The American Thoracic Society published a guideline in November 2026 on inhaled corticosteroid-containing reliever therapy in adolescents and adults, based on systematic reviews and GRADE assessment across six questions.
At the two mildest steps, it makes a strong recommendation for as-needed ICS-formoterol or ICS-SABA over SABA alone, and a conditional recommendation for them over daily ICS with SABA as needed. At steps 3 to 5, it makes a strong recommendation for maintenance-and-reliever therapy with ICS-formoterol over fixed ICS-LABA with SABA reliever. For patients who stay on fixed ICS-LABA, it conditionally recommends an ICS-SABA reliever over SABA. The panel weighed prevention of severe exacerbations and the risks of SABA-only treatment and systemic steroid exposure.
This brings the US society closer to approaches already used internationally. In India, budesonide-formoterol inhalers are widely available, so maintenance-and-reliever therapy is feasible; the barrier is habit and patient education rather than access.
- Stop prescribing SABA alone for adolescents and adults with asthma.
- Offer as-needed ICS-formoterol for mild asthma.
- Use ICS-formoterol as both maintenance and reliever at steps 3 to 5.
- Teach patients that the same inhaler is used daily and for symptoms.
- Consider an ICS-SABA reliever for patients who remain on fixed ICS-LABA.
Why it matters
SABA-only treatment remains common in mild asthma, the group that still dies from it.
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