The Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program Coordinating Committee (NAEPP) recommend single maintenance and reliever therapy (SMART), utilizing a single inhaler containing an inhaled corticosteroid (ICS) and formoterol, a long-acting bronchodilator, in steps 3 and 4 of asthma management. This article offers practical guidance, grounded in evidence and clinical experience, for successfully implementing SMART in clinical practice.
A core principle of SMART is the ability of ICS-formoterol to provide rapid relief from asthma symptoms, comparable to short-acting β2-agonists like albuterol. Crucially, it also reduces the risk of severe asthma exacerbations while simultaneously lowering overall ICS exposure.
Clinical trials evaluating SMART primarily involved adults and adolescents (≥12 years old). These studies typically used budesonide-formoterol 160/4.5 μg (delivered dose). The regimen included one inhalation once or twice daily for step 3 asthma management and two inhalations twice daily for step 4. In both steps, patients could take additional inhalations of budesonide-formoterol 160/4.5 μg as needed for symptom relief. Adults and adolescents were instructed to not exceed a maximum of 12 total inhalations in a single day, delivering a maximum of 54 μg of formoterol.
The efficacy and safety profiles of SMART have been established for budesonide-formoterol and beclometasone-formoterol combinations. It is important to note that other ICS-long-acting bronchodilator combinations have not undergone the same level of scrutiny in clinical trials.
Introducing the SMART regimen necessitates a thorough explanation of its role in asthma self-management. Ideally, this explanation should be accompanied by a personalized, written asthma action plan. This ensures the patient understands how to appropriately adjust their medication based on their symptoms.
Patient cost and the availability of SMART treatment options are subject to factors such as the prescribed dosage and national or local healthcare payer agreements. Healthcare providers should be aware of these variables when discussing treatment options with their patients.
In summary, SMART offers a valuable approach to asthma management by providing both maintenance and quick relief with a single inhaler. Proper patient education and a tailored asthma action plan are essential for successful implementation. Healthcare professionals should consider cost and availability factors when prescribing SMART.
