A Practical Guide to Implementing SMART in asthma management.

Abstract The use of a S ingle inhaler containing the combination of an inhaled corticosteroid (ICS) and formoterol, a specific long-acting bronchodilator (LABA), for both M aintenance A nd quick R elief T herapy (SMART, or MART) is recommended by both the Global Initiative for Asthma (GINA) and the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee in Steps 3 and 4 of asthma management. This article provides practical advice about implementation of SMART in clinical practice based on evidence and clinical experience. Fundamental to SMART is that ICS-formoterol provides similarly quick relief of asthma symptoms as short-acting beta2-agonist (SABA) such as albuterol, while reducing the risk of severe asthma exacerbations, at an overall lower ICS exposure. Most SMART clinical trials were in adults and adolescents (≥12 years), using budesonide-formoterol 160/4.5 mcg (delivered dose), 1 inhalation once or twice daily (Step 3) and 2 inhalations twice daily (Step 4). For both Step 3 and 4, patients also take additional inhalations of budesonide-formoterol 160/4.5 mcg, 1 inhalation whenever needed for symptom relief, up to a maximum for adults/adolescents of 12 total inhalations in any single day (delivering 54mcg formoterol). The efficacy and safety of SMART with budesonide-formoterol and beclometasone-formoterol have been confirmed, but other ICS-long-acting bronchodilator combinations have not been studied. The SMART regimen should be introduced with a careful explanation of its role in self-management and preferably with a customized written asthma action plan. The cost to patients and availability of SMART treatment will depend on prescribed dose and national/local payer agreements.