SMART therapy stands for Single Maintenance and Reliever Therapy. It is primarily for patients with moderate to severe asthma who need a combination treatment. This combined treatment includes an inhaled corticosteroid and an inhaled long-acting beta-2 agonist (LABA).
Typical therapy involves using different inhalers for maintenance and reliever. With SMART therapy, it allows patients to use one inhaler for both. The maintenance dose can be adjusted based on the needs of the individual, but it is typically at least two doses a day (either two at once or one dose twice a day).
What medicines are in SMART therapy?
SMART therapy is a combination of an inhaled corticosteroid and an inhaled LABA. Currently, this combination is available in two medications:
- budesonide/formoterol (Symbicort®)
- mometasone/formoterol (Dulera®)
In asthma guidelines for SMART therapy, the budesonide/formoterol combination is the recommended first treatment.
How does SMART therapy work?
SMART therapy allows people with asthma to use just one medication. They use this single medication for both maintenance and reliever therapy.
Typical quick-relief inhalers contain only a bronchodilator. Maintenance medications often include an anti-inflammatory inhaled corticosteroid. But with SMART therapy, the inhaler has both a bronchodilator and an anti-inflammatory medication. This is helpful as it means people are getting daily medicine to keep their airways open. When they are experiencing symptoms, they are getting extra anti-inflammatories. This helps to reduce airway inflammation.
Who can receive SMART therapy?
Under asthma guidelines, SMART therapy is recommended for people with moderate to severe asthma, especially children ages 5 and older. In general, SMART therapy is considered an easier treatment plan to follow.
SMART therapy may also be considered as an as-needed treatment for mild asthma. Formoterol is a long-acting inhaled medication but it works quickly, similar to quick-relief albuterol. Researchers recently conducted a series of clinical trials called SYGMA (Symbicort Given as Needed in Mild Asthma). The clinical trials found the rate of severe asthma flares in adolescents (ages 12 to 18) and adults with mild asthma was significantly lower when using Symbicort as needed, instead of just a short-acting bronchodilator as needed.
Important: SMART therapy for mild asthma is not FDA-approved. Talk with your doctor about whether this may be an option for you or your child. Since it’s not FDA-approved, your health insurance may not cover it.
What is moderate to severe persistent asthma?
People with moderate asthma have daily symptoms or wake up at night due to symptoms at least once a week.
People with severe asthma have symptoms throughout the day. They also report waking up at night with symptoms, even after taking treatment. Learn more about understanding asthma severity.
How will I know if SMART therapy is right for me or my child?
To determine if SMART therapy is right for you or your child, consider Shared Decision-Making. In Shared Decision-Making, you partner with your doctor to decide the right treatment approach. The treatment approach is based on your asthma control, lifestyle and other healthcare needs and preferences. Then you work together to develop an Asthma Action Plan so you know what to do for treatment when symptoms occur.
Some questions to ask your doctor include:
- Do I have moderate to severe asthma? Does my child?
- Is SMART therapy appropriate for me or my child?
- How can I tell if SMART therapy is working well?
What are important points for clinicians to know about SMART therapy?
- Traditional asthma management uses different medicines for maintenance versus reliever. SMART therapy uses the same medication for the maintenance and reliever.
- SMART therapy may take away some of the confusion about which inhaler to use and when for many patients.
- SMART therapy is part of the current National Asthma Education and Prevention Program (NAEPP). It is detailed in the 2020 National Heart, Lung, and Blood Institute (NHLBI) guidelines. SMART therapy is also detailed in 2022 Global Initiative for Asthma (GINA) guidelines.
- SMART therapy is not currently FDA-approved for mild asthma.
There is a new drug combination being studied for moderate to severe asthma. The MANDALA study found effectiveness in a combination of albuterol and budesonide. This may lead to another new combination drug for treatment of moderate to severe asthma
Bradley Chipps, MD, FACAAI, is a board-certified allergist and pediatric pulmonologist with Capital Allergy and Respiratory Disease Center in Sacramento, California. He earned his medical degree from University of Texas Medical Branch in Galveston in 1972. He is Past President of the American College of Allergy, Asthma and Immunology (ACAAI).