For patients with moderate-to-severe persistent asthma, new guidelines from the NAEPP recommend SMART, particularly for patients with a recent disease exacerbation.
The use of single maintenance and reliever therapy, SMART, for asthma is recommended for patients with moderate to severe persistent asthma and patients who have had a severe exacerbation in the prior year are noted as particularly good candidates.
These recommendations are from 2020 updated guidelines from the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI), published in December 2020 in the Journal of Allergy and Clinical Immunology.
The "focused updates" are the agency's first since 2007. SMART is recommended within the section focused on use of intermittent inhaled corticosteroids.
The Guideline Toplines slide show below offers a quick look at the recommendations for SMART, including patient selection, dosing schedule and dosage, and benefits associated with this approach.
NAEPP Recommendation 13. In individuals aged 12 years and older with moderate to severe persistent asthma, the Expert Panel conditionally recommends inhaled corticosteroid/formoterol
in a single inhaler used as both daily controller and reliever therapy vs higher-dose ICS-LABA as daily controller therapy and SABA for quick-relief therapy.
ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; SABA, short-acting beta agonist.
Target Population. Individuals aged ≥4 yrs with a severe exacerbation in the prior year are particularly good candidates for SMART to reduce exacerbations. Do not use ICS/formoterol as reliever therapy in individuals taking ICS/salmeterol as maintenance therapy.
Treatment. Inhaled ICS-formoterol in a single inhaler. This form of SMART therapy has only been studied with formoterol as the long-acting beta2-agonist (LABA). SMART is appropriate for Step 3 (low-dose ICS) and Step 4 (medium-dose ICS) treatment.
Treatment. Individuals whose asthma is uncontrolled on maintenance ICS-LABA with SABA as quick-relief therapy should receive the preferred SMART if possible before moving to a higher step of therapy. Note: maintenance ICS-LABA with SABA as quick-relief therapy does not need to be changed if it is providing adequate control.
SMART dosing. ICS-formoterol should be administered as maintenance therapy with 1–2 puffs once or twice daily (depending on age, asthma severity, and ICS dose in the ICS-formoterol preparation) and 1–2 puffs as needed for relief of asthma symptoms.
SMART Maximum puffs-per-day. Children aged 4-11 yrs: 8 puffs (36 µg formoterol). Individuals aged ≥12 yrs: 12 puffs (54 µg formoterol). Dose of formoterol was based on 4.5 µg /inhalation, the most common preparation used in the studies reviewed.
Advise & Assess. Patients should be advised to contact the treating clinician if they need to exceed maximum dosage. Patients using SMART should be assessed for efficacy, inhaler use technique, etc,
on a regular basis.
NAEPP: SMART Benefits. In studies reviewed, SMART consistently reduced asthma exacerbations requiring unscheduled medical visits or systemic corticosteroids and, in some studies, improved asthma control and QOL. Reduced exposure to OCS and ICS suggest that SMART might reduce future corticosteroid-associated harms (ie, growth suppression in children aged 4-11 yrs.
NAEPP: Risks? Studies found no difference in documented harms between SMART and daily ICS, or ICS-LABA controller therapy
with SABA for quick relief.
NAEPP: SMART Considerations. This recommendation might not be appropriate for some patients because of cost, formulary considerations, or medication intolerance. A 1-month supply of ICS-formoterol that is sufficient for maintenance therapy may not last a month if the inhaler is used for reliever therapy as well.