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SMART dosing in asthma patients 'reduces the risk of serious exacerbations'

Patients using their combination inhaler for rescue relief and prevention are 40% less likely to experience a severe asthma exacerbation, compared with those using standard dosing, shows a large study that provides ‘remarkable’ new evidence for SMART dosing.

The study - the first to be independent of pharmaceutical industry funding - found that the use of SMART dosing in asthma reduced the risk of beta-agonist overuse and did not increase the use of long-term systemic corticosteroids, compared with standard dosing with a combination inhaler and salbutamol.

The study found SMART dosing with a combination budesonide-formoterol inhaler significantly reduced the number of high-use days by four – defined as using the inhaler 12 times or more in a day – compared with the standard dosing group.

SMART dosing is recommended at step three of the BTS/SIGN guidelines, but only in adults who are poorly controlled. The guidelines also suggest it as a possible treatment at step two, but only in poorly controlled adults who are taking more than 400 mcg/day of beclometasone.

The 24-week study - published recently in The Lancet - randomised 303 patients aged 16 to 65 years who had at least one exacerbation in the previous 12 months to receive either SMART dosing with a budesonide-formoterol inhaler, or a standard twice-daily dosing of budesonide-formoterol as maintenance with salbutamol added in to be taken as a reliever when needed.

They found participants on the SMART dosing strategy were 44% less likely to experience a severe exacerbation, compared with those on standard treatment.

The authors concluded: ‘The SMART regimen reduces the risk of beta-agonist overuse without medical review or increasing the long-term systemic corticosteroid burden.

‘The SMART regiment has a favourable risk-benefit profile compared with standard maintenance treatment and can be recommended for use in adults at risk of severe asthma exacerbations.’

An accompanying editorial, authored by Dr Rene Aalbers, a respiratory specialist at Martini Hospital in Groningen said the findings were ‘remarkable’.

He said: ‘When compared with the traditional fixed-dose inhaled corticosteroid and a LABA, the dissociation between no improvements in functional measurements of the SMART approach on the one hand and significant improvements in exacerbations on the other hand are remarkable, yet in accord with those findings in earlier studies.’

Dr Rupert Jones, a GPSI in respiratory medicine and lead of the respiratory research unit at the Universities of Exeter and Plymouth, said the data added to the growing popularity of SMART dosing in asthma.

He said: ‘There is room for this approach in general practice. I find some patients benefit from the one inhaler as it reduces confusion over regimes with two or more. It is not for everybody, but there are patients for whom this strategy is worthwhile.’

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Readers' comments (3)

  • Vinci Ho

    This is not new . In fact , the evidence is over 10 years.
    The key is formoterol doses can be varied but you cannot do the same with salmeterol. Some patient really cannot handle with power form inhaler and
    overusing can still be an Issue with any inhalers .

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  • Vinci Ho

    Sorry
    I mean this evidence is new but the SMART use is well over 10 years

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  • I would agree that this info is not world shattering nor new per se. Whilst this is of interest, and for certain patients effective, we should look at the costs of widespread increased SMART use. LABA s are expensive and patients may use higher doses for longer and more often than necessary. In my experience only a small number of patients grasp how to use this approach properly. Used in BTS 2 for example, in Practices who may not closely monitor frequency of inhaler ordering, the costs could be a) massive (Symbicort is nearly £40 a shot..12 puffs a day, means an inhaler gone in 10 days) and b) not deliver what this study shows. SMART, when appropriately targeted and closely monitored in high risk patients can be very effective, but handle with care !!

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