Why SMART Should be Adopted in Asthma Management
Single Maintenance and Reliever Therapy (SMART) is a technique where a single inhaler is used for daily asthma control and used for as- needed symptom relief. This strategy combines prescription inhalers containing an inhaled corticosteroid (budesonide or mometasone) and a long-acting beta2-agonist (formoterol), which are indicated for indicated for SMART. Given its dual-purpose approach, adopting SMART in asthma management improves disease control and enhances the quality of life for patients.
Components of SMART Therapy
Inhaled corticosteroids (ICS) function to reduce and control inflammation within the lungs through its potent glucocorticoid activity, which helps prevent the occurrence of asthma attacks. Below are examples of ICS medications:
Inhaled corticosteroids (ICS)
- Fluticasone
- Budesonide
- Mometasone
- Beclomethasone
- Flunisolide
The intended use for ICS in asthma is for controller therapy. During episodes of inflammation, capillaries in the lung become more permeable or “leaky.” This contributes to immune cells and fluid accumulating in the surrounding tissues, and ultimately it leads to swelling and airway narrowing. Budesonide and mometasone, two ICSs typically used in SMART, work to reverse the permeability of capillaries, leading to the reduction of airway obstruction caused by swelling. In addition, budesonide and mometasone also work to prevent tissue damage. They contribute to the lysosome stabilization, which reduces the quantity of degrading enzymes released. This limits the extent of injury to tissues in the airway. Previously, ICS treatment was only used in patients who experienced persistent symptoms. However, large clinical studies have demonstrated that regularly using ICS reduces the risk of severe asthma exacerbation. This reduction decreases the number of asthma-related hospitalizations and death.
Long-acting Beta2-agonist (LABA) drugs functions as a potent bronchodilator through stimulating beta2 receptors located on bronchial smooth muscle, increasing cyclic adenosine monophosphate (cAMP). The downstream effects of cAMP lead to muscle relaxation and bronchodilation. Below are examples of LABA medications:
Long-acting Beta2-agonist (LABA)
- Salmeterol
- Formoterol
- Vilanterol
Compared to short-acting Beta2-agonists (SABAs), LABAs have a higher degree of selectivity for bronchial smooth muscle beta2 receptors. This increased receptor selectivity contributes to a more favorable adverse effect profile, offering a therapeutic advantage over SABAs. However, the greatest difference between LABAs and SABAs is their onset of action and duration of therapeutic effects. SABAs act quickly, but wear off quickly, making them ideal for the use of rescue/reliever therapy. In contrast, LABAs have a slower onset of action and a longer duration of action. Because of this, we have typically have only seen LABAs used as controller therapy. However, unlike other LABAs, formoterol offers a rapid onset of action, typically seen within 1-2 minutes. This unique pharmacokinetic profile gives formoterol the advantage over other LABAs because it may be of being used as a rescue/reliever in addition to controller therapy. There is an FDA black box warning for LABA monotherapy in asthma treatment. It is important to note that LABA without ICS is contraindicated in asthma due to the increase in severe exacerbations and asthma-related death.
Where do SABAs Fit in SMART?
Previously, SABA monotherapy was a cornerstone approach to patients with mild asthma. However, the use of SABA monotherapy in asthma treatment has been found to have severe clinical consequences, largely due to their unfavorable dose-response relationship. One of the key concerns is the development of tolerance, which can occur within a week of regular use. Tolerance is driven by the downregulation of bronchial smooth muscle beta2-receptors and a decrease in drug-receptor binding affinity. As a result, the bronchodilator response to SABAs becomes less effective over time, which results in reduced symptom control. In addition to reduced efficacy, there is evidence to support that the frequent use of SABA alone, even over short durations, is associated with an increased risk for asthma-related death. This prompted The Global Initiative for Asthma (GINA) to reassess the role of SABAs, and search for a new approach in the treatment and management of asthma. Formoterol has been found to be effective as a controller and as a rescue/reliever, causing a shift in what the guidelines previously recommended in 2019.
Why use SMART?
GINA and the National Asthma Education and Prevention Program (NAEPP) recommend SMART in patients with mild asthma who are 12 years of age or older. ICS-formoterol combination is the preferred approach to SMART because it is widely available as either Symbicort or Dulera. In addition, since SMART uses a single inhaler to provide maintenance and symptom control, patients no longer will need two inhalers for asthma management. Simplifying the treatment regimen to one inhaler leads to reduced confusion, increased adherence, and potentially cost savings.
The FDA has not approved the use of ICS-formoterol inhalers as part of SMART in the United States. This can affect prescription drug coverage as insurance may not cover a treatment that has not formally been approved. Despite this, GINA and the NAEPP endorse SMART for asthma. Although there is no FDA approval for SMART, ICS-formoterol can still be prescribed “off-label” as a rescue/reliever and controller.
Where do Pharmacists Fit in with SMART?
There is an overwhelming overwhelming number of medications available on the market for management and treatment of asthma. Pharmacists specialize in product selection and therapeutic substitution to ensure that patients receive the most appropriate medication regimen. For patients who are currently using separate inhalers for controller and rescue/reliever therapy, or those relying solely on SABA monotherapy due to adherence challenges or other barriers, pharmacists can recommend SMART. Pharmacists can help identify formulary-preferred options that are covered by the patient’s insurance plan, leading to cost savings. Additionally, pharmacists can advocate for this therapeutic switch in practices that operate under a Collaborative Practice Agreement (CPA), and pharmacists are also authorized to initiate this change directly. Another impactful way pharmacists can support the implementation of SMART is through comprehensive patient education, particularly in teaching proper inhaler techniques and reinforcing adherence. Ensuring that patients understand the dual purpose of the inhaler and clarifying when and how to use it is important to optimize treatment. Lastly, pharmacists can monitor for potential drug-drug interactions that may interfere with treatment or exacerbate asthma symptoms.
SMART Takeaway
SMART represents a significant advancement in the treatment and management of asthma by combining an ICS with formoterol in a single inhaler for both control and symptom relief. This approach simplifies therapy and reduces costs. Clinical trials have demonstrated effectiveness in reducing exacerbations and improving overall asthma control. Supported by current guideline recommendations, including those from GINA, SMART is now the preferred treatment strategy for patients 12 years of age or older. Adopting SMART into clinical practice provides the opportunity to significantly enhance patient outcomes and quality of life.
Cierra L., APPE Student
References:
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- American Academy of Allergy, Asthma & Immunology. SMART Therapy for Asthma. Published 2024. Accessed June 5, 2025. https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/smart