What Is SMART Therapy for Asthma?

Asthma can be a frightening disease, and the treatment for it is complicated. New treatment guidelines aim to make life simpler — and safer — for many people with asthma by encouraging the 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.

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 only available in the following inhalers:

• Symbicort (budesonide / formoterol)

• Dulera (mometasone / formoterol)

How does SMART work for asthma?

Asthma management often means taking at least two medications — one for prevention and one for treatment:

• An inhaled steroid, for asthma prevention: Common examples include budesonide (Pulmicort), fluticasone (Flovent), and mometasone (Asmanex). These medications keep your airways from swelling, and they’re important for controlling asthma over time. 

• A bronchodilator, or beta-2 agonists, to treat symptoms: These medications work by opening up tight airways. They can be short-acting beta-2 agonists (SABAs), for example albuterol (ProAir, Proventil, or Ventolin), or long-acting (LABAs), like formoterol or salmeterol (Serevent). 

SMART therapy puts asthma prevention medications and asthma treatment medications into the same inhaler, by combining formoterol with an inhaled steroid. It works because long-acting formoterol plays 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 for asthma?

SMART works well. Here’s what some big studies showed: 

• SMART works when you use it regularly. A review of all the scientific studies showed that people with persistent asthma who used SMART therapy had fewer asthma attacks overall than people who were taking different prevention and rescue medications. 

• SMART works when you use it as needed. A series of clinical trials called SYGMA (Symbicort Given as Needed in Mild Asthma) found that even in mild asthma, using Symbicort as needed was better for preventing symptoms than a short-acting bronchodilator alone. 

Despite what some may think, SMART doesn’t mean taking extra steroids. For most people, since SMART lowers your risk of asthma attacks, you’re actually less likely to need high-dose steroids — like prednisone or dexamethasone — when you get sick. 

EXPERT PICKS: WHAT TO READ NEXT

• Understanding side effects of combination inhalers: Learn which side effects to watch out for when using combination inhalers like Symbicort or Dulera — and what to do if you notice them.

• How much does Dulera cost — and can you save? Dulera can be expensive, especially without insurance. This guide breaks down pricing and offers tips for lowering your out-of-pocket costs.

• Symbicort isn’t the only option. Explore other inhalers that may work just as well and could be easier on your budget.

• Your guide to asthma inhalers: From maintenance inhalers to rescue options, understanding how each type works can help you manage asthma more effectively.

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.

SMART is supported by experts and international recommendations

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 known as the Global Initiative for Asthma (GINA) 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.

Who might benefit from SMART therapy for asthma?

GINA updated their guidelines in 2024 (and again in 2025) to recommend SMART therapy as a preferred treatment for all people ages 12 years and older with asthma, even those with infrequent symptoms: 

• Step 1 and 2 treatment for people who don’t get symptoms very often: low-dose SMART inhaler, used as-needed

• Step 3 treatment for people who get symptoms most days of the week: low-dose SMART inhaler used regularly, plus extra doses when they get symptoms

• Step 4 treatment for people who get symptoms every day: medium-high dose SMART inhaler used regularly, plus extra doses when they get symptoms

GINA also recommended SMART inhalers for children ages 6 to 11 years who get symptoms most days of the week, despite using a SABA like albuterol and a steroid inhaler. 

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 — shouldn’t take formoterol, too. And, other steroid/LABA combinations with medications other than formoterol (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 6 years, daily and as-needed medications should still be given separately. 

Getting SMART to treat your asthma

The biggest problem with SMART right now is the cost. Because only a couple of companies make the particular mix of medications needed, it can be difficult to find the inhaler you need at a price you can afford.

And, although experts are recommending SMART for many people with asthma, combination inhalers haven’t been approved for this use yet by the FDA, despite being approved in the U.K., Australia, and New Zealand. 

Because the lack of FDA approval affects health insurance coverage, 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. 

Talk with a healthcare professional

If you think SMART might be a good fit for you, talk with a healthcare professional. SMART therapy has good science to support it, and it could make your life easier. 

Paying for SMART

Right now, the cost of SMART therapy can be tough to stretch to. 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 with your healthcare team or your pharmacist to explore options. 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 good news is that Symbicort now has a generic version, called Breyna, which may be more affordable. Dulera is still only available as a brand-name medication.

And keep in mind, GoodRx can help with ways to save, including manufacturer copay cards. 

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Written by:

Kerry R. McGee, MD, FAAP

Kerry McGee, MD, FAAP, has over a decade of experience caring for babies, children, and teenagers as a primary care pediatrician. She has a special interest in adolescent health, particularly in adolescent mental health.

Edited by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. A pulmonologist and hospitalist, she practiced and taught clinical medicine at hospitals in London for a decade before entering a career in health education and technology.

Reviewed by:

Alyssa Billingsley, PharmD

Alyssa Billingsley, PharmD, is the director of pharmacy content for GoodRx. She has over a decade of experience as a pharmacist and has worked in clinical, academic, and administrative roles.

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