SMART Therapy for Asthma
What does SMART stand for?
SMART or MART therapy stands for "Single Maintenance and Reliever Therapy." It uses one inhaler that combines two medicines: an inhaled corticosteroid (ICS) to treat inflammation, and formoterol, a long-acting beta-2 agonist (LABA) to help open up the lungs. You use this inhaler every day to control asthma and also for quick relief when you need it.
Who recommends it?
The Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program (NAEPP) recommend this approach for patients with moderate to severe asthma.
What patients should use it?
• Teens and Adults (12+ years): Recommended for those with moderate to severe asthma not well-controlled by a low- or medium-dose daily inhaled corticosteroid alone.
• Children (4+ years): Suggested for children not well-controlled on a low- or medium-dose daily inhaled corticosteroid alone.
How does it work?
SMART therapy combines two medications with different mechanisms of action in one inhaler:
• Inhaled corticosteroid: helps reduce the ongoing inflammation in the airway, which addresses the root cause of asthma.
• Long-acting beta-2 agonist: a bronchodilator that quickly opens the airway and lasts approximately 12 hours which provides symptom relief.
What medications are used in SMART therapy?
SMART therapy combines ICS and a rapid-onset LABA. The studies for SMART therapy were conducted using formoterol, and it is the only LABA approved for this type of therapy. Currently, there are two medications containing an ICS + formoterol available in the United States:
• Budesonide/formoterol (Symbicort®)
• Mometasone/formoterol (Dulera®)
Of note, medications with other LABAs, like vilanterol or salmeterol, should not be used in SMART therapy as they do not open up the airways as quickly as formoterol.
What are the maximum doses?
For budesonide/formoterol—the most commonly used combination— the recommended formulation for children between 5 and 11 years old is 80/4.5mcg with a maximum dose of 8 puffs daily. The preferred formulation for individuals older than 12 years is 160/4.5mcg with a maximum dose of 12 puffs a day.
There are no current studies on using mometasone/formoterol for SMART. However, if considered, the preferred formulation for adults is 100/5mcg with a maximum dose of 11 puffs a day and 50/5mcg for children with a maximum dose of 7 puffs a day.
What are the potential benefits?
• Fewer Severe Asthma Attacks: SMART therapy helps prevent serious asthma attacks better than using separate inhalers for daily control and quick relief.
• Less Corticosteroid Use: It can reduce the amount of corticosteroids you need, which can help lower the risk of side effects.
What are some potential barriers?
Although several studies support the implementation of SMART therapy in patients with moderate to severe asthma, the Food and Drug Administration (FDA) has not approved the use of ICS-formoterol inhalers as rescue inhalers or as part of SMART therapy in the United States. However, SMART therapy has been approved in other countries, such as the UK, Australia and New Zealand. The lack of FDA approval likely impacts health insurance coverage of inhaler prescriptions. Additionally, current insurance formularies limit the number of inhalers they cover per month, and patients might need more than one inhaler per month, depending on their asthma control.
Using SMART therapy in the real world
The hope is that GINA and NAEPP's evidence-based recommendations will push policymakers and health insurance companies to review their current indications, formularies and inhaler quantity limits. The Missouri Medicaid Program is currently taking the lead with a policy promoting SMART therapy, hopefully generating further data to support a change in asthma care. In the meantime, physicians should openly discuss with their patients the potential benefits, risks, costs and feasibility of SMART therapy.
How You Can Benefit from Shared Decision-Making (SDM) with SMART Therapy:
1. Learn About SMART: Understand that your SMART inhaler controls asthma and provides quick relief by combining two medicines.
2. Get a Personalized Plan: Work with your doctor to create a clear plan on how and when to use your SMART inhaler for both maintenance and relief.
3. Address Concerns: Discuss any worries or questions about using a single inhaler for both control and relief with your doctor.
4. Use Helpful Tools: Decision aids and apps can help you understand and choose the best treatment for you.
5. Keep Up with Check-Ups: Regular follow-ups help ensure your treatment is working and make any needed adjustments.
6. Stay Motivated: Motivational techniques can help you overcome doubts and stay committed to your treatment plan.
Following these steps can help you manage your asthma more effectively with SMART therapy.
An allergy and immunology specialist physician is a trained expert in asthma and can develop an individualized therapy plan for your asthma. See your allergy and immunology physician for evaluation of your asthma and your other allergic conditions.
Find out more about asthma.
References
1. Cloutier MM, Baptist AP, Blake KV, Brooks EG, Bryant-Stephens T, DiMango E, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020;146(6):1217-1270.
2. Global Initiative for Asthma. Global strategy for asthma management and prevention, 2024 update. Fontana, WI: Global Initiative for Asthma; 2024. Available from: https://ginasthma.org/2024-report/
3. Reddel HK, Bateman ED, Schatz M, Krishnan JA, Cloutier MM. A practical guide to implementing SMART in asthma management. J Allergy Clin Immunol Pract. 2022;10(1).
4. Arora NS, Zhou S, Baptist AP. Regulatory and insurance challenges must be overcome in the United States to meet global standards for asthma management. J Allergy Clin Immunol Pract. 2024;12(3):624-626.
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11/12/2024