This article in the Drug and Therapeutics Bulletin (DTB) reviews the use of single maintenance and reliever therapy (SMART). This involves using a single inhaler containing a corticosteroid (budesonide) and a long-acting beta2 agonist (LABA; formoterol), for regular maintenance treatment, but also for additional ‘rescue’ use on an as-needed basis.

The following topics are covered:

• Background

• Current treatment options

• Issues and problems

• About SMART

• Clinical evidence

• Unwanted effects

• Issues when considering and using SMART
 

The review notes that the SMART regimen is included as a possible option for adults at ‘step 3’ of the joint asthma guideline from the BTS/SIGN for people with poorly controlled asthma. Furthermore, there is published evidence supporting its use at the two lower-dose budesonide-formoterol (Symbicort) Turbohalers, but none for other combination inhalers. The data indicate that in some comparisons, the Symbicort SMART regimen appeared to reduce the rate of exacerbations requiring treatment with oral corticosteroids but not those that resulted in hospitalisation. However, SMART was not shown to be more effective than current ‘best practice’. The review concludes “in theory, use of the SMART regimen might help by reducing the number of inhalers required. However, patients using this approach would need a clear action plan and close monitoring of the number of inhalations that they are taking. Consequently, its place in practice remains unclear.”