthma Council Australia (NAC) have now followed suit, and the NAC’s updated Australian Asthma Handbook states that short-acting beta2-agonists (SABA), such as salbutamol, are no longer recommended as sole therapy for asthma in adults and adolescents. The NAC now recommends anti-inflammatory reliever (AIR) therapy as needed from day one when it comes to asthma treatment in adults and adolescents.2 AIR-only therapy refers to the as-needed use of a low-dose inhaled corticosteroid (ICS)–formoterol combination, budesonide–formoterol, to provide both symptom relief and anti-inflammatory action.1
According to Asthma Australia, over 90% of asthma-related hospitalisations in 2022–23 were potentially preventable with optimised care in the community.3,4 This powerful statistic underscores the critical role pharmacists can play in reducing asthma morbidity through education, medicines management, and promoting adherence to treatment.
Asthma is a significant health concern in Australia, reported to affect nearly 2.8 million individuals (1 in 9 Australians) as at 2022.5 The prevalence of asthma is higher in certain demographic groups, such as Aboriginal and Torres Strait Islander peoples, who report asthma rates of 16%.6
Hospitalisation rates related to asthma have increased in recent years, with over 31,000 hospital admissions recorded in 2022–2023.3 Additionally, asthma exacerbations often lead to emergency department visits, with approximately 97,000 Australians presenting with asthma in 2022–2023.7
Asthma-related mortality remains a major concern. In 2023, 474 Australians died from asthma, with females, particularly those aged 75 and over, accounting for 43% of these deaths.8,9
Asthma is a chronic inflammatory airway disorder influenced by both genetic and environmental factors. A family history of asthma significantly increases risk, particularly where first-degree relatives are affected. Genetic variations in interleukin-4, -5, -13, and the beta-adrenergic receptor contribute to Th2-mediated immune responses, leading to eosinophilic inflammation and heightened bronchial reactivity.10
Environmental triggers include allergens (e.g. dust mites, pollen, animal dander) and irritants (e.g. tobacco smoke, air pollution). Infectious triggers commonly include viral respiratory tract infections.1 Urban living and socioeconomic disadvantage, often associated with poor air quality and reduced healthcare access, also contribute to asthma risk.11,12 In utero and childhood exposure to second-hand smoke is an established risk factor for asthma development.13
Asthma is increasingly recognised as a heterogeneous disease, with several phenotypes defined by clinical and inflammatory characteristics. Common phenotypes include allergic (eosinophilic, IgE-mediated), non-allergic (often neutrophilic or paucigranulocytic), late-onset adult asthma, obesity-associated asthma, and asthma with persistent airflow limitation.14 Identifying phenotypes supports individualised treatment strategies, particularly in those with severe asthma, and better long-term outcomes.
The hallmark pathophysiological process is chronic airway inflammation. Upon allergen or irritant exposure, mast cells, eosinophils and T-helper cells release mediators, including histamine, leukotrienes and cytokines. These drive bronchoconstriction, mucus hypersecretion and airway oedema. Long-standing inflammation may lead to structural changes (airway remodelling), including basement membrane thickening and smooth muscle hypertrophy, sustaining airway hyperresponsiveness and fixed airflow obstruction, increasing the risk of asthma-COPD overlap (ACO), particularly among older adults and those with a history of smoking.14–16
Asthma presents with variable symptoms, including wheezing, chest tightness, breathlessness and cough, particularly at night or early morning; however, not all patients with asthma experience all of the above symptoms. Symptoms reflect underlying airway hyperresponsiveness and inflammation and can vary in frequency and severity. Acute exacerbations may involve tachypnoea, prolonged expiration and accessory muscle use.2
Persistent, poorly controlled asthma can result in airway remodelling and progressive lung function decline, underscoring the importance of early diagnosis and proactive management.1,2,15
Atopy is commonly associated with asthma, particularly in childhood-onset disease, and may coexist with other allergic conditions, including eczema and allergic rhinitis.2,10
Thunderstorm asthma refers to the sudden onset of severe asthma symptoms triggered by a combination of high pollen counts, humidity and storm activity, which can cause pollen grains to rupture into smaller particles that are easily inhaled into the lower airways.17
Exercise-induced bronchoconstriction (EIB) is the temporary narrowing of the airways during or after exercise, causing cough, wheeze or breathlessness. It is more common in people with poorly controlled asthma.17 Management includes optimising asthma control with ICS, with low-dose ICS–formoterol now preferred as an AIR or maintenance and reliever therapy (MART) approach. A SABA may be taken 5–15 minutes before exercise but is often no longer needed after several weeks of consistent ICS use.2
Asthma diagnosis relies on a comprehensive assessment, including a detailed history of variable respiratory symptoms along with relevant family history, response to therapy, and objective confirmation of variable airflow limitation.2 Spirometry is the preferred initial test for confirming variable airflow obstruction and reversibility, with an improvement in FEV₁ of ≥12% and ≥200 mL post-bronchodilator supporting the diagnosis.18 However, normal spirometry does not exclude asthma, particularly if the patient is asymptomatic at the time of testing. In such cases, additional tests such as peak expiratory flow (PEF) variability or fractional exhaled nitric oxide (FeNO) may provide further diagnostic evidence.2
Differential diagnoses must be considered, especially in older adults, and include chronic obstructive pulmonary disease (COPD), bronchiectasis, vocal cord dysfunction, cardiac failure and inducible laryngeal obstruction. Accurate diagnosis is critical to ensure appropriate management and avoid misclassification, particularly where ACO is suspected.19
Prognosis is highly variable and depends on factors such as severity, trigger exposure, comorbidities, and medication device technique and adherence. With timely diagnosis, evidence-based treatment and regular review, most patients can achieve good asthma control and a significant reduction in symptoms and exacerbations.20
The 2025 approach to asthma management in adults and adolescents, as outlined by the Australian Asthma Handbook, represents a significant shift from symptom-only treatment to proactive, anti-inflammatory care. The use of SABAs alone is no longer recommended. Instead, all adults and adolescents should receive treatment that includes ICS to target underlying airway inflammation from the outset.2
Step 1: Initial and long-term treatment
The recommended starting point for most patients is as-needed low-dose budesonide–formoterol, a combination ICS–long-acting beta2-agonist (LABA) inhaler used in AIR-only therapy. This dual-purpose inhaler provides both rapid symptom relief and anti-inflammatory action. Formoterol is uniquely suitable for this role due to its rapid onset of action, making it the only LABA approved for use as-needed (PRN).2
Steps 2 and 3: Maintenance and reliever therapy (MART)
If symptoms are more frequent or severe, or the patient is at high risk of exacerbations, treatment should escalate to MART. This involves using a low- or medium-dose ICS–formoterol inhaler for both daily maintenance and as-needed relief (Steps 2 and 3). This simplified regimen improves adherence and ensures consistent anti-inflammatory treatment. Recommended formulations include budesonide–formoterol or beclometasone–formoterol.2
Step 4: Specialist review and targeted therapy
For patients with persistent symptoms despite medium-dose MART, Step 4 involves targeted intensive treatment and specialist referral. Options may include high-dose ICS–LABA, the addition of a long-acting muscarinic antagonist (LAMA), such as tiotropium, or other advanced therapies, including biologics. This level is reserved for those with severe asthma who may benefit from specialist input and a personalised treatment plan.2
Alternative: SABA as reliever
While the recommended approach is the use of ICS–formoterol as both maintenance and reliever, an alternative pathway allows for low-dose ICS (Step 1) or low- to medium-dose ICS–LABA (Steps 2 and 3) maintenance therapy with SABA as the reliever. However, this is less favoured due to delayed anti-inflammatory action during a worsening of symptoms.2
MART with ICS–formoterol reduces the risk of severe exacerbations requiring oral corticosteroids (OCS), hospitalisation or emergency department visit, compared with the same or higher dose of ICS or ICS–LABA.21
Treatment is guided by a stepwise approach. Stepwise medicines adjustment should be carried out under supervision of the prescriber. Before stepping up treatment, clinicians must confirm that2:
Conversely, stepping down should be considered when asthma is well-controlled for 2–3 months, to minimise medication exposure while maintaining control.2
Severe asthma
In cases where asthma remains uncontrolled despite optimal inhaled therapy, or requires frequent OCS, early specialist referral is critical. Patients may be eligible for monoclonal antibody therapies, such as mepolizumab, benralizumab, dupilumab, or omalizumab. These patients must continue inhaled preventer medicines alongside biologics to maintain baseline control.2,17
Oral corticosteroids are reserved for managing acute exacerbations or as a last resort due to their adverse effects.2,17
Effective asthma management relies on timely intervention, ongoing assessment and alignment with current clinical guidelines. Management goals should be tailored in collaboration with the patient, based on recent symptom burden, risk factors and individual preferences.17
Asthma can develop at any age, and a formal diagnosis is essential to guide appropriate management.2
Validated tools such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) can support structured assessment of asthma control.22 According to the Australian Asthma Handbook, well-controlled asthma is defined as having2:
Failure to meet any of these criteria may indicate poor control, warranting further investigation or therapeutic intervention.2,17
Effective self-management is crucial for long-term symptom control. Inhaler technique remains a common barrier, with up to 94% of patients using their devices incorrectly.23 Patients should carry a reliever (budesonide–formoterol or SABA, depending on management) at all times for prompt symptom relief in the event of worsening symptoms or acute episodes.
Comorbid conditions can complicate asthma management. Assess for and help address factors such as allergic rhinitis, which affects up to 80% of people with asthma,24 as well as gastro-oesophageal reflux disease (GORD), anxiety, depression, obstructive sleep apnoea and smoking.
Individuals with asthma are recommended to receive annual influenza and COVID-19 vaccinations, to reduce the risk of respiratory infections that can trigger asthma exacerbations and lead to serious complications. Pneumococcal and RSV vaccines should be considered depending on asthma severity and age of the patient.25,26
Pharmacists should initiate and support informed conversations with patients about changes to asthma management in light of the updated guidelines.
Patients presenting to a pharmacy who use SABA should be referred to their GP or nurse practitioner (NP) for review2; however, they may still access SABAs as a Pharmacist Only medicine when required, especially for acute symptom relief. Reviewing a patient’s dispensing history can help to identify patients in need of a referral to their GP or NP.27 Red flags include frequent SABA use or irregular preventer use, potentially indicating poor adherence or sub-optimal therapy.27 Where practicable, patients should be referred to their GP or NP for a written asthma action plan. Patients should be supported in understanding and using the plan and educated on identifying and avoiding individual triggers.28
Pharmacists should educate patients on correct use of devices, recommend spacers with pressurised metered dose inhalers (pMDIs), and apply ancillary labels, such as Label 130: INHALE SLOW and STEADY or Label 131: INHALE QUICK and DEEP, to prompt regular device checks.27 Simplifying regimens through daily dosing or single-inhaler strategies like MART may enhance adherence.
All patients with asthma should receive asthma first-aid education.29 Pharmacists can also provide balanced information about thunderstorm asthma risks without causing undue alarm.30
Other pharmacy services such as vaccinations, MedsChecks, Home Medicines Reviews (HMRs) and smoking cessation can support asthma management. Structured fee-for-service in-pharmacy clinics like sleep apnoea screening, weight loss programs and allergic rhinitis clinics can address associated broader health needs.
Pharmacists should encourage responsible disposal of expired or unused inhalers through pharmacy return schemes to reduce environmental harm.31 Where clinically appropriate, pharmacists can raise awareness of the environmental impact of pMDIs and suggest that patients discuss the option of switching to a dry powder inhaler (DPI) with their doctor. DPIs generally have a significantly lower carbon footprint.32
These interventions help optimise medicine use, identify barriers to asthma control, and improve clinical outcomes across all age groups.
The updated Australian Asthma Handbook recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation that is the hallmark of asthma.
Patients requesting a SABA in the pharmacy may still access it as a Pharmacist Only medicine. If the SABA is being used as their sole therapy, the patient should be referred to their GP or NP for review and initiation of AIR-only therapy or MART where appropriate. Reliever therapy should not be withheld if required for acute symptom relief, and pharmacists should apply careful clinical judgement in such interactions.
Pharmacists are uniquely positioned to bridge gaps in asthma care, advise on the updated guidelines, particularly at the community level, and reduce asthma morbidity through education and by promoting the quality use of medicines.
Case scenario continuedYou explain to Amir that he should always have a reliever on hand and that he can have salbutamol today. You also explain that the Australian asthma guidelines have recently changed in line with best available evidence. You refer Amir to his GP to ask about anti-inflammatory reliever (AIR) therapy, an asthma review and an asthma action plan. You check Amir’s inhaler technique and recommend a spacer. You also provide education on asthma first aid should Amir experience an episode while he is away. Amir is grateful for your advice. |
Sherri Barden BPharm, FANZCAP (Resp/CommPharm), MPS is a pharmacist and asthma educator with over 30 years of experience in community pharmacy. She founded APLUS Pharmacy Education in 2023 to support pharmacies across Australia in managing asthma, hay fever, eczema and COPD, with an emphasis on improving respiratory health outcomes in the community.
Debbie Rigby BPharm, GradDipClinPharm, AdvPracPharm, AdvDipNutrPharm, FASCP, FPS, CredPharm (MMR), FACP, FAICD, FSHP, FANZCAP
Debbie Rigby is the Clinical Executive Lead of the National Asthma Council Australia. She has received honorariums for presentations, publications, conferences, travel and advisory groups with AstraZeneca, Mundipharma, MSD, Teva, GSK, Menarini, Boehringer Ingelheim, Care Pharmaceuticals, Respiri, Chiesi, Viatris, Moderna and Trudell. She has received honorariums for webinars with HealthEd, ThinkGP and Praxhub education organisations.
[post_title] => Time to vent: changes to asthma management in adults and adolescents [post_excerpt] => The updated Australian Asthma Handbook now recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => time-to-vent-changes-to-asthma-management-in-adults-and-adolescents [to_ping] => [pinged] => [post_modified] => 2025-10-20 15:22:20 [post_modified_gmt] => 2025-10-20 04:22:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30337 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Time to vent: changes to asthma management in adults and adolescents [title] => Time to vent: changes to asthma management in adults and adolescents [href] => https://www.australianpharmacist.com.au/time-to-vent-changes-to-asthma-management-in-adults-and-adolescents/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30649 [authorType] => )td_module_mega_menu Object
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[post_content] => Half the country has funded the roll out of the intranasal influenza vaccine in 2026.
With a new formulation of the most-administered vaccine by pharmacists on the horizon, pharmacists need to update their vaccination knowledge.
Why introduce an intranasal vaccine?
Needlephobia is a significant deterrent to childhood vaccination. The Royal Children's Hospital (RCH) Melbourne's Child Health Poll found that one in four children aged 4 years or more (27%) has an intense fear of needles, often preventing them from being vaccinated.
The intranasal vaccine, FluMist, also has a higher vaccine coverage rate than traditional injectable flu vaccines, said community pharmacist and PSA’s Vaccination Ambassador Anna Theophilos MPS.
‘Data indicates that [it provides] all-year coverage, as opposed to weaning off after a few months,’ Ms Theophilos said.
Who is the vaccine indicated for?
The intranasal influenza vaccine has been approved by the Therapeutic Goods Administration for children and adolescents between 2–18 years of age.
‘However, it is assumed [the manufacturer] will keep petitioning for greater expansion of the vaccine,’ Ms Theophilos said.
Which jurisdictions have approved it?
At this stage, three states have provided funding to cover the costs of the vaccine for children aged 2 to under 5 from 2026, including:
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[post_content] => The Australian Technical Advisory Group on Immunisation (ATAGI) 2025 statement paints a mixed picture.
While Australia has made important gains with new vaccines and national immunisation reforms, rising cases of pertussis, measles and mpox reveal how fragile protection can be when coverage falters.
Australian Pharmacist explores where progress has been made and where urgent focus is required.
1. Vaccination rates are declining across the board
An ongoing decline in vaccination rates has been identified among all children, adolescents and adults. The steepest and most troubling drop is in childhood vaccination rates at 12 months of age – reducing 3.2 percentage points since 2020. Coverage for children aged 24 months has also dipped below 90% for the first time since 2016. Coverage at 60 months is the highest milestone (92.7%) – indicating that catch-up vaccination is occurring.
Adolescent human papillomavirus (HPV) vaccination rates are also on a downward trend, sitting well below the 90% target at 81.1% in females and 77.9% in males for at least one dose of the vaccine at 15 years of age. Concerningly, the rates are even lower among Aboriginal and Torres Strait Islander people, sitting at 76.7% in females and 69.2% in males.
Uptake of COVID-19 vaccines fell sharply in 2024 across all adult age groups, with only a fraction (2.3%) of younger adults aged 18 to <50 receiving at least one dose of the vaccine. Among those most vulnerable to severe complications, patients aged 75 and older, the vaccination rate dropped from 52.3% to 36.5%.
ATAGI will track declining coverage for selected vaccines to inform additional control strategies, and monitor the effects of schedule changes on coverage and disease – such as the shift to a 1-dose HPV schedule in 2023.
2. Australia’s RSV vaccination campaign is world leading
In 2024, Australia became the first country to put a combined maternal and infant respiratory syncytial virus (RSV) immunisation program in place. Pregnant women were given free access to Abrysvo under the National Immunisation Program (NIP)
from 28 weeks gestation ahead of the 2025 RSV season. Monoclonal antibody nirsevimab is funded for infants under various state and territory arrangements to ensure protection for at-risk infants and/or those whose mother did not receive the vaccine during pregnancy.
These arrangements include:
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[post_content] => PSA has announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education offerings and professional and practice support for members and the pharmacy profession.
PSA’s Board announced negotiations had successfully concluded. While there are still steps to be completed before the settlement, PSA is focused on how the acquisition will strengthen its leadership in education and training for pharmacists, pharmacy assistants, and technicians.
The acquisition allows PSA to grow its industry-leading education and workforce development programs. The PSA Board is confident this is the right path forward for PSA, its members and the broader profession.
National President and Chair of the PSA Board Associate Professor Fei Sim FPS said the agreement was a transformational opportunity for the future of pharmacy education.
‘This agreement is a major milestone in our journey to strengthen and unify pharmacy education in Australia,’ A/Prof Sim said.
‘As the custodian for standards and guidelines for professional practice, the acquisition of the College by the PSA is a further strategic step toward building scale, capability, and capacity for pharmacy education in Australia, amidst the fast-evolving practice landscape.
‘This agreement reflects our shared intent and commitment to invest in the future of the profession and ensure pharmacists, pharmacy assistants, and technicians are supported at every stage of their careers. The acquisition aligns with PSA’s broader strategy to support the profession through a period of significant transformation, including the expansion of scope of practice and increasing demands on the healthcare system.
‘This is about building a stronger, more sustainable future for pharmacy education, so we can do more for our members. As the peak body representing all pharmacists in Australia, PSA continues to represent pharmacists across the profession and their interests, while continuing our commitment to uphold and support high standards of practice.
‘We are proud to lead this work and look forward to continuing to support our members with the highest quality education and professional development.’
PSA will continue to engage with stakeholders throughout the transition process, with a focus on continuity, quality and innovation in education delivery.
[post_title] => PSA to lead unified future for pharmacy education
[post_excerpt] => PSA announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education.
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[post_content] => Serious adverse events in infants prompted the Therapeutic Goods Administration (TGA) to issue a safety alert about prilocaine/lidocaine cream.
The anaesthetic cream, sold under the brand name Emla and various other generics, is typically used for topical anaesthesia of the skin before various minor procedures. It is commonly used prior to circumcision, insertion of catheters and vaccination.
What are the signs and symptoms of overdose?
Prilocaine/lidocaine overdose can lead to methaemoglobinaemia, disrupting haemoglobin’s capacity to carry oxygen. Common symptoms include:
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[post_content] => Case scenario
Amir, a 35-year-old male, presents to the pharmacy requesting a salbutamol inhaler. Upon questioning, he informs you he needs salbutamol for his asthma and has ‘used it since he was a kid’. Amir says his asthma has been well controlled of late and that it only flares with a chest infection and when he gets hay fever. He states he would like to have the salbutamol as he is going away and wants to have one on hand. He is on no other asthma medicines and has only used salbutamol twice in the past month.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
The Global Initiative for Asthma (GINA) strategy defines asthma as ‘a heterogeneous disease, usually characterised by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation’.1
In 2019, GINA comprehensively revised its recommendations for asthma management. This was based on its committee of asthma experts reviewing the evidence. Asthma guidelines from the National Asthma Council Australia (NAC) have now followed suit, and the NAC’s updated Australian Asthma Handbook states that short-acting beta2-agonists (SABA), such as salbutamol, are no longer recommended as sole therapy for asthma in adults and adolescents. The NAC now recommends anti-inflammatory reliever (AIR) therapy as needed from day one when it comes to asthma treatment in adults and adolescents.2 AIR-only therapy refers to the as-needed use of a low-dose inhaled corticosteroid (ICS)–formoterol combination, budesonide–formoterol, to provide both symptom relief and anti-inflammatory action.1
According to Asthma Australia, over 90% of asthma-related hospitalisations in 2022–23 were potentially preventable with optimised care in the community.3,4 This powerful statistic underscores the critical role pharmacists can play in reducing asthma morbidity through education, medicines management, and promoting adherence to treatment.
Asthma is a significant health concern in Australia, reported to affect nearly 2.8 million individuals (1 in 9 Australians) as at 2022.5 The prevalence of asthma is higher in certain demographic groups, such as Aboriginal and Torres Strait Islander peoples, who report asthma rates of 16%.6
Hospitalisation rates related to asthma have increased in recent years, with over 31,000 hospital admissions recorded in 2022–2023.3 Additionally, asthma exacerbations often lead to emergency department visits, with approximately 97,000 Australians presenting with asthma in 2022–2023.7
Asthma-related mortality remains a major concern. In 2023, 474 Australians died from asthma, with females, particularly those aged 75 and over, accounting for 43% of these deaths.8,9
Asthma is a chronic inflammatory airway disorder influenced by both genetic and environmental factors. A family history of asthma significantly increases risk, particularly where first-degree relatives are affected. Genetic variations in interleukin-4, -5, -13, and the beta-adrenergic receptor contribute to Th2-mediated immune responses, leading to eosinophilic inflammation and heightened bronchial reactivity.10
Environmental triggers include allergens (e.g. dust mites, pollen, animal dander) and irritants (e.g. tobacco smoke, air pollution). Infectious triggers commonly include viral respiratory tract infections.1 Urban living and socioeconomic disadvantage, often associated with poor air quality and reduced healthcare access, also contribute to asthma risk.11,12 In utero and childhood exposure to second-hand smoke is an established risk factor for asthma development.13
Asthma is increasingly recognised as a heterogeneous disease, with several phenotypes defined by clinical and inflammatory characteristics. Common phenotypes include allergic (eosinophilic, IgE-mediated), non-allergic (often neutrophilic or paucigranulocytic), late-onset adult asthma, obesity-associated asthma, and asthma with persistent airflow limitation.14 Identifying phenotypes supports individualised treatment strategies, particularly in those with severe asthma, and better long-term outcomes.
The hallmark pathophysiological process is chronic airway inflammation. Upon allergen or irritant exposure, mast cells, eosinophils and T-helper cells release mediators, including histamine, leukotrienes and cytokines. These drive bronchoconstriction, mucus hypersecretion and airway oedema. Long-standing inflammation may lead to structural changes (airway remodelling), including basement membrane thickening and smooth muscle hypertrophy, sustaining airway hyperresponsiveness and fixed airflow obstruction, increasing the risk of asthma-COPD overlap (ACO), particularly among older adults and those with a history of smoking.14–16
Asthma presents with variable symptoms, including wheezing, chest tightness, breathlessness and cough, particularly at night or early morning; however, not all patients with asthma experience all of the above symptoms. Symptoms reflect underlying airway hyperresponsiveness and inflammation and can vary in frequency and severity. Acute exacerbations may involve tachypnoea, prolonged expiration and accessory muscle use.2
Persistent, poorly controlled asthma can result in airway remodelling and progressive lung function decline, underscoring the importance of early diagnosis and proactive management.1,2,15
Atopy is commonly associated with asthma, particularly in childhood-onset disease, and may coexist with other allergic conditions, including eczema and allergic rhinitis.2,10
Thunderstorm asthma refers to the sudden onset of severe asthma symptoms triggered by a combination of high pollen counts, humidity and storm activity, which can cause pollen grains to rupture into smaller particles that are easily inhaled into the lower airways.17
Exercise-induced bronchoconstriction (EIB) is the temporary narrowing of the airways during or after exercise, causing cough, wheeze or breathlessness. It is more common in people with poorly controlled asthma.17 Management includes optimising asthma control with ICS, with low-dose ICS–formoterol now preferred as an AIR or maintenance and reliever therapy (MART) approach. A SABA may be taken 5–15 minutes before exercise but is often no longer needed after several weeks of consistent ICS use.2
Asthma diagnosis relies on a comprehensive assessment, including a detailed history of variable respiratory symptoms along with relevant family history, response to therapy, and objective confirmation of variable airflow limitation.2 Spirometry is the preferred initial test for confirming variable airflow obstruction and reversibility, with an improvement in FEV₁ of ≥12% and ≥200 mL post-bronchodilator supporting the diagnosis.18 However, normal spirometry does not exclude asthma, particularly if the patient is asymptomatic at the time of testing. In such cases, additional tests such as peak expiratory flow (PEF) variability or fractional exhaled nitric oxide (FeNO) may provide further diagnostic evidence.2
Differential diagnoses must be considered, especially in older adults, and include chronic obstructive pulmonary disease (COPD), bronchiectasis, vocal cord dysfunction, cardiac failure and inducible laryngeal obstruction. Accurate diagnosis is critical to ensure appropriate management and avoid misclassification, particularly where ACO is suspected.19
Prognosis is highly variable and depends on factors such as severity, trigger exposure, comorbidities, and medication device technique and adherence. With timely diagnosis, evidence-based treatment and regular review, most patients can achieve good asthma control and a significant reduction in symptoms and exacerbations.20
The 2025 approach to asthma management in adults and adolescents, as outlined by the Australian Asthma Handbook, represents a significant shift from symptom-only treatment to proactive, anti-inflammatory care. The use of SABAs alone is no longer recommended. Instead, all adults and adolescents should receive treatment that includes ICS to target underlying airway inflammation from the outset.2
Step 1: Initial and long-term treatment
The recommended starting point for most patients is as-needed low-dose budesonide–formoterol, a combination ICS–long-acting beta2-agonist (LABA) inhaler used in AIR-only therapy. This dual-purpose inhaler provides both rapid symptom relief and anti-inflammatory action. Formoterol is uniquely suitable for this role due to its rapid onset of action, making it the only LABA approved for use as-needed (PRN).2
Steps 2 and 3: Maintenance and reliever therapy (MART)
If symptoms are more frequent or severe, or the patient is at high risk of exacerbations, treatment should escalate to MART. This involves using a low- or medium-dose ICS–formoterol inhaler for both daily maintenance and as-needed relief (Steps 2 and 3). This simplified regimen improves adherence and ensures consistent anti-inflammatory treatment. Recommended formulations include budesonide–formoterol or beclometasone–formoterol.2
Step 4: Specialist review and targeted therapy
For patients with persistent symptoms despite medium-dose MART, Step 4 involves targeted intensive treatment and specialist referral. Options may include high-dose ICS–LABA, the addition of a long-acting muscarinic antagonist (LAMA), such as tiotropium, or other advanced therapies, including biologics. This level is reserved for those with severe asthma who may benefit from specialist input and a personalised treatment plan.2
Alternative: SABA as reliever
While the recommended approach is the use of ICS–formoterol as both maintenance and reliever, an alternative pathway allows for low-dose ICS (Step 1) or low- to medium-dose ICS–LABA (Steps 2 and 3) maintenance therapy with SABA as the reliever. However, this is less favoured due to delayed anti-inflammatory action during a worsening of symptoms.2
MART with ICS–formoterol reduces the risk of severe exacerbations requiring oral corticosteroids (OCS), hospitalisation or emergency department visit, compared with the same or higher dose of ICS or ICS–LABA.21
Treatment is guided by a stepwise approach. Stepwise medicines adjustment should be carried out under supervision of the prescriber. Before stepping up treatment, clinicians must confirm that2:
Conversely, stepping down should be considered when asthma is well-controlled for 2–3 months, to minimise medication exposure while maintaining control.2
Severe asthma
In cases where asthma remains uncontrolled despite optimal inhaled therapy, or requires frequent OCS, early specialist referral is critical. Patients may be eligible for monoclonal antibody therapies, such as mepolizumab, benralizumab, dupilumab, or omalizumab. These patients must continue inhaled preventer medicines alongside biologics to maintain baseline control.2,17
Oral corticosteroids are reserved for managing acute exacerbations or as a last resort due to their adverse effects.2,17
Effective asthma management relies on timely intervention, ongoing assessment and alignment with current clinical guidelines. Management goals should be tailored in collaboration with the patient, based on recent symptom burden, risk factors and individual preferences.17
Asthma can develop at any age, and a formal diagnosis is essential to guide appropriate management.2
Validated tools such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) can support structured assessment of asthma control.22 According to the Australian Asthma Handbook, well-controlled asthma is defined as having2:
Failure to meet any of these criteria may indicate poor control, warranting further investigation or therapeutic intervention.2,17
Effective self-management is crucial for long-term symptom control. Inhaler technique remains a common barrier, with up to 94% of patients using their devices incorrectly.23 Patients should carry a reliever (budesonide–formoterol or SABA, depending on management) at all times for prompt symptom relief in the event of worsening symptoms or acute episodes.
Comorbid conditions can complicate asthma management. Assess for and help address factors such as allergic rhinitis, which affects up to 80% of people with asthma,24 as well as gastro-oesophageal reflux disease (GORD), anxiety, depression, obstructive sleep apnoea and smoking.
Individuals with asthma are recommended to receive annual influenza and COVID-19 vaccinations, to reduce the risk of respiratory infections that can trigger asthma exacerbations and lead to serious complications. Pneumococcal and RSV vaccines should be considered depending on asthma severity and age of the patient.25,26
Pharmacists should initiate and support informed conversations with patients about changes to asthma management in light of the updated guidelines.
Patients presenting to a pharmacy who use SABA should be referred to their GP or nurse practitioner (NP) for review2; however, they may still access SABAs as a Pharmacist Only medicine when required, especially for acute symptom relief. Reviewing a patient’s dispensing history can help to identify patients in need of a referral to their GP or NP.27 Red flags include frequent SABA use or irregular preventer use, potentially indicating poor adherence or sub-optimal therapy.27 Where practicable, patients should be referred to their GP or NP for a written asthma action plan. Patients should be supported in understanding and using the plan and educated on identifying and avoiding individual triggers.28
Pharmacists should educate patients on correct use of devices, recommend spacers with pressurised metered dose inhalers (pMDIs), and apply ancillary labels, such as Label 130: INHALE SLOW and STEADY or Label 131: INHALE QUICK and DEEP, to prompt regular device checks.27 Simplifying regimens through daily dosing or single-inhaler strategies like MART may enhance adherence.
All patients with asthma should receive asthma first-aid education.29 Pharmacists can also provide balanced information about thunderstorm asthma risks without causing undue alarm.30
Other pharmacy services such as vaccinations, MedsChecks, Home Medicines Reviews (HMRs) and smoking cessation can support asthma management. Structured fee-for-service in-pharmacy clinics like sleep apnoea screening, weight loss programs and allergic rhinitis clinics can address associated broader health needs.
Pharmacists should encourage responsible disposal of expired or unused inhalers through pharmacy return schemes to reduce environmental harm.31 Where clinically appropriate, pharmacists can raise awareness of the environmental impact of pMDIs and suggest that patients discuss the option of switching to a dry powder inhaler (DPI) with their doctor. DPIs generally have a significantly lower carbon footprint.32
These interventions help optimise medicine use, identify barriers to asthma control, and improve clinical outcomes across all age groups.
The updated Australian Asthma Handbook recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation that is the hallmark of asthma.
Patients requesting a SABA in the pharmacy may still access it as a Pharmacist Only medicine. If the SABA is being used as their sole therapy, the patient should be referred to their GP or NP for review and initiation of AIR-only therapy or MART where appropriate. Reliever therapy should not be withheld if required for acute symptom relief, and pharmacists should apply careful clinical judgement in such interactions.
Pharmacists are uniquely positioned to bridge gaps in asthma care, advise on the updated guidelines, particularly at the community level, and reduce asthma morbidity through education and by promoting the quality use of medicines.
Case scenario continuedYou explain to Amir that he should always have a reliever on hand and that he can have salbutamol today. You also explain that the Australian asthma guidelines have recently changed in line with best available evidence. You refer Amir to his GP to ask about anti-inflammatory reliever (AIR) therapy, an asthma review and an asthma action plan. You check Amir’s inhaler technique and recommend a spacer. You also provide education on asthma first aid should Amir experience an episode while he is away. Amir is grateful for your advice. |
Sherri Barden BPharm, FANZCAP (Resp/CommPharm), MPS is a pharmacist and asthma educator with over 30 years of experience in community pharmacy. She founded APLUS Pharmacy Education in 2023 to support pharmacies across Australia in managing asthma, hay fever, eczema and COPD, with an emphasis on improving respiratory health outcomes in the community.
Debbie Rigby BPharm, GradDipClinPharm, AdvPracPharm, AdvDipNutrPharm, FASCP, FPS, CredPharm (MMR), FACP, FAICD, FSHP, FANZCAP
Debbie Rigby is the Clinical Executive Lead of the National Asthma Council Australia. She has received honorariums for presentations, publications, conferences, travel and advisory groups with AstraZeneca, Mundipharma, MSD, Teva, GSK, Menarini, Boehringer Ingelheim, Care Pharmaceuticals, Respiri, Chiesi, Viatris, Moderna and Trudell. She has received honorariums for webinars with HealthEd, ThinkGP and Praxhub education organisations.
[post_title] => Time to vent: changes to asthma management in adults and adolescents [post_excerpt] => The updated Australian Asthma Handbook now recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation. [post_status] => publish [comment_status] => open [ping_status] => open [post_password] => [post_name] => time-to-vent-changes-to-asthma-management-in-adults-and-adolescents [to_ping] => [pinged] => [post_modified] => 2025-10-20 15:22:20 [post_modified_gmt] => 2025-10-20 04:22:20 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.australianpharmacist.com.au/?p=30337 [menu_order] => 0 [post_type] => post [post_mime_type] => [comment_count] => 0 [filter] => raw ) [title_attribute] => Time to vent: changes to asthma management in adults and adolescents [title] => Time to vent: changes to asthma management in adults and adolescents [href] => https://www.australianpharmacist.com.au/time-to-vent-changes-to-asthma-management-in-adults-and-adolescents/ [module_atts:td_module:private] => Array ( ) [td_review:protected] => Array ( [td_post_template] => single_template_4 ) [is_review:protected] => [post_thumb_id:protected] => 30649 [authorType] => )td_module_mega_menu Object
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[post_content] => Half the country has funded the roll out of the intranasal influenza vaccine in 2026.
With a new formulation of the most-administered vaccine by pharmacists on the horizon, pharmacists need to update their vaccination knowledge.
Why introduce an intranasal vaccine?
Needlephobia is a significant deterrent to childhood vaccination. The Royal Children's Hospital (RCH) Melbourne's Child Health Poll found that one in four children aged 4 years or more (27%) has an intense fear of needles, often preventing them from being vaccinated.
The intranasal vaccine, FluMist, also has a higher vaccine coverage rate than traditional injectable flu vaccines, said community pharmacist and PSA’s Vaccination Ambassador Anna Theophilos MPS.
‘Data indicates that [it provides] all-year coverage, as opposed to weaning off after a few months,’ Ms Theophilos said.
Who is the vaccine indicated for?
The intranasal influenza vaccine has been approved by the Therapeutic Goods Administration for children and adolescents between 2–18 years of age.
‘However, it is assumed [the manufacturer] will keep petitioning for greater expansion of the vaccine,’ Ms Theophilos said.
Which jurisdictions have approved it?
At this stage, three states have provided funding to cover the costs of the vaccine for children aged 2 to under 5 from 2026, including:
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[post_content] => The Australian Technical Advisory Group on Immunisation (ATAGI) 2025 statement paints a mixed picture.
While Australia has made important gains with new vaccines and national immunisation reforms, rising cases of pertussis, measles and mpox reveal how fragile protection can be when coverage falters.
Australian Pharmacist explores where progress has been made and where urgent focus is required.
1. Vaccination rates are declining across the board
An ongoing decline in vaccination rates has been identified among all children, adolescents and adults. The steepest and most troubling drop is in childhood vaccination rates at 12 months of age – reducing 3.2 percentage points since 2020. Coverage for children aged 24 months has also dipped below 90% for the first time since 2016. Coverage at 60 months is the highest milestone (92.7%) – indicating that catch-up vaccination is occurring.
Adolescent human papillomavirus (HPV) vaccination rates are also on a downward trend, sitting well below the 90% target at 81.1% in females and 77.9% in males for at least one dose of the vaccine at 15 years of age. Concerningly, the rates are even lower among Aboriginal and Torres Strait Islander people, sitting at 76.7% in females and 69.2% in males.
Uptake of COVID-19 vaccines fell sharply in 2024 across all adult age groups, with only a fraction (2.3%) of younger adults aged 18 to <50 receiving at least one dose of the vaccine. Among those most vulnerable to severe complications, patients aged 75 and older, the vaccination rate dropped from 52.3% to 36.5%.
ATAGI will track declining coverage for selected vaccines to inform additional control strategies, and monitor the effects of schedule changes on coverage and disease – such as the shift to a 1-dose HPV schedule in 2023.
2. Australia’s RSV vaccination campaign is world leading
In 2024, Australia became the first country to put a combined maternal and infant respiratory syncytial virus (RSV) immunisation program in place. Pregnant women were given free access to Abrysvo under the National Immunisation Program (NIP)
from 28 weeks gestation ahead of the 2025 RSV season. Monoclonal antibody nirsevimab is funded for infants under various state and territory arrangements to ensure protection for at-risk infants and/or those whose mother did not receive the vaccine during pregnancy.
These arrangements include:
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[post_content] => PSA has announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education offerings and professional and practice support for members and the pharmacy profession.
PSA’s Board announced negotiations had successfully concluded. While there are still steps to be completed before the settlement, PSA is focused on how the acquisition will strengthen its leadership in education and training for pharmacists, pharmacy assistants, and technicians.
The acquisition allows PSA to grow its industry-leading education and workforce development programs. The PSA Board is confident this is the right path forward for PSA, its members and the broader profession.
National President and Chair of the PSA Board Associate Professor Fei Sim FPS said the agreement was a transformational opportunity for the future of pharmacy education.
‘This agreement is a major milestone in our journey to strengthen and unify pharmacy education in Australia,’ A/Prof Sim said.
‘As the custodian for standards and guidelines for professional practice, the acquisition of the College by the PSA is a further strategic step toward building scale, capability, and capacity for pharmacy education in Australia, amidst the fast-evolving practice landscape.
‘This agreement reflects our shared intent and commitment to invest in the future of the profession and ensure pharmacists, pharmacy assistants, and technicians are supported at every stage of their careers. The acquisition aligns with PSA’s broader strategy to support the profession through a period of significant transformation, including the expansion of scope of practice and increasing demands on the healthcare system.
‘This is about building a stronger, more sustainable future for pharmacy education, so we can do more for our members. As the peak body representing all pharmacists in Australia, PSA continues to represent pharmacists across the profession and their interests, while continuing our commitment to uphold and support high standards of practice.
‘We are proud to lead this work and look forward to continuing to support our members with the highest quality education and professional development.’
PSA will continue to engage with stakeholders throughout the transition process, with a focus on continuity, quality and innovation in education delivery.
[post_title] => PSA to lead unified future for pharmacy education
[post_excerpt] => PSA announced it has signed an agreement to acquire the Australasian College of Pharmacy, marking a significant step for expanding education.
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[post_content] => Serious adverse events in infants prompted the Therapeutic Goods Administration (TGA) to issue a safety alert about prilocaine/lidocaine cream.
The anaesthetic cream, sold under the brand name Emla and various other generics, is typically used for topical anaesthesia of the skin before various minor procedures. It is commonly used prior to circumcision, insertion of catheters and vaccination.
What are the signs and symptoms of overdose?
Prilocaine/lidocaine overdose can lead to methaemoglobinaemia, disrupting haemoglobin’s capacity to carry oxygen. Common symptoms include:
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[post_content] => Case scenario
Amir, a 35-year-old male, presents to the pharmacy requesting a salbutamol inhaler. Upon questioning, he informs you he needs salbutamol for his asthma and has ‘used it since he was a kid’. Amir says his asthma has been well controlled of late and that it only flares with a chest infection and when he gets hay fever. He states he would like to have the salbutamol as he is going away and wants to have one on hand. He is on no other asthma medicines and has only used salbutamol twice in the past month.
Learning objectivesAfter reading this article, pharmacists should be able to:
|
The Global Initiative for Asthma (GINA) strategy defines asthma as ‘a heterogeneous disease, usually characterised by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation’.1
In 2019, GINA comprehensively revised its recommendations for asthma management. This was based on its committee of asthma experts reviewing the evidence. Asthma guidelines from the National Asthma Council Australia (NAC) have now followed suit, and the NAC’s updated Australian Asthma Handbook states that short-acting beta2-agonists (SABA), such as salbutamol, are no longer recommended as sole therapy for asthma in adults and adolescents. The NAC now recommends anti-inflammatory reliever (AIR) therapy as needed from day one when it comes to asthma treatment in adults and adolescents.2 AIR-only therapy refers to the as-needed use of a low-dose inhaled corticosteroid (ICS)–formoterol combination, budesonide–formoterol, to provide both symptom relief and anti-inflammatory action.1
According to Asthma Australia, over 90% of asthma-related hospitalisations in 2022–23 were potentially preventable with optimised care in the community.3,4 This powerful statistic underscores the critical role pharmacists can play in reducing asthma morbidity through education, medicines management, and promoting adherence to treatment.
Asthma is a significant health concern in Australia, reported to affect nearly 2.8 million individuals (1 in 9 Australians) as at 2022.5 The prevalence of asthma is higher in certain demographic groups, such as Aboriginal and Torres Strait Islander peoples, who report asthma rates of 16%.6
Hospitalisation rates related to asthma have increased in recent years, with over 31,000 hospital admissions recorded in 2022–2023.3 Additionally, asthma exacerbations often lead to emergency department visits, with approximately 97,000 Australians presenting with asthma in 2022–2023.7
Asthma-related mortality remains a major concern. In 2023, 474 Australians died from asthma, with females, particularly those aged 75 and over, accounting for 43% of these deaths.8,9
Asthma is a chronic inflammatory airway disorder influenced by both genetic and environmental factors. A family history of asthma significantly increases risk, particularly where first-degree relatives are affected. Genetic variations in interleukin-4, -5, -13, and the beta-adrenergic receptor contribute to Th2-mediated immune responses, leading to eosinophilic inflammation and heightened bronchial reactivity.10
Environmental triggers include allergens (e.g. dust mites, pollen, animal dander) and irritants (e.g. tobacco smoke, air pollution). Infectious triggers commonly include viral respiratory tract infections.1 Urban living and socioeconomic disadvantage, often associated with poor air quality and reduced healthcare access, also contribute to asthma risk.11,12 In utero and childhood exposure to second-hand smoke is an established risk factor for asthma development.13
Asthma is increasingly recognised as a heterogeneous disease, with several phenotypes defined by clinical and inflammatory characteristics. Common phenotypes include allergic (eosinophilic, IgE-mediated), non-allergic (often neutrophilic or paucigranulocytic), late-onset adult asthma, obesity-associated asthma, and asthma with persistent airflow limitation.14 Identifying phenotypes supports individualised treatment strategies, particularly in those with severe asthma, and better long-term outcomes.
The hallmark pathophysiological process is chronic airway inflammation. Upon allergen or irritant exposure, mast cells, eosinophils and T-helper cells release mediators, including histamine, leukotrienes and cytokines. These drive bronchoconstriction, mucus hypersecretion and airway oedema. Long-standing inflammation may lead to structural changes (airway remodelling), including basement membrane thickening and smooth muscle hypertrophy, sustaining airway hyperresponsiveness and fixed airflow obstruction, increasing the risk of asthma-COPD overlap (ACO), particularly among older adults and those with a history of smoking.14–16
Asthma presents with variable symptoms, including wheezing, chest tightness, breathlessness and cough, particularly at night or early morning; however, not all patients with asthma experience all of the above symptoms. Symptoms reflect underlying airway hyperresponsiveness and inflammation and can vary in frequency and severity. Acute exacerbations may involve tachypnoea, prolonged expiration and accessory muscle use.2
Persistent, poorly controlled asthma can result in airway remodelling and progressive lung function decline, underscoring the importance of early diagnosis and proactive management.1,2,15
Atopy is commonly associated with asthma, particularly in childhood-onset disease, and may coexist with other allergic conditions, including eczema and allergic rhinitis.2,10
Thunderstorm asthma refers to the sudden onset of severe asthma symptoms triggered by a combination of high pollen counts, humidity and storm activity, which can cause pollen grains to rupture into smaller particles that are easily inhaled into the lower airways.17
Exercise-induced bronchoconstriction (EIB) is the temporary narrowing of the airways during or after exercise, causing cough, wheeze or breathlessness. It is more common in people with poorly controlled asthma.17 Management includes optimising asthma control with ICS, with low-dose ICS–formoterol now preferred as an AIR or maintenance and reliever therapy (MART) approach. A SABA may be taken 5–15 minutes before exercise but is often no longer needed after several weeks of consistent ICS use.2
Asthma diagnosis relies on a comprehensive assessment, including a detailed history of variable respiratory symptoms along with relevant family history, response to therapy, and objective confirmation of variable airflow limitation.2 Spirometry is the preferred initial test for confirming variable airflow obstruction and reversibility, with an improvement in FEV₁ of ≥12% and ≥200 mL post-bronchodilator supporting the diagnosis.18 However, normal spirometry does not exclude asthma, particularly if the patient is asymptomatic at the time of testing. In such cases, additional tests such as peak expiratory flow (PEF) variability or fractional exhaled nitric oxide (FeNO) may provide further diagnostic evidence.2
Differential diagnoses must be considered, especially in older adults, and include chronic obstructive pulmonary disease (COPD), bronchiectasis, vocal cord dysfunction, cardiac failure and inducible laryngeal obstruction. Accurate diagnosis is critical to ensure appropriate management and avoid misclassification, particularly where ACO is suspected.19
Prognosis is highly variable and depends on factors such as severity, trigger exposure, comorbidities, and medication device technique and adherence. With timely diagnosis, evidence-based treatment and regular review, most patients can achieve good asthma control and a significant reduction in symptoms and exacerbations.20
The 2025 approach to asthma management in adults and adolescents, as outlined by the Australian Asthma Handbook, represents a significant shift from symptom-only treatment to proactive, anti-inflammatory care. The use of SABAs alone is no longer recommended. Instead, all adults and adolescents should receive treatment that includes ICS to target underlying airway inflammation from the outset.2
Step 1: Initial and long-term treatment
The recommended starting point for most patients is as-needed low-dose budesonide–formoterol, a combination ICS–long-acting beta2-agonist (LABA) inhaler used in AIR-only therapy. This dual-purpose inhaler provides both rapid symptom relief and anti-inflammatory action. Formoterol is uniquely suitable for this role due to its rapid onset of action, making it the only LABA approved for use as-needed (PRN).2
Steps 2 and 3: Maintenance and reliever therapy (MART)
If symptoms are more frequent or severe, or the patient is at high risk of exacerbations, treatment should escalate to MART. This involves using a low- or medium-dose ICS–formoterol inhaler for both daily maintenance and as-needed relief (Steps 2 and 3). This simplified regimen improves adherence and ensures consistent anti-inflammatory treatment. Recommended formulations include budesonide–formoterol or beclometasone–formoterol.2
Step 4: Specialist review and targeted therapy
For patients with persistent symptoms despite medium-dose MART, Step 4 involves targeted intensive treatment and specialist referral. Options may include high-dose ICS–LABA, the addition of a long-acting muscarinic antagonist (LAMA), such as tiotropium, or other advanced therapies, including biologics. This level is reserved for those with severe asthma who may benefit from specialist input and a personalised treatment plan.2
Alternative: SABA as reliever
While the recommended approach is the use of ICS–formoterol as both maintenance and reliever, an alternative pathway allows for low-dose ICS (Step 1) or low- to medium-dose ICS–LABA (Steps 2 and 3) maintenance therapy with SABA as the reliever. However, this is less favoured due to delayed anti-inflammatory action during a worsening of symptoms.2
MART with ICS–formoterol reduces the risk of severe exacerbations requiring oral corticosteroids (OCS), hospitalisation or emergency department visit, compared with the same or higher dose of ICS or ICS–LABA.21
Treatment is guided by a stepwise approach. Stepwise medicines adjustment should be carried out under supervision of the prescriber. Before stepping up treatment, clinicians must confirm that2:
Conversely, stepping down should be considered when asthma is well-controlled for 2–3 months, to minimise medication exposure while maintaining control.2
Severe asthma
In cases where asthma remains uncontrolled despite optimal inhaled therapy, or requires frequent OCS, early specialist referral is critical. Patients may be eligible for monoclonal antibody therapies, such as mepolizumab, benralizumab, dupilumab, or omalizumab. These patients must continue inhaled preventer medicines alongside biologics to maintain baseline control.2,17
Oral corticosteroids are reserved for managing acute exacerbations or as a last resort due to their adverse effects.2,17
Effective asthma management relies on timely intervention, ongoing assessment and alignment with current clinical guidelines. Management goals should be tailored in collaboration with the patient, based on recent symptom burden, risk factors and individual preferences.17
Asthma can develop at any age, and a formal diagnosis is essential to guide appropriate management.2
Validated tools such as the Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) can support structured assessment of asthma control.22 According to the Australian Asthma Handbook, well-controlled asthma is defined as having2:
Failure to meet any of these criteria may indicate poor control, warranting further investigation or therapeutic intervention.2,17
Effective self-management is crucial for long-term symptom control. Inhaler technique remains a common barrier, with up to 94% of patients using their devices incorrectly.23 Patients should carry a reliever (budesonide–formoterol or SABA, depending on management) at all times for prompt symptom relief in the event of worsening symptoms or acute episodes.
Comorbid conditions can complicate asthma management. Assess for and help address factors such as allergic rhinitis, which affects up to 80% of people with asthma,24 as well as gastro-oesophageal reflux disease (GORD), anxiety, depression, obstructive sleep apnoea and smoking.
Individuals with asthma are recommended to receive annual influenza and COVID-19 vaccinations, to reduce the risk of respiratory infections that can trigger asthma exacerbations and lead to serious complications. Pneumococcal and RSV vaccines should be considered depending on asthma severity and age of the patient.25,26
Pharmacists should initiate and support informed conversations with patients about changes to asthma management in light of the updated guidelines.
Patients presenting to a pharmacy who use SABA should be referred to their GP or nurse practitioner (NP) for review2; however, they may still access SABAs as a Pharmacist Only medicine when required, especially for acute symptom relief. Reviewing a patient’s dispensing history can help to identify patients in need of a referral to their GP or NP.27 Red flags include frequent SABA use or irregular preventer use, potentially indicating poor adherence or sub-optimal therapy.27 Where practicable, patients should be referred to their GP or NP for a written asthma action plan. Patients should be supported in understanding and using the plan and educated on identifying and avoiding individual triggers.28
Pharmacists should educate patients on correct use of devices, recommend spacers with pressurised metered dose inhalers (pMDIs), and apply ancillary labels, such as Label 130: INHALE SLOW and STEADY or Label 131: INHALE QUICK and DEEP, to prompt regular device checks.27 Simplifying regimens through daily dosing or single-inhaler strategies like MART may enhance adherence.
All patients with asthma should receive asthma first-aid education.29 Pharmacists can also provide balanced information about thunderstorm asthma risks without causing undue alarm.30
Other pharmacy services such as vaccinations, MedsChecks, Home Medicines Reviews (HMRs) and smoking cessation can support asthma management. Structured fee-for-service in-pharmacy clinics like sleep apnoea screening, weight loss programs and allergic rhinitis clinics can address associated broader health needs.
Pharmacists should encourage responsible disposal of expired or unused inhalers through pharmacy return schemes to reduce environmental harm.31 Where clinically appropriate, pharmacists can raise awareness of the environmental impact of pMDIs and suggest that patients discuss the option of switching to a dry powder inhaler (DPI) with their doctor. DPIs generally have a significantly lower carbon footprint.32
These interventions help optimise medicine use, identify barriers to asthma control, and improve clinical outcomes across all age groups.
The updated Australian Asthma Handbook recommends that no adult or adolescent with asthma be treated with a SABA alone, as it does not treat the underlying inflammation that is the hallmark of asthma.
Patients requesting a SABA in the pharmacy may still access it as a Pharmacist Only medicine. If the SABA is being used as their sole therapy, the patient should be referred to their GP or NP for review and initiation of AIR-only therapy or MART where appropriate. Reliever therapy should not be withheld if required for acute symptom relief, and pharmacists should apply careful clinical judgement in such interactions.
Pharmacists are uniquely positioned to bridge gaps in asthma care, advise on the updated guidelines, particularly at the community level, and reduce asthma morbidity through education and by promoting the quality use of medicines.
Case scenario continuedYou explain to Amir that he should always have a reliever on hand and that he can have salbutamol today. You also explain that the Australian asthma guidelines have recently changed in line with best available evidence. You refer Amir to his GP to ask about anti-inflammatory reliever (AIR) therapy, an asthma review and an asthma action plan. You check Amir’s inhaler technique and recommend a spacer. You also provide education on asthma first aid should Amir experience an episode while he is away. Amir is grateful for your advice. |
Sherri Barden BPharm, FANZCAP (Resp/CommPharm), MPS is a pharmacist and asthma educator with over 30 years of experience in community pharmacy. She founded APLUS Pharmacy Education in 2023 to support pharmacies across Australia in managing asthma, hay fever, eczema and COPD, with an emphasis on improving respiratory health outcomes in the community.
Debbie Rigby BPharm, GradDipClinPharm, AdvPracPharm, AdvDipNutrPharm, FASCP, FPS, CredPharm (MMR), FACP, FAICD, FSHP, FANZCAP
Debbie Rigby is the Clinical Executive Lead of the National Asthma Council Australia. She has received honorariums for presentations, publications, conferences, travel and advisory groups with AstraZeneca, Mundipharma, MSD, Teva, GSK, Menarini, Boehringer Ingelheim, Care Pharmaceuticals, Respiri, Chiesi, Viatris, Moderna and Trudell. She has received honorariums for webinars with HealthEd, ThinkGP and Praxhub education organisations.
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[post_content] => Half the country has funded the roll out of the intranasal influenza vaccine in 2026.
With a new formulation of the most-administered vaccine by pharmacists on the horizon, pharmacists need to update their vaccination knowledge.
Why introduce an intranasal vaccine?
Needlephobia is a significant deterrent to childhood vaccination. The Royal Children's Hospital (RCH) Melbourne's Child Health Poll found that one in four children aged 4 years or more (27%) has an intense fear of needles, often preventing them from being vaccinated.
The intranasal vaccine, FluMist, also has a higher vaccine coverage rate than traditional injectable flu vaccines, said community pharmacist and PSA’s Vaccination Ambassador Anna Theophilos MPS.
‘Data indicates that [it provides] all-year coverage, as opposed to weaning off after a few months,’ Ms Theophilos said.
Who is the vaccine indicated for?
The intranasal influenza vaccine has been approved by the Therapeutic Goods Administration for children and adolescents between 2–18 years of age.
‘However, it is assumed [the manufacturer] will keep petitioning for greater expansion of the vaccine,’ Ms Theophilos said.
Which jurisdictions have approved it?
At this stage, three states have provided funding to cover the costs of the vaccine for children aged 2 to under 5 from 2026, including:
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
