Study Finds SMART Combination Inhaler Regimen For Asthma Treatment Is Under Prescribed


The study estimates that over 40% of academic pulmonary and allergy providers have not adopted the Single Maintenance and Reliever Therapy combination method in their practices.

According to study findings, approximately 14.5% of adult patients who have moderate to severe asthma are prescribed the recommended Single Maintenance and Reliever Therapy (SMART) combination inhaler regimen. The data were presented that the 2024 American Thoracic Society International Conference in San Diego, which was held May 17 to May 22.1,2

Asthma inhaler with cartridge -- Image credit: Davizro Photography |

Image credit: Davizro Photography |

The National Asthma Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) have updated their guidelines by 2021 to recommend that patients use SMART plus an inhaled corticosteroid (ICS)-formoterol to manage their moderate-to-severe persistent asthma. The SMART guidelines note that these inhalers can be used as both maintenance—twice per day—or rescue inhalers during asthma attacks. Although SMART has demonstrated in previous research to significantly reduce exacerbations related to asthma, there is little research on the actual uptake of SMART.1,2

“There has been limited data to describe the use of SMART following the update in asthma management guidelines, with no data on the implementation of SMART using administrative or electronic medical records in the United States to the best of our knowledge,” said first author Zoe Zimmerman, BS, medical student and researcher in the Department of Pulmonary, Critical Care, and Sleep Medicine at Yale University School of Medicine, in a news release.1

For this study, an electronic medical record search was used to select patients who had at least 1 pulmonary or allergy clinic visit between January 2021 and August 2023, a diagnosis of asthma, no alternative pulmonary diagnoses, and a prescription for either a maintenance ICS-long-acting beta-agonist (LABA) or ICS. Further, the investigators conducted a chart review and assessed provider documentation to confirm whether patients were eligible for the study and were prescribed SMART.2

A total of 1502 patients with an average age of 48.6 years with moderate-to-severe asthma were included in the final analysis. Of these patients, approximately 75.2% of patients were women, 23.6% were Hispanic or Latinx, and 59.7% were White. Additionally, about 44% (n = 656) were prescribed ICS-formoterol—such as budesonide/formoterol (Symbicort; AstraZeneca) or mometasone/formoterol (Dulera; Organon, LLC)—as a controller inhaler. Approximately 15% (n – 219) of patients were prescribed SMART, and among this subgroup, 89% (n = 195) were co-prescribed a short-acting beta-agonist (SABA) reliever.2

According to the findings, patients who were prescribed an ICS-formoterol as a baseline controller were more likely to be prescribed SMART. Further, patients who were considered obese and those with a higher number of comorbidities were less likely to be prescribed SMART. Medicaid patients were also less likely to be prescribed SMART compared with their privately insured counterparts. The authors note that this is likely because providers believe that older patients may be less resistant to changing treatment regimens, especially if they have previously used the same treatments or inhalers for years.1,2

“Our findings suggest current asthma management guidelines are not being routinely implemented or adopted by clinicians,” said senior author Sandra Zaeh, MD, MS, pulmonary and critical care medicine physician, Yale University School of Medicine, in the news release.1

The findings show that SMART is under-prescribed to patients who qualify, with most patients simultaneously being prescribed a SABA. In addition, the investigators note that health care providers may be more likely to prescribe SMART to those who are using ICS-formoterol as a controller inhaler compared to other controllers. Further, the investigators emphasize that approximately 40% of academic pulmonary and allergy providers have not yet adopted the SMART combination inhaler regimen in their practice. This is especially noteworthy because, according to the investigators, past studies have suggested that it can take over 15 years for guidelines to become widely adopted by health care providers. Their findings align with prior research.1,2

“This discordance (shown in the current study) between guidelines and practice is important to recognize and remedy as use of SMART can improve asthma outcomes by reducing asthma exacerbations. It is important to not only do research to identify the most effective therapies for patients, but also to track implementation and address limitations,” said the authors in the news release.1

1. American Thoracic Society. Few Moderate or Severe Asthma Patients Prescribed Recommended Inhaler Regimen. News release. May 13, 2024. Accessed May 23, 2024.
2. Zimmermam, Z, Eakin, M, Chupp, GL, et al. Utilization of Single Maintenance and Reliever Therapy (SMART) for Moderate and Severe Asthma (abstract). Am J Respir Crit Care Med 2024;209:A6601. doi:10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A6601
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