Combination inhalers (ICS/LABA and triple) — patient guide

This page covers combination preventer inhalers — ICS/LABA (two medicines in one) and ICS/LABA/LAMA (triple therapy, three medicines in one). If your inhaler is one of the brand names below, this is your page.

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Find your inhaler

Brand	Generic	Device	Strengths	How often	MART?
Symbicort Turbuhaler	budesonide / formoterol	DPI	100/6, 200/6, 400/12 mcg	Twice daily	Yes (100/6, 200/6)
Symbicort Rapihaler	budesonide / formoterol	pMDI	50/3, 100/3, 200/6 mcg	Twice daily	Yes
DuoResp Spiromax	budesonide / formoterol (generic)	DPI	160/4.5, 320/9 mcg	Twice daily	Yes
Seretide Accuhaler	salmeterol / fluticasone propionate	DPI	100/50, 250/50, 500/50 mcg	Twice daily	No
Seretide MDI	salmeterol / fluticasone propionate	pMDI	50/25, 125/25, 250/25 mcg	Twice daily	No
Breo Ellipta	vilanterol / fluticasone furoate	DPI	25/100, 25/200 mcg	Once daily	No
Flutiform	formoterol / fluticasone propionate	pMDI	50/5, 125/5, 250/10 mcg	Twice daily	No (not AU-approved for MART)
Trelegy Ellipta	vilanterol / fluticasone furoate / umeclidinium	DPI (triple)	25/100/62.5 (COPD), 25/200/62.5 (asthma)	Once daily	No (triple)
Trimbow	formoterol / beclomethasone / glycopyrronium	pMDI (triple)	87/5/9 mcg	Twice daily	No (triple)

MART note. Three AU inhalers — Symbicort Turbuhaler, Symbicort Rapihaler, and DuoResp Spiromax — can be used both as your daily preventer AND as your reliever when you’re short of breath. This is called Maintenance And Reliever Therapy (MART), and it works because formoterol is a fast-onset LABA. The other inhalers on this list are fixed-dose only — you take them twice a day (or once for Breo) AND carry a separate blue salbutamol reliever. Ask whether you’re on a MART regimen, because the answer changes what you do when you get tight.

Closely related families. ICS-only inhalers (Pulmicort, Flixotide, QVAR, Alvesco) are the step before combination. LAMA inhalers (Spiriva, Seebri, Bretaris) and LABA/LAMA combinations (Anoro, Ultibro, Brimica) are used in COPD. Salbutamol (Ventolin) is still the reliever when you’re not on MART.

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What it treats

Combination inhalers are prescribed when a single preventer isn’t enough — or because the inhaler structure suits your day-to-day asthma or COPD better. Your reason may be:

• Asthma not controlled on ICS alone — adding a LABA opens the airways further and reduces flare-ups beyond what an ICS does on its own per the Cochrane review of ICS/LABA vs ICS.
• Asthma on a MART regimen — same inhaler does both jobs. The SYGMA-1 NEJM 2018 trial was one of the key studies that changed AU and international practice on this.
• COPD with frequent exacerbations — ICS/LABA reduces flare-ups in patients who have multiple a year, per TORCH (NEJM 2007).
• COPD not controlled on dual therapy — triple therapy adds a LAMA. IMPACT (NEJM 2018) and ETHOS (NEJM 2020) supported the COPD use case; CAPTAIN (Lancet Respir Med 2020) supported the asthma indication.

The mechanism is the same across all of them. The differences that matter day-to-day are device, dosing frequency, and whether your inhaler is MART-eligible. Your GP or respiratory team will tell you which lane you’re in.

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The basics

1. Take it every day even when you feel well. The ICS component is the part that prevents flare-ups, and it doesn’t have a felt effect. Stopping a preventer because you feel fine is the most common reason people end up in ED with an asthma attack.
2. Rinse and spit after every dose. Reduces thrush and voice changes. Use a spacer if your inhaler is a pMDI (Symbicort Rapihaler, Seretide MDI, Flutiform, Trimbow).
3. Know your reliever plan. On MART (Symbicort or DuoResp): the same inhaler is your reliever. Not on MART (Seretide, Breo, Flutiform, Trelegy, Trimbow): you need a separate salbutamol on hand.
4. Sudden swelling of face, lips, tongue, or throat — call 000. Severe attack with no response to reliever — call 000. Blue lips or can’t speak in sentences — call 000.
5. Don’t stop on your own. If something feels wrong, message us — we can almost always sort the problem without stopping the inhaler.

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Inhaler technique — the most important thing on this page

The medicine only works if it reaches the airways. Studies routinely find that more than half of inhaler users get technique wrong in ways that meaningfully reduce drug delivery. Re-check yours every time you start a new device, and ask your GP or pharmacist to watch you use it.

Quick principles by device family:

• Turbuhaler (Symbicort) — load by twisting the base until it clicks, breathe out away from the device, then breathe in hard and fast through the mouthpiece. Hold for 5-10 seconds. Rinse and spit.
• Spiromax (DuoResp) — open the cap, breathe out away from the device, then breathe in hard and fast through the mouthpiece. Hold for 5-10 seconds. Rinse and spit. Technique differs from Turbuhaler despite both being DPIs.
• Accuhaler (Seretide) — slide the lever until it clicks, breathe out away from the device, then breathe in hard and fast. Hold for 5-10 seconds. Rinse and spit.
• Ellipta (Breo, Trelegy) — open the cover (this loads the dose; don’t open more than once per dose), breathe out away from the device, then breathe in hard and fast through your mouth. Hold for 5-10 seconds. Rinse and spit.
• pMDI (Symbicort Rapihaler, Seretide MDI, Flutiform, Trimbow) — shake (if needed for the device), breathe out, press the canister AS you start to breathe in slowly and steadily, keep breathing in for 4-5 seconds, hold for 5-10 seconds. Use a spacer if you’ve got one — it makes the coordination easier and gets more drug to the airways, less to the throat.

The National Asthma Council technique videos cover each device with footage. Worth 5 minutes once.

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Tap any section below to expand the detail.

How do they work?

Combination inhalers carry two or three medicines that hit asthma and COPD from different angles.

• ICS (inhaled corticosteroid) — calms the underlying airway inflammation. This is the preventer part. Examples: budesonide (in Symbicort, DuoResp), fluticasone propionate (in Seretide, Flutiform), fluticasone furoate (in Breo, Trelegy), beclomethasone (in Trimbow).
• LABA (long-acting beta2-agonist) — relaxes airway smooth muscle for 12 hours (formoterol, salmeterol) or 24 hours (vilanterol). Formoterol is fast-onset (minutes), which is what makes Symbicort MART-eligible. Salmeterol and vilanterol are slow-onset and can’t be used as relievers.
• LAMA (long-acting muscarinic antagonist) — further opens the airways via a different receptor (the acetylcholine pathway), and is most useful in COPD where vagal tone is part of the airway obstruction. Examples: umeclidinium (in Trelegy), glycopyrronium (in Trimbow).

Two reasons combination matters. First, the LABA opens the door, and the ICS calms the inflammation behind it — you get more drug to the small airways and more inflammation control than with either alone. Second, packaging both into one inhaler means one daily routine instead of two, which substantially improves adherence — the SALFORD Lung Study (Lancet 2017) showed this in real-world asthma care.

Why a LABA is dangerous on its own in asthma

This is the single most important safety point in the class.

A long-acting beta2-agonist used without a paired inhaled corticosteroid in asthma is associated with an increased risk of severe asthma attacks and asthma deaths. The signal was strong enough that in 2010 the FDA issued a black-box warning, and salmeterol monotherapy was withdrawn from the US market — see the FDA LABA safety communication.

The mechanism: a LABA on its own can mask airway inflammation. You feel better — the muscle is relaxed, you can breathe — but the underlying inflammation is uncontrolled and getting worse. When you eventually have an attack, it’s a bigger attack than it would have been.

The fix is mandatory pairing. Every LABA used for asthma is delivered alongside an ICS in the same inhaler — Symbicort, DuoResp, Seretide, Breo, Flutiform, Trelegy, Trimbow all do this by design. Never use a LABA-only inhaler for asthma. If you’re on a LABA/LAMA dual inhaler (Anoro, Ultibro, Brimica — these are LAMA + LABA, no ICS) AND you have asthma, that’s a conversation to have at your next review.

In COPD the LABA-only situation is different — the asthma-death signal hasn’t been replicated in COPD, and LABA-only or LABA/LAMA inhalers are used in COPD without an ICS in many people. Your GP will be clear on which class your inhaler sits in.

Side effects in detail

Common (usually manageable)

• Oral thrush (white patches in the mouth) and hoarseness. From ICS deposition in the throat. Rinse-and-spit after every dose, use a spacer with pMDIs — that takes most of it away. Nystatin drops or a course of oral antifungal sorts most cases that do happen.
• Mild tremor, fast heart rate, palpitations. Beta2-agonist effects, more likely at high LABA dose or when you’re using a MART inhaler heavily as a reliever. Usually settles. If it’s persistent, message us.
• Headache in the first weeks, usually settling.
• Dry mouth, constipation — particularly with triple-therapy inhalers (the LAMA component, Trelegy, Trimbow).
• Higher voice strain or hoarse voice — same source as the thrush, same fix.

Uncommon

• Muscle cramps with high LABA dose, sometimes related to potassium or magnesium shift.
• Sleep disturbance, mood change at high doses or in sensitive individuals.

Rare but serious — go to ED

• Paradoxical bronchospasm. Chest tightens immediately after a puff rather than opening. Rare but reported with any inhaler, slightly more with pMDIs. Stop the inhaler and seek urgent review.
• Angioedema or anaphylaxis. Sudden swelling of face, lips, tongue, or throat. Call 000.
• Pneumonia in COPD. ICS-containing inhalers carry a small consistent increase in pneumonia risk in COPD per TORCH and IMPACT. For most patients with frequent exacerbations the exacerbation-reduction benefit outweighs — both are true, hold both. The action: if you develop new fever, a productive cough that’s different from your usual, or worsening breathlessness, get reviewed early.
• Acute angle-closure glaucoma with triple-therapy inhalers (Trelegy, Trimbow) — eye pain, blurred vision, halos around lights. Go to ED.
• Urinary retention with triple-therapy inhalers — particularly in men with significant prostate enlargement.
• Hypokalaemia at high LABA dose, particularly combined with a thiazide or loop diuretic, or during an oral steroid burst for an exacerbation. We’d check a potassium level in that scenario.

Drugs, food, and alcohol

Tell your GP or pharmacist before combining with:

• Other LABA-containing inhalers. Never double up. If you’re on an ICS/LABA combination and your COPD specialist wants to add a LAMA, the right move is usually to switch to a single triple-therapy inhaler — not stack two devices.
• Non-selective beta-blockers (propranolol, timolol eye drops). Can blunt the LABA bronchodilator effect and provoke bronchospasm in asthma. Cardioselective beta-blockers (bisoprolol, metoprolol) are usually fine in COPD and in well-controlled asthma at the lowest effective dose — but it’s worth raising at your next review.
• Strong CYP3A4 inhibitors — ritonavir (HIV), ketoconazole, itraconazole, clarithromycin, cobicistat. These can raise systemic exposure to fluticasone substantially — there are case reports of Cushing syndrome and adrenal suppression from this combination. If you need one of these antibiotics or antifungals, your GP may switch you temporarily to a non-fluticasone ICS (budesonide or beclomethasone).
• Diuretics (thiazide, loop). Additive risk of low potassium when combined with high-dose LABA.
• QT-prolonging drugs (sotalol, amiodarone, escitalopram at high dose, methadone, ondansetron, fluoroquinolone antibiotics). Combined with high-dose LABA, additive cardiac risk. Most patients on standard inhaler doses don’t need to worry; high-dose or known-long-QT patients should mention the combination.
• Anticholinergic burden (tricyclic antidepressants, oxybutynin, sedating antihistamines) combined with triple-therapy inhalers (Trelegy, Trimbow). Watch for cognition changes, urinary retention, and constipation in elderly patients.

Food. No food restrictions.

Alcohol. No specific interaction. Heavy drinking worsens reflux and disrupts sleep, both of which destabilise asthma.

Generic substitution. DuoResp Spiromax is a PBS-listed generic of Symbicort Turbuhaler — same drug, different device. The device technique is different, so if your pharmacist offers the swap, ask them to walk you through the Spiromax technique. The price difference can be meaningful.

Sick day rules and asthma action plans

Asthma is the kind of condition where having a written plan beats trying to remember what to do at 3am when you’re tight.

Every adult and child with asthma should have a written Asthma Action Plan. The National Asthma Council template is free and clear — your GP fills it in with your specific inhalers, doses, and step-up actions. The plan tells you: what to take when you’re well, what to take when you start to flicker, when to start oral prednisolone (if your plan includes that), when to call the GP, and when to call 000.

General principles:

• Getting tight more often than usual, or needing your reliever more than 2-3 times a week — review your preventer dose and your technique. Don’t just keep reaching for the reliever.
• A cold or chest infection — many people need to step up their preventer for the duration of the illness. Your action plan should specify the step-up.
• Severe attack — symptoms not improving despite reliever, can’t speak in full sentences, blue lips, drowsy or confused — call 000. Continue using the reliever every few minutes while waiting.

For COPD — similar principle. Many patients have a written action plan with a course of antibiotics and prednisolone on standby for early exacerbation treatment. Use as agreed with your GP or respiratory team.

Monitoring — what to track and when

• Annual review at minimum — asthma control questionnaire, technique check, action plan update, lung function (spirometry every 1-2 years for most adults).
• More often if you’re using your reliever more than 2-3 times a week, having night-time symptoms, missing days of work or school, or have been in ED.
• Inhaler technique check at every review and every time you start a new device. Studies routinely show drift over time.
• Bone health — patients on long-term moderate-to-high-dose ICS, particularly with COPD or severe asthma, benefit from periodic vitamin D and calcium review and DEXA scanning per the indication.
• Eye review for triple-therapy users with known glaucoma.

Message us if you start a new medicine (including over-the-counter or supplements), have an exacerbation, change inhalers at the pharmacy, or notice persistent side effects.

Stopping or pausing

Don’t stop your preventer without a conversation. Stopping a combination inhaler suddenly — especially during a respiratory infection or pollen season — is one of the most common pathways to a serious attack.

• If side effects are the problem, we usually switch device or molecule rather than stop.
• If you’re doing brilliantly — controlled, no symptoms, no rescue use, normal spirometry — there’s sometimes room to step DOWN (lower strength, or back to ICS-only). This is done gradually with monitoring, not on your own. Asthma comes back fast.
• Before surgery, take your usual preventer on the morning of surgery unless your anaesthetist tells you otherwise. Bring your inhalers to hospital.
• During a flare — increase, don’t decrease.

Pregnancy and breastfeeding

Uncontrolled asthma in pregnancy is the bigger risk to the baby. This is the consistent AU position from the National Asthma Council, GINA, and the AU obstetric colleges — keep the inhaler going.

• Planning a pregnancy on an ICS/LABA combination — usually keep it. Discuss at preconception review.
• Already pregnant on an ICS/LABA — keep it. Stopping a preventer because of pregnancy fear has caused harm; using it during pregnancy has the safest combined data of any chronic-disease medication class.
• Triple-therapy inhalers (Trelegy, Trimbow) are a more complex conversation because pregnancy safety data on the LAMA component is more limited. If you’re on triple therapy and planning pregnancy, raise it early with your respiratory team — there may be a step-down option for the duration.
• Breastfeeding is compatible with all the ICS/LABA combinations and the triple inhalers — drug transfer into breast milk is minimal.

If you’ve just found out you’re pregnant and you’re on any of these — don’t stop on your own. Message us; we’ll talk it through.

If you’re on a combination involving an oral medicine

ICS/LABA combination inhalers are already combination products — the “combination” in the name refers to two medicines packaged in one device. Some patients are on additional oral asthma medicines alongside:

• Montelukast (Singulair) — a leukotriene receptor antagonist, taken once at night. Used as an add-on in asthma not controlled on ICS/LABA, or in patients with allergic rhinitis driving asthma symptoms. Has its own side-effect profile (mood and sleep changes — watch for these).
• Theophylline — older oral bronchodilator, narrow therapeutic window. Less commonly used now.
• Biologics (omalizumab, mepolizumab, benralizumab, dupilumab) — injectable add-on therapy for severe asthma, specialist-prescribed.

Everything on this page applies to the ICS/LABA inhaler portion. The other medicines have their own considerations — ask us, and we’ll get you the relevant page when it’s ready.

Cost

Most ICS/LABA inhalers are on the PBS. From 1 January 2026, the PBS co-payment is:

• General patient: up to $25.00 per script
• Concession card holder: up to $7.70 per script

Authority criteria vary by product and by indication. Some triple-therapy inhalers (Trelegy, Trimbow) sit under PBS streamlined authority, and the criteria differ between asthma and COPD indications. Generic options (DuoResp Spiromax for Symbicort) can substantially reduce out-of-pocket cost.

Your pharmacist can show you the exact price for your specific script and tell you the cheapest equivalent option — particularly worth asking when starting a new inhaler.

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The integrative view

Most of the patients I see want to do everything they reasonably can alongside the inhaler. This is the longer version of that conversation.

Two principles. First: combination inhalers work and the evidence is strong. Lifestyle and integrative interventions also work — and several of them work on a different mechanism, so the gains are additive, not redundant. Second: a goal for many patients is the lowest effective dose, not zero medication. Earning a step-down in dose while staying well is a legitimate win.

Strong evidence — these reliably help airway disease

• Smoking cessation. Non-negotiable in COPD — it is the single biggest lever you have for slowing disease progression and reducing exacerbations. In asthma, smoking blunts ICS response and worsens control. If you smoke and want help, this is the conversation. Nicotine replacement, varenicline, behavioural support — combined they work better than any one alone.
• Pulmonary rehabilitation in COPD. A structured 6-8 week program of supervised exercise plus education. Meaningful improvement in breathlessness, exercise capacity, and hospitalisations. Available across Australia — ask for a referral.
• Exercise as a controller in asthma. Regular aerobic exercise improves asthma control over months — counter-intuitive if you’ve been told to avoid exertion. Warm-up is the key; pre-exercise reliever if needed. Pool-based exercise is often particularly well-tolerated.
• Weight loss in adult-onset asthma. Obesity-related asthma is a recognised phenotype and responds to weight loss with genuine improvement in symptoms and lung function. Even modest loss (5-10% of body weight) helps.
• Allergen control. If your asthma is allergic — house dust mite, pet, mould, pollen — identifying and reducing the load matters. Allergy testing through your GP or a clinical immunologist is the starting point.

Moderate evidence — likely helpful

• Breathing pattern retraining. Buteyko and Papworth methods have moderate Cochrane evidence for improving symptom scores and reliever use in adult asthma — though they don’t change underlying inflammation. The benefit is real for the right patient (chronic hyperventilation pattern, breath-holding, mouth breathing). Worth a trial with a trained physio if your control is mediocre on adequate inhaler therapy.
• Vitamin D adequacy. Patients with very low vitamin D and asthma have more exacerbations; replacement reduces this in deficient individuals. Aim for 25-OH vitamin D > 50 nmol/L. Test if you suspect deficiency.
• Indoor air quality. Smoke, wood-heater particulates, mould, strong cleaning fumes, fragrance — all common triggers. Ventilation, HEPA filtration in the bedroom, removing the trigger if you can identify it.
• Diet quality — fruits and vegetables, omega-3 intake, low processed-food load. Modest effects on asthma control in observational and some interventional data. Worth doing for many reasons.

Limited or emerging evidence

• Magnesium. Intravenous magnesium has an established role in severe asthma exacerbations in hospital. Oral magnesium has weaker evidence — but if you’re getting muscle cramps or palpitations on high-dose LABA, dietary magnesium adequacy (leafy greens, nuts, legumes) is reasonable.
• Probiotics. Mixed evidence in childhood asthma prevention; weaker in adult asthma control.
• Honey, herbal preparations (Boswellia, Pycnogenol, ivy leaf) — small studies, modest effects. Not first-line; not actively discouraged if used sensibly.

Specific to being on a combination inhaler

• Oral hygiene. Rinse and spit after every dose. Use a spacer with pMDIs. Brush teeth before bed if the evening dose is your last oral activity. Thrush prevention is mostly about technique.
• Vitamin D and calcium for bone density on long-term ICS, particularly in COPD or severe asthma.
• Caffeine. If you’re getting tremor or palpitations on a higher LABA dose, reducing caffeine usually helps within days.
• Potassium and magnesium during exacerbations or when on prednisolone bursts — check the bloods early if you’re symptomatic.
• Don’t stop the preventer in the integrative push. The conversation is “lifestyle PLUS inhaler, with a view to earning a step-down over time”, not “lifestyle INSTEAD of inhaler”. Stopping a preventer because you’ve taken up yoga is the version of this that ends in ED.

Earning a lower dose

For asthma, if you achieve sustained excellent control (no symptoms, no rescue use, normal spirometry) on a stable inhaler regimen, there is usually room to step down — typically by 25-50% at a time, with 3-month observation between steps. This is done together with monitoring, not on your own. The honest truth is that asthma is a relapsing condition for most people — many will need some level of preventer indefinitely. The goal is the lowest effective dose, not necessarily zero.

For COPD, the picture is different. Lung function decline is gradual and largely irreversible (smoking cessation is the main exception that slows it). The combination inhaler is usually a long-term commitment. Pulmonary rehab and smoking cessation are the levers that change the trajectory.

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Track these between now and your next visit

• Symptoms — number of days per week with symptoms, number of nights waking, reliever use frequency.
• Peak flow if you have a meter and a chart that’s calibrated to you.
• Any flares — what happened, what triggered it (if known), what helped.
• Technique drift — anything new about how you’re using the inhaler that feels different.
• New medicines, supplements, salt substitutes you’ve started.

Bring the list to your review.

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This is general information, not personal medical advice. Every patient with asthma or COPD is different. Decisions about your inhalers — which one, what dose, MART vs fixed-dose, when to step up or down — are made with the doctor who prescribed them. If anything on this page appears to contradict advice from your treating doctor or respiratory team, follow them; they have context about your situation that this page cannot.

Reading this page does not establish a doctor-patient relationship with Dr Hoebing Lo. If you are not a current patient, please discuss your inhalers with your own GP, respiratory physician, or pharmacist.

About the integrative content. The lifestyle, dietary, and complementary recommendations on this page summarise current published research. Individual response varies, and real-world results are commonly smaller than trial results because day-to-day life differs from study conditions. Supplements and herbal products are not interchangeable with prescribed inhaler therapy and can interact with it. Talk to your doctor and pharmacist before starting any new supplement or herbal product, and before any significant change to your inhaler routine.

Currency. This page reflects clinical practice as of the last-reviewed date. Inhaler ranges and PBS listings change — Flutiform AU supply has been intermittent in recent years and Trelegy and Trimbow PBS authority criteria have been revised over time. Confirm specific product availability and pricing with your pharmacist.

No commercial relationships. Dr Hoebing Lo has no financial or commercial relationship with the manufacturer of any inhaler, brand, or supplement mentioned on this page.

Emergencies. If your chest tightens immediately after a puff (paradoxical bronchospasm), if your reliever is not improving an attack, if you have blue lips, severe breathlessness, can’t speak in sentences, sudden swelling of face, lips, tongue or throat, or eye pain with blurred vision on a triple-therapy inhaler — call 000 or go to your nearest emergency department. Do not wait, and do not message us first.