Asthma Management

Introduction to Maintenance And Reliever Therapy (MART)

The American College of Respiratory Medicine and other guideline societies recommend budesonide-formoterol as the primary inhaler combination for MART in asthma, containing both an inhaled corticosteroid (ICS) and a rapid-onset long-acting beta-agonist (LABA) for maintenance and rescue, based on high-certainty evidence 1, 2

The National Asthma Education and Prevention Program (NAEPP) Expert Panel strongly recommends ICS-formoterol in a single inhaler as daily controller and reliever therapy for patients aged 4 years and older with moderate to severe persistent asthma, with superior outcomes compared to higher-dose ICS with SABA for rescue, based on high-certainty evidence 2
The Global Initiative for Asthma (GINA) guidelines recommend as-needed low-dose ICS-formoterol as the preferred reliever for patients prescribed maintenance and reliever therapy, based on evidence from studies using budesonide-formoterol 1
The recommended maintenance dose for SMART with Symbicort is budesonide/formoterol 160/4.5 μg, 1-2 inhalations once or twice daily, with a maximum daily limit of 8-12 total inhalations per day, and an alternative dose of 80/4.5 μg, 1-2 inhalations daily, with a maximum daily limit of up to 8 puffs per day 3

The effectiveness of MART therapy depends partly on the inhaler device used, with an ideal inhaler providing consistent dosing, being easy to use, and comfortable for patients, and dry powder inhalers (DPIs) may have a lower carbon footprint compared to metered dose inhalers (MDIs) 4

Patient education is crucial, including explaining the dual purpose of the inhaler, maximum daily dose limits, and the indication of inadequate control with increasing use, with a recommended maximum daily limit of 8 puffs for children and 10-12 puffs for adults 3, 1, 2
Patients should be assessed for symptom control after 2-4 weeks of initiating therapy, and consideration should be given to stepping down therapy if control is maintained for at least 3 months, and increasing use of the reliever function may indicate inadequate control and require stepping up maintenance therapy 5, 2
Formoterol is essential for SMART therapy due to its rapid onset of action, and age restrictions apply, as SMART therapy has not been extensively studied in children under 5 years old, and insurance coverage issues may arise 3

SMART therapy is currently an off-label use in the United States, and the evidence base is primarily based on clinical trials using budesonide/formoterol, although other ICS-formoterol combinations may be effective 3