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Single Maintenance and Reliever Therapy

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Single Maintenance and Reliever Therapy, SMART Asthma Management Protocol

  • See Also
  1. Long-Acting Beta Agonist
  2. Short-acting Beta Agonist
  3. Beta Agonist
  4. Moderate Persistent Asthma
  5. Severe Persistent Asthma
  • Indications
  1. Moderate to Severe Persistent Asthma in age 12 years and older (preferred management)
  2. Moderate to Severe Persistent Asthma in age 4 to 11 years (may be considered as alternative option)
  • Background
  1. Uses combination Inhaled Corticosteroid with LABA products
  2. Limited to Formoterol (Symbicort or Dulera) due to short onset of action (5 minutes)
  • Protocol
  1. Use combination agent for additional prn dose for exacerbation symptoms
  2. Maintenance base dosing as above
    1. Dose 1-2 puffs (1 puff if under age 12 years) daily or twice daily
  3. Use 1-2 puffs prn up to maximum based on age (additional doses above the maintenance dose)
    1. Age over 12 years old: Up to 12 puffs (Symbicort) or 10 puffs (Dulera) per day (including maintenance)
    2. Age 4 to 11 years old: Up to 8 puffs (Symbicort) or 7 puffs (Dulera) per day (including maintenance)
  4. Indications for medical evaluation
    1. Red Zone Symptoms (call 911, and use rescue puffs every 1-3 minutes up to 6 puffs until EMS arrival)
    2. Yellow zone symptoms for 2-3 days (>4 rescue puffs/day in age <12 years, >6 rescue puffs/day if older)
      1. See Asthma Exacerbation
      2. Consider Corticosteroid burst (e.g. Prednisone 40 mg daily for 5 to 7 days)
      3. Consider increasing maintenance therapy
  • Efficacy
  1. Reduced systemic steroids, ED Visits, hospitalizations (NNT 16)
  2. Now a recommended protocol in the NHLBI Asthma Guidelines 2020
  • Precautions
  1. Extra LABA dosing has been cautioned against in past
  2. Do not use with LABA agents (maintenance or rescue) other than Formoterol
  3. SMART Protocol has been controversial for >10 years
  4. Albuterol rescue Inhaler cost is far less than the combination Corticosteroid/LABA
    1. Extra doses may not be covered by insurance (e.g. early medication refill)
  • References
  1. (2021) Presc Lett 28(3): 14-5
  2. (2022) Presc Lett, August Issue, accessed online 8/2/2022
  3. (2010) Thorax 65(8):747-52 [PubMed]
  4. (2011) Drug Ther Bull 49(11):126-9 [PubMed]
  5. Nalin (2019) Curr Opin Allergy Clin Immunol 19(2):111-7 [PubMed]
  6. Cloutier (2020) J Allergy Clin Immunol 146(6):1217-20 +PMID: 33280709 [PubMed]