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Current guidelines recommend anti-inflammatory reliever (AIR) therapies that combine inhaled corticosteroids (ICS) and formoterol for newly diagnosed asthma and patients treated with SABA only. Budesonide-formoterol (BUD-F) is the only combination licensed for as-needed AIR in the UK; however, beclometasone-formoterol (BDP-F) may be used as an alternative in the real-world setting. We conducted a non-inferiority study (pre-specified 20% non-inferiority margin; IRR 1.20) for exacerbation prevention of BDP-F (Fostair) AIR compared with BUD-F (Symbicort) AIR. We compared exacerbations pre- and post-AIR initiation, oral corticosteroid (OCS) use, and risk of acute cardiovascular (CVD) events.A historical cohort study using the Optimum Patient Care Research Database, UK. Adults with asthma, no other chronic respiratory condition, and ≥1 year GP registration who initiated BDP-F AIR or BUD-F AIR (‘likely intent’ based on prescription instructions and ≤1 SABA inhaler at follow-up) for the first time (index date) after July 2012 were followed up for ≤1 year. Inverse probability treatment weighting (IPTW), adjustment and prior event rate ratio (PERR) methods controlled for baseline differences between groups. Non-inferiority of exacerbations used Poisson regression (incident rate ratios [IRR] with bootstrapped confidence intervals [95% CI]). Changes in OCS use and incidence of acute CVD events post-initiation of AIR were also compared.Among 8,750 adult patients, 1,630 (18.6%) were initiated onto BDP-F AIR and 7,120 (81.4%) BUD-F AIR between Jul 2012 and Apr 2025. BDP-F AIR was found to be non-inferior to BUD-F AIR for exacerbation prevention: IRR=0.85 (0.61,1.16). The percentage of people with ≥1 exacerbation at baseline reduced by 7.0% after initiation of BDP-F AIR (relative reduction: 67.5% [57.1,79.8]; p<0.001) and 3.3% after initiation of BUD-F AIR (relative reduction: 76.9% [66.2,88.9]; p<0.001). OCS use reduced with both AIR regimens, but the reduction was significantly greater in the BDP-F AIR group (0.24 mg vs 0.05 mg; p<0.001). Incidence of CVD events post-initiation of AIR was similar for both groups: IRR=1.04 for BDP-F vs BUD-F [0.46,2.34]).BDP-F AIR is non-inferior to BUD-F AIR for exacerbation prevention, results in significantly lower OCS use, and has comparable outcomes for acute cardiovascular events.