What Is SMART Therapy for Asthma?
Key takeaways:
SMART therapy for asthma means needing only one inhaler for both “daily” and “rescue” asthma treatment.
A SMART treatment inhaler contains two medications: a steroid and a particular long-acting beta-2 agonist (LABA) called formoterol.
Although experts recommend SMART for most people who use asthma inhalers, it’s a new idea that hasn’t been approved by the FDA yet.
Right now, there aren’t many medication choices available for SMART, and those that are available can be very expensive.
Asthma can be a frightening disease, and the treatment for it is complicated. New guidelines aim to make life simpler — and safer — for many people with asthma by encouraging use of a single two-medication inhaler for both everyday and emergency use.
What does SMART therapy mean?
SMART stands for “single maintenance and reliever therapy.” It means using one inhaler every day to prevent asthma — and then using the same inhaler as treatment when you do have asthma symptoms.
SMART asthma therapy has recently been recommended as a first-choice treatment for people over age 5 with asthma — even if they don’t get symptoms very often.
Breathe Better with Dulera
Dulera may help control and prevent symptoms of asthma. Pay as little as $199 with GoodRx.
The medication used for SMART is a combination of an inhaled steroid and a particular long-acting beta-2 agonist (LABA) called formoterol. Currently, this combination is available as:
How does SMART work?
SMART therapy puts asthma prevention and asthma treatment into the same inhaler.
Asthma management often means taking at least two medications — one for prevention, and one for treatment. Some people need additional medications as well.
Inhaled steroids like budesonide (Pulmicort), fluticasone (Flovent), and mometasone (Asmanex) are the most common asthma preventatives. These medications keep your airways from swelling, and they’re important for controlling asthma over time.
Beta-2 agonists (SABAs and LABAs) treat the symptoms of asthma by opening airways that have gotten tight. Short-acting beta-2 agonists (SABAs) like albuterol (ProAir, Proventil, or Ventolin) are often used as rescue medications.
Formoterol is a LABA. It’s not new, but using it in a rescue inhaler is a new idea.
The combination of formoterol and an inhaled steroid together — SMART — turns out to be a handy mix. That’s because long-lasting formoterol can play a role in prevention, as well as in treating symptoms. And adding that extra burst of steroid during flares helps dial back lung inflammation — right when you need it most.
What does the science say about SMART?
SMART works well. A 2018 review of all the scientific studies looking into this question showed that people who used SMART therapy had fewer asthma attacks overall than people who were taking different prevention and rescue medications.
For most people, SMART doesn’t mean taking extra steroids. With fewer asthma attacks overall, you’re less likely to need high-dose steroids — like prednisone or dexamethasone — when you get sick.
Plus, SMART simplifies asthma management because you only need one inhaler. With standard asthma therapy, trying to remember which medication to use can be tricky. With SMART, one inhaler is all that’s needed.
Who might benefit from SMART for asthma?
People with asthma who need daily controller medication, and who also sometimes take albuterol as a rescue medication, can benefit from SMART.
Some people who only use albuterol occasionally, and don’t need to take a preventative every day, might also benefit from SMART. That’s because the steroid in SMART is better at targeting the root cause of asthma than albuterol alone.
Is there anyone who shouldn’t use SMART?
SMART is for people with asthma — that is, people whose airways react and swell in response to illnesses, allergies, or triggers in the environment. People who use inhalers for different conditions might not benefit from SMART.
Anyone using a different LABA for asthma — such as salmeterol (Serevent) — should not take formoterol too. Other steroid/LABA combinations (Advair, AirDuo, Wixela Inhub) haven’t been studied yet for use as SMART.
People with very difficult-to-control asthma, such as those who require high doses of daily steroids, could need stronger medications than what SMART can offer.
SMART medications aren’t great for little kids. For children younger than age 5, daily and as-needed medications should still be given separately.
What are the downsides to using SMART?
The biggest problem with SMART right now is the cost. Because only a couple companies make the particular mix of medications needed, it can be difficult to find the inhaler you need at a reasonable price.
And although experts are recommending SMART for many people with asthma, combination inhalers haven’t been approved for rescue use yet by the Food and Drug Administration (FDA). That means you could face some headaches trying to get your prescription covered by insurance. And getting refills could also present problems, especially if you need to use your inhaler frequently.
Why did the guidelines change?
In 2020, a group of experts from the National Institutes of Health (NIH) released new recommendations about the best ways to manage asthma. The following year, a different group of international experts released another set of recommendations. Both reports summarized the most up-to-date asthma research and laid out guidelines to improve asthma treatment for everyone. The recommendations for SMART were part of both sets of guidelines.
Does this mean I should change my asthma treatment?
Maybe. If you take inhalers for asthma, and especially if you need to use an inhaler every day, SMART therapy could make sense for you.
Talk to your healthcare provider
If you think SMART might be a good fit for you, talk to your healthcare provider. SMART therapy has good science to support it, and it could make your life easier.
But keep in mind: The fact that there aren’t many medication options available, and that those that are available aren’t FDA-approved for SMART yet, could mean hassles at the pharmacy counter.
Paying for SMART
Right now, the cost of SMART therapy is very high. While some insurances might cover it, there could be problems because of the unusual way this medication is used. For example, a 1-month supply might be covered for daily use, but depending on your dose, you might not have extra to use if your asthma flares.
Medicare coverage can be tricky, too. Again, although SMART therapy might be covered as an everyday medication, you might have trouble getting those as-needed doses paid for.
If SMART is right for you but you’re having trouble paying for it, talk to your healthcare provider and your pharmacist to see what ideas they have. Everyone’s situation is a little different. Depending on your daily medication dose, how often you need a rescue inhaler, and your insurance coverage, there might be ways to get it covered.
The bottom line
If you have moderate or severe asthma and you use multiple inhalers, the new SMART asthma therapy could make things easier. Talk to your healthcare provider about whether or not it’s right for you.
Why trust our experts?
References
Global Initiative for Asthma. (2021). Pocket guide for asthma management and prevention.
Global Initiative for Asthma. (2023) Reports.
Global Initiative for Asthma. (2023). Science Committee.
National Heart, Lung, and Blood Institute. (n.d.). National Asthma Education and Prevention Program Coordinating Committee.
National Heart, Lung, and Blood Institute. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee expert panel working group.
Sobieraj, D. M., et al. (2018). Association of inhaled corticosteroids and long-acting β-agonists as controller and quick relief therapy With exacerbations and symptom control in persistent asthma. JAMA.
