What are the alternatives?
How to Use this Section:
This page provides detailed prescribing considerations for common pMDIs and potential lower-emission alternatives. It is intended to support GP review, not automatic switching. Before changing devices, check the clinical indication, disease control, inhaler technique, inspiratory flow, dose equivalence, PBS access, and patient preference.
Indicated for the prevention of asthma
Current pMDI: QVAR (beclometasone)
Potential DPI alternative: Budesonide DPI (Pulmicort Turbuhaler)
These inhalers have different active ingredients; however, budesonide can be considered a clinically appropriate alternative given no specific contraindications.¹ Both are approved for use from age five. Pulmicort Turbuhaler requires the user to take a fast, deep breath to draw the powder into the lungs. If the patient is unable to do this comfortably, switching is not advised.² Both are maintenance inhalers, not rescue inhalers. Clinical trials demonstrate similar efficacy when the medication and dose are suitable and the patient can use the device correctly.³
Indicated for the prevention of asthma.
Current pMDI: Flixotide pMDI (fluticasone propionate)
Potential DPI alternative: Flixotide/Axotide Accuhaler (fluticasone propionate) OR Arnuity Ellipta (fluticasone furoate)
Flixotide and Flixotide Accuhaler contain the same active ingredient.¹ If the patient is able to use a DPI clinically and with appropriate technique, a switch is likely to be successful as the medicine compound is identical.²
If a DPI is suitable, Arnuity Ellipta (fluticasone furoate) may also be considered. Fluticasone furoate maintains the same therapeutic chemical but has a different delivery formulation.⁴ This change in carrier molecule, from propionate to furoate, results in a more potent and long-lasting medicine.⁴ ⁵ Fluticasone furoate can be dosed once daily, as opposed to twice daily with propionate.⁴ This results in fewer doses per day with equivalent symptom control.³ This is more convenient for the patient and results in less plastic waste and environmental pollution.³ Fluticasone furoate is only available as a DPI. Since fluticasone furoate is a more potent medicine, dose should be adjusted based on the severity of the condition and need for management, not substituted microgram-for-microgram.¹ ⁵
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Indicated for the prevention of asthma
Current pMDI: Alvesco (ciclesonide)
DPI/SMI alternative: No direct DPI or SMI equivalent available.
In Australia, ciclesonide is only available in pMDI formulation as of July 2026, as Alvesco 80 and 160.¹ Chiesi, the product's Australian sponsor, announced on June 29, 2026 that Alvesco would be discontinued due to a global manufacturing partner's decision to halt production. The company has stated this decision is not related to any concerns with the safety, efficacy, or quality of the product; the product remains safe to use.⁷
No specific clinical guidance has been published by Chiesi or regulatory bodies in response to this discontinuation. However, as of 2022, Montgomery and Blakey² suggest switching patients taking ciclesonide 80-160 micrograms per day to budesonide DPI 200-400 micrograms per day where clinically appropriate.
Prescribers should confirm current supply status via the TGA Medicine Shortage Reports Database and the PBS.⁶ If unsure about further direction, clinicians are strongly advised to contact their relevant professional body for further information.
Preventer / combination inhaler
Current pMDI: Symbicort Rapihaler (budesonide/formoterol)
DPI option 1: Symbicort Turbuhaler (budesonide/formoterol)
DPI option 2: DuoResp Spiromax (budesonide/formoterol)
This is a same-molecule switch: the active medicines remain budesonide and formoterol, and only the device changes from a pressurised metered dose inhaler (pMDI) to a dry powder inhaler (DPI). Moving from a pMDI to a DPI halves the inhaler carbon footprint without loss of asthma or COPD control, provided the patient can generate adequate inspiratory flow and use a DPI correctly.² ³
Match on total daily dose rather than on the number printed on the device.¹ ⁸ In Australia, all three brands are labelled by metered dose (for example, 200/6 and 400/12), so the strength numbers align across devices, but the Rapihaler pMDI is usually taken as two actuations per dose while the Turbuhaler and Spiromax DPIs are usually taken as one inhalation for the equivalent dose.⁹ Update the dose instructions and the patient's asthma action plan accordingly.¹⁰
Where budesonide/formoterol is used as maintenance-and-reliever therapy (MART) or as an anti-inflammatory reliever (AIR), the dual function is preserved on switching.¹
Note the age-related approval differences: Symbicort Turbuhaler 200/6 is approved for adults and adolescents aged 12 and over, whereas DuoResp Spiromax 200/6 is approved for adults 18 and over only, so the Turbuhaler is the appropriate DPI for an adolescent.⁹
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Preventer/combination inhaler
Current pMDI: Seretide MDI (fluticasone propionate/salmeterol)
DPI alternative (same combination): Seretide Accuhaler (fluticasone propionate/salmeterol). Other same-combination DPI brands include Airzate Accuhaler and Pavtide Accuhaler.¹²
This is a same-molecule switch: the active medicines remain fluticasone propionate and salmeterol, and only the device changes from a pressurised metered dose inhaler (pMDI) to a dry powder inhaler (DPI). Switching from the pMDI form to the DPI form of this medicine is appropriate, provided the patient can generate adequate inspiratory flow and use DPIs correctly.¹ ³
Importantly, fluticasone propionate/salmeterol serves as regular maintenance (preventer) therapy for asthma and COPD; regardless of the delivery system, these medicines are not intended for relief of an acute asthma attack. Fluticasone propionate/salmeterol is not indicated as a form of maintenance-and-reliever therapy (MART) or anti-inflammatory reliever (AIR). The patient will still require a separate short-acting reliever.¹ ¹¹
Regarding dosing, the total daily dose should be calculated and matched rather than relying on the number printed on the device. The Seretide MDI (50/25, 125/25 or 250/25) is taken as two puffs twice daily, whereas the Seretide Accuhaler (100/50, 250/50 or 500/50) is taken as one inhalation twice daily; for example, MDI 250/25 two puffs twice daily corresponds to Accuhaler 500/50 one inhalation twice daily.¹¹ Update the dose instructions accordingly and document in the patient's asthma action plan.¹ ¹¹
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Preventer / combination inhaler
Current pMDI: Fostair (beclometasone dipropionate/formoterol)
DPI or SMI alternative (same molecule): None available in Australia
There is no beclometasone/formoterol dry powder inhaler (DPI) or soft mist inhaler (SMI) registered in Australia; Fostair is available only as an extra-fine particle pMDI.¹³
If alternatives are being considered, assessment of whether a different ICS/LABA combination would be clinically appropriate for the patient would need to occur.¹ ¹⁴ If the switch is justified on clinical grounds, a DPI formulation of the new medicine should be considered.¹ ¹⁴ Importantly, since the active ingredient would be different, dosing must be matched based on the severity of the condition within the target medicine's therapeutic range.
If the patient uses Fostair 100/6 as maintenance-and-reliever therapy (MART), the DPI options that preserve MART are the budesonide/formoterol dry powder inhalers (Symbicort Turbuhaler or DuoResp Spiromax), as these ICS/formoterol combinations are available as DPIs and approved for MART.¹ ¹³
Combinations containing a slower-onset LABA, such as fluticasone/salmeterol or fluticasone furoate/vilanterol, cannot be used as MART and would require a separate short-acting reliever.¹ ¹³
Fostair is approved for adults aged 18 and over.¹³
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Preventer / combination inhaler
Current pMDI: Flutiform (fluticasone propionate/formoterol)
DPI or SMI alternative (same molecule): None available in Australia
DPI option (different molecules): Atectura Breezhaler (indacaterol/mometasone furoate)
There is no fluticasone propionate/formoterol dry powder inhaler (DPI) or soft mist inhaler (SMI) registered in Australia, so a like-for-like device switch is not possible; Flutiform is available only as a pMDI.¹⁶
Atectura Breezhaler may be considered as an alternative DPI where clinically appropriate, but it is a change of molecule rather than a device-only switch: it contains indacaterol and mometasone furoate rather than formoterol and fluticasone propionate. Because the active ingredient differs, the alternative should be matched by dose category rather than microgram-for-microgram.¹ ¹⁴
Atectura is dosed once daily, whereas Flutiform is twice daily. A switch could improve adherence and make condition management more convenient for the patient. However, clinical considerations are primary.
Neither product is a reliever. Flutiform is a maintenance combination and Atectura is a once-daily maintenance combination; both require a separate short-acting reliever, and neither is approved for maintenance-and-reliever therapy (MART).¹⁶ ¹⁷
Both Atectura and Flutiform are approved for asthma only in Australia. Neither medicine has been approved for COPD. Both are approved for adults and adolescents aged 12 and over.¹⁶ ¹⁷
Atectura is one of several DPI ICS/LABA options, and because any switch changes the molecule, the choice should be based on individual clinical presentation and requirements.¹ ¹⁴
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Triple therapy may be used for COPD or refractory asthma. Single-inhaler triple therapy can reduce device count and waste. DPI triple therapies avoid propellant entirely and are class-equivalent options. While triple therapy is indicated for refractory asthma, all of the available options are DPIs. They have not been included in the following section to avoid redundancy.
Combination inhaler
Current pMDI: Trimbow (beclometasone dipropionate/formoterol/glycopyrronium), extra-fine particle
DPI/SMI alternative (same molecule): None available in Australia
DPI options (different molecules): Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol) or Enerzair Breezhaler (indacaterol/glycopyrronium/mometasone furoate)
There is no beclometasone/formoterol/glycopyrronium dry powder inhaler (DPI) or soft mist inhaler (SMI) registered in Australia, so a like-for-like device switch is not possible; Trimbow is available only as an extra-fine particle pMDI, dosed as two inhalations twice daily.¹⁹
If a lower-emission option is being considered, it would need to be assessed whether a single-inhaler triple therapy available as a DPI is clinically appropriate. Any switch would involve all three active ingredients changing, so the alternative should be chosen on clinical grounds and the inhaled corticosteroid matched by dose category rather than microgram-for-microgram.¹ ¹⁴
Trelegy Ellipta is licensed for both COPD and asthma, whereas Enerzair Breezhaler is licensed for asthma only, so a patient using Trimbow for COPD should be considered for Trelegy Ellipta rather than Enerzair Breezhaler. For a patient using Trimbow for asthma, either may be appropriate.²⁰ ²¹ ²²
The dosing frequency and device also change. Both DPI options are once daily against Trimbow's twice-daily regimen, because vilanterol and indacaterol are once-daily long-acting beta-2 agonists rather than twice-daily formoterol. Trelegy uses the Ellipta, a reservoir DPI delivering a single once-daily inhalation; Enerzair uses a single-dose capsule Breezhaler that the patient loads and pierces before each dose, which requires adequate dexterity and technique. Confirm the patient can use the chosen device and generate adequate inspiratory flow before switching.²⁰ ²²
None of these products is a reliever. Triple therapy is maintenance treatment and does not treat acute symptoms, so the patient must retain a separate short-acting reliever across any switch.¹⁹ ²⁰ ²²
Especially in cases of long-term treatment, any switch must involve close monitoring and an individualised discussion with the patient to ensure continued effective symptom management.
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Combination inhaler
Current pMDI: Breztri Aerosphere (budesonide/glycopyrronium/formoterol)
DPI or SMI alternative (same molecule): None available
DPI option (different molecules): Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol)
There is no budesonide/glycopyrronium/formoterol dry powder inhaler (DPI) or soft mist inhaler (SMI), so a like-for-like device switch is not possible; this combination exists only as the Breztri Aerosphere pMDI, dosed as two inhalations twice daily for maintenance treatment of COPD in adults.²⁴
If a lower-emission option is being considered, it would need to be assessed whether a single-inhaler triple therapy available as a DPI is clinically appropriate. As all three active ingredients differ, the alternative should be chosen on clinical grounds and the inhaled corticosteroid matched by dose category rather than microgram-for-microgram.²⁰ ²⁴ ²¹
Because Breztri is a COPD product, the appropriate DPI triple therapy is Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol), which is licensed for COPD in Australia. Enerzair Breezhaler, the other single-inhaler triple DPI, is licensed for asthma only and is therefore not an option for a patient treated for COPD.²⁰ ²²
The dosing frequency and device also change. Trelegy is dosed once daily against Breztri's twice-daily regimen. Trelegy uses the Ellipta, a reservoir DPI delivering a single once-daily inhalation. It must be confirmed that the patient can use the device and generate adequate inspiratory flow before switching.²⁰
Neither product is a reliever. Triple therapy is maintenance treatment and does not treat acute symptoms, so the patient must retain a separate short-acting reliever across any switch.²⁰ ²⁴
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Current pMDI: Salbutamol (Ventolin, Asmol, Airomir and other salbutamol brands)
DPI alternative (same class, different molecule): Terbutaline (Bricanyl Turbuhaler)
Salbutamol and terbutaline are both short-acting beta-2 agonists. Terbutaline via the Bricanyl Turbuhaler is a dry powder inhaler, so it avoids the propellant carbon footprint of a salbutamol pMDI, but it is a different molecule rather than a same-molecule swap and requires adequate inspiratory flow and correct technique.¹ ²
Positioning has changed. SABA-only treatment, meaning a reliever used without a preventer, is no longer recommended for asthma in adults and adolescents, because SABA-only use is associated with a higher risk of severe exacerbations and death. The recommended reliever for adults and adolescents with asthma is now as-needed ICS-formoterol (anti-inflammatory reliever, AIR). SABAs are not withdrawn: they remain the reliever of choice in COPD and retain a central role in acute asthma management.¹ ¹⁴
Reducing SABA over-reliance is also the single largest inhaler carbon-reduction opportunity in respiratory prescribing, as SABA pMDIs are frequently used and account for a large share of inhaler emissions. Moving eligible patients from SABA-only or SABA-heavy regimens to as-needed ICS-formoterol reduces both exacerbation risk and emissions, and generally has a greater impact than switching the reliever device alone.² ³
Acute severe exacerbation caveat: during a severe attack, inspiratory flow is often too low to use a dry powder inhaler effectively, so salbutamol via a pMDI and spacer, or nebulised salbutamol, is preferred. A DPI reliever should not be relied on for acute severe asthma.¹
Access and cost: Salbutamol is available without a prescription as a pharmacist-only medicine (Schedule 3) and is inexpensive, with supply limited to one inhaler per purchase without referral. Terbutaline (Bricanyl Turbuhaler) is also Pharmacist Only, but PBS subsidy is authority-restricted, in practice for patients who cannot use a salbutamol pMDI; otherwise it is purchased at full price.²⁶ ²⁷
Neither SABA should be used as the sole treatment or as a first-line option for asthma in adults and adolescents. The September 2025 change to first-line asthma treatment is set out in the National Asthma Council Australia's Australian Asthma Handbook, consistent with GINA.¹ ¹⁴
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Reference list
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National Asthma Council Australia. Australian Asthma Handbook: the national guidelines for health professionals. Australian Asthma Handbook. Version 3.0. September 16, 2025. Accessed June 24, 2026. https://www.asthmahandbook.org.au
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Montgomery BD, Blakey JD. Respiratory inhalers and the environment. Aust J Gen Pract. 2022;51(12):929-934. doi:10.31128/AJGP-08-22-6536
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Woodcock A, Janson C, Rees J, Frith L, Löfdahl M, Moore A, et al. Effects of switching from a metered dose inhaler to a dry powder inhaler on climate emissions and asthma control: post-hoc analysis. Thorax. 2022;77(12):1187-1192. doi:10.1136/thoraxjnl-2021-218088
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Biggadike K. Fluticasone furoate/fluticasone propionate: different drugs with different properties. Clin Respir J. 2011;5(3):183-184. doi:10.1111/j.1752-699X.2011.00244.x
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Salter M, Biggadike K, Matthews JL, West MR, Haase MV, Farrow SN, et al. Pharmacological properties of the enhanced-affinity glucocorticoid fluticasone furoate in vitro and in an in vivo model of respiratory inflammatory disease. Am J Physiol Lung Cell Mol Physiol. 2007;293(3):L660-L667. doi:10.1152/ajplung.00108.2007
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Therapeutic Goods Administration. Medicine shortage reports database. Therapeutic Goods Administration. Accessed June 20, 2026. https://apps.tga.gov.au/Prod/msi/search
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Chiesi Australia Pty Ltd. Products. Chiesi Australia Pty Ltd. Accessed June 30, 2026. https://www.chiesi.com.au/products/
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Therapeutic Goods Administration. Australian public assessment report for budesonide/eformoterol: Symbicort Rapihaler. Therapeutic Goods Administration. December 6, 2011. Updated February 26, 2013. Accessed June 23, 2026. https://www.tga.gov.au/sites/default/files/auspar-budesonide-130226.pdf
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Reddel HK. Updated Australian guidelines for mild asthma: what’s changed and why? Aust Prescr. 2020;43(6):220-224. doi:10.18773/austprescr.2020.076
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National Asthma Council Australia. Asthma treatment levels for adults and adolescents chart. National Asthma Council Australia. Updated December 2025. Accessed June 26, 2026. https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/charts/asthma-treatment-levels-adults-adolescents
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GlaxoSmithKline Australia Pty Ltd. Seretide: fluticasone propionate/salmeterol xinafoate: Accuhaler and MDI: Australian product information. GlaxoSmithKline Australia Pty Ltd. Version 12.0. Accessed June 27, 2026. https://au.gsk.com/media/xlbfru31/seretide_accuhaler_mdi_pi_au.pdf
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Australian Government Department of Health, Disability and Ageing. Fluticasone propionate + salmeterol: 8519J. Pharmaceutical Benefits Scheme. Accessed June 23, 2026. https://www.pbs.gov.au/medicine/item/8519J
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Chiesi Australia Pty Ltd. Fostair: beclometasone dipropionate/formoterol fumarate dihydrate: Australian product information. Chiesi Australia Pty Ltd. Version 9.0. 2025. Accessed June 25, 2026. https://www.chiesi.com.au/fostair_pi.pdf
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Global Initiative for Asthma. Global strategy for asthma management and prevention. Global Initiative for Asthma. 2025. Accessed June 28, 2026. https://ginasthma.org
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Australian Government Department of Health, Disability and Ageing. Beclometasone + formoterol: 12183F. Pharmaceutical Benefits Scheme. Accessed June 22, 2026. https://www.pbs.gov.au/medicine/item/12183F
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Therapeutic Goods Administration. Australian public assessment report for fluticasone propionate/eformoterol fumarate dihydrate: Flutiform. Therapeutic Goods Administration. June 13, 2013. Accessed June 30, 2026. https://www.tga.gov.au/sites/default/files/auspar-fluticasone-propionate-130613.pdf
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Therapeutic Goods Administration. Atectura Breezhaler: Novartis Pharmaceuticals Australia Pty Ltd. Therapeutic Goods Administration. Accessed June 25, 2026. https://www.tga.gov.au/resources/prescription-medicines-registrations/atectura-breezhaler-novartis-pharmaceuticals-australia-pty-ltd
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Australian Government Department of Health, Disability and Ageing. Fluticasone propionate + formoterol: 14344Y. Pharmaceutical Benefits Scheme. Accessed June 21, 2026. https://www.pbs.gov.au/medicine/item/14344Y
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Chiesi Australia Pty Ltd. Trimbow: beclometasone dipropionate/formoterol fumarate dihydrate/glycopyrronium: Australian product information. Chiesi Australia Pty Ltd. 2024. Accessed June 24, 2026. https://www.chiesi.com.au/trimbow_PI.pdf
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GlaxoSmithKline Australia Pty Ltd. Trelegy Ellipta. GlaxoSmithKline Australia Pty Ltd. Accessed June 29, 2026. https://au.gsk.com/en-au/products/product-list/trelegy-ellipta/
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Lung Foundation Australia. COPD-X Handbook: summary clinical practice guidelines for the management of chronic obstructive pulmonary disease (COPD). COPD-X. 2024. Accessed June 20, 2026. https://copdx.org.au
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Therapeutic Goods Administration. Enerzair Breezhaler: indacaterol/glycopyrronium/mometasone furoate: Australian product information. Therapeutic Goods Administration. April 6, 2021. Accessed June 26, 2026. https://www.tga.gov.au/sites/default/files/auspar-indacaterol-acetate-glycopyrronium-bromide-mometasone-furoate-210406-pi.pdf
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Australian Government Department of Health, Disability and Ageing. Beclometasone + formoterol + glycopyrronium. Pharmaceutical Benefits Scheme. Accessed June 27, 2026. https://www.pbs.gov.au/medicine/search?term=12468F-14606R-14310E-15243G-13200R-15232Q
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Therapeutic Goods Administration. Breztri Aerosphere: AstraZeneca Pty Ltd. Therapeutic Goods Administration. Accessed June 23, 2026. https://www.tga.gov.au/resources/prescription-medicines-registrations/breztri-aerosphere-astrazeneca-pty-ltd
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Australian Government Department of Health, Disability and Ageing. Budesonide + glycopyrronium + formoterol: 12672Y, 14536C. Pharmaceutical Benefits Scheme. Accessed June 25, 2026. https://www.pbs.gov.au/medicine/search?term=12672Y-14536C
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Australian Government Department of Health, Disability and Ageing. Terbutaline: 1034K, 12267P. Pharmaceutical Benefits Scheme. Accessed June 22, 2026. https://www.pbs.gov.au/medicine/search?term=1034K-12267P
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Australian Government Department of Health, Disability and Ageing. Terbutaline: 12267P. Pharmaceutical Benefits Scheme. Accessed June 21, 2026. https://www.pbs.gov.au/medicine/item/12267P