A SMARTer Way to Treat Asthma: Pharmacist-led Initiative Shows Improvement in SMART Prescribing


SMART uses an ICS and a long-acting beta-2 agonist (LABA) product, giving patients 4 years and older with moderate to severe uncontrolled persistent asthma 1 inhaler for dual symptom relief.

The Global Initiative for Asthma (GINA) and the National Asthma and Education Prevention Program of the National Heart, Lung, and Blood Institute (NHLBI) recommend single maintenance and reliever therapy (SMART) for patients with asthma. The typical approach to asthma therapy has been to use an inhaled corticosteroid (ICS) routinely, along with a β-2 agonist (e.g. albuterol) as a reliever. SMART uses an ICS and a long-acting beta-2 agonist (LABA) product, giving patients 4 years and older with moderate to severe uncontrolled persistent asthma 1 inhaler for dual symptom relief.

Boy using an asthma inhaler

Image credit: wavebreakmediaMicro | stock.adobe.com

However, implementation of the new therapy has been slow, due in part to the FDA’s hesitancy to adopt these guidelines. Drug insurance coverage mandates on potential early refills or over-utilization cause additional provider concerns, leading to a lack of protocol adoption.

Clinical pharmacists at M Health Fairview Bethesda Family Medicine Clinic in St. Paul, Minnesota, responded to a call to action to impact asthma using SMART protocol in their outpatient clinic. The Journal of the American College of Clinical Pharmacy published their work in the January 2024 issue.

The study’s goal was to determine whether a pharmacist-led initiative could increase SMART prescribing to adults and children older than 6 years. Patients needed to have a diagnosis of asthma and at least 1 clinic visit during the time period. An observational cohort study using retroactive electronic health record (EHR) data found 807 potential patients; 459 patients fit the criteria, females outnumbered males, and the average age was 39.

Although 2 forms of fixed dose inhaled corticosteroid and LABA are marketed in the US—budesonide-formoterol (Symbicort; AstraZeneca) and mometasone-formoterol (Dulera; Organon)—researchers have only studied the budesonide-formoterol sufficiently. This study used budesonide-formoterol as 80-4.5mcg/actuation, or 160-4.5mcg/actuation, and patients were prescribed 2 10.2-gram inhalers for a 30-day supply, with the directions shown in Table 1.

Table 1. SMART Study Dosing

Table 1. SMART Study Dosing

The study evaluated patients over 2 years of age to assess changes in SMART prescribing. As an aside, the researchers reviewed whether the prescribing and use of single inhaler rescue albuterol decreased as a result of the implementation of SMART.

Intervention data consisted of provider drug therapy education and aids to appropriate prescribing. Prescription filling interventions included populating the electronic prescribing “Notes to Pharmacist” fields with text outlining SMART protocol. An interprofessional team of pharmacists, nurses, prescribers, and supportive clinic personnel was formed to discover potential barriers to success. They queried the most common insurance carriers to determine the drug’s coverage status and prior authorization requirements. Prescribers provided drug utilization review (DUR) override codes to minimize pharmacist-physician callbacks, reducing or eliminating rejected prescription claims when dispensed.

Upon completion of the review, SMART prescribing increased from 0.44% to 11.5%. Budesonide-formoterol prescriptions increased from 7.4% to 34.6%, and albuterol prescriptions decreased from 79.7% to 66.2%. Although not causative, the success of this study suggests that similar SMART initiatives by clinical pharmacists at other institutions is promising and worth exploring.


Harris IM, Philbrick AM, Klemenhagen KC. Evaluation of single maintenance and reliever therapy (SMART) prescribing of budesonide- formoterol for asthma after a clinical pharmacist-led initiative. J Am Coll Clin Pharm. 2024;7(3):215‐223. doi:10.1002/ jac5.1922

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