A new treatment for asthma with just one inhaler

New recommendations by the Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) recommend treating asthma in a new way for better and longer-lasting relief from symptoms.

It is called SMART or MART therapy (Single Maintenance And Reliever Therapy) and is recommended for patients with moderate to severe asthma and uses just one inhaler.

Asthma is a respiratory disease that causes inflammation and swelling of the airways making it difficult to breathe. More than 28 million people in the U.S. have asthma and it is a leading chronic disease in approximately 4.9 million children under the age of 18, according to the Asthma and Allergy Foundation of America (AAFA).

Symptoms can include shortness of breath, wheezing, coughing and tightness in the chest.

What is SMART Therapy?

There are two basic components of asthma. They are:

• Narrowing of the bronchial airways caused by constriction of bronchial airway muscle, and
• Bronchial wall thickening caused by inflammation.

“It has taken us years to incorporate into our management strategies the fact that asthma is caused by both bronchoconstriction and inflammation,” said Roberto Cruz-Gervis, MD, a pulmonologist with Cape Cod Healthcare Pulmonary Medicine.

“When the bronchial airways become inflamed, the muscles get irritated, which causes them to constrict, and makes the airways narrower. A third component is mucous production that can add to the narrowing of the airways.”

With SMART therapy, the patient uses one inhaler that contains a corticosteroid to reduce inflammation in the airway, plus a long-acting bronchodilator that works by relieving muscle constriction for up to 12 hours. While all inhalers containing both a corticosteroid and a long-acting bronchodilator can be used for daily control of symptoms, some of them can also be used for quick symptom relief when asthma symptoms exacerbate.

Before the new recommendations for treatment, intermittent flare-ups of asthma symptoms were treated with Albuterol, a bronchodilator known as a “reliever/rescue inhaler.” It works quickly to open airways but does not last long, said Dr. Cruz-Gervis.

“It only targets the muscle layer around the bronchial tubes and, while it causes relaxation of the muscle, it doesn’t have an anti-inflammatory effect.

“This is why modifying our current management strategy to include a reliever inhaler that targets both bronchoconstriction and inflammation makes so much sense. And, furthermore, being able to use the same maintenance inhaler as the quick reliever inhaler (SMART) is being strongly advocated by current treatment guidelines. This treatment strategy not only makes theoretical sense, but it has also been shown to improve outcomes and decrease acute exacerbations of asthma.”

Needs FDA Approval

While the new GINA guidelines recommend the use of one inhaler as a daily maintenance inhaler to prevent asthma and the same inhaler to treat immediate symptoms as a rescue inhaler, it has not yet been approved by the U.S. Food and Drug Administration (FDA) , said Dr. Cruz-Gervis.

Health providers are able to implement the SMART recommendation for treatment by using inhalers that contain both a corticosteroid and formoterol; the latter being the only known long-acting bronchodilator with quick relief properties.

Currently, there are two inhalers on the market that can be used for this purpose: budesonide and formoterol (aka Symbicort), and mometasone and formoterol (aka Dulera).

“Due to insurance restrictions for using these inhalers as both maintenance and quick relief, we currently have the option of using a recently FDA-approved quick relief inhaler that contains albuterol and budesonide, which is commercially available by the name Airsupra. It can be used as a rescue inhaler to treat asthma four to six times a day as needed,” said Dr. Cruz-Gervis.

It is important to know that all asthma is not created equal, he said.

“It can be intermittent or persistent and patients can have exacerbations when their asthma is not optimally controlled. We treat them by a step-up approach according to the severity and/or frequency of their asthma symptoms.”

These steps, in a simplified way, include the following, according to Dr. Cruz-Gervis:

• Step one: Infrequent symptoms for which an Albuterol inhaler is used once or twice a month. This qualifies as mild, intermittent asthma. With the current availability of Airsupra (albuterol + budesonide), this inhaler can be substituted instead of albuterol alone for management of intermittent symptoms.
• Step two: Symptoms are not controlled by step one treatment. In addition to the Albuterol (or Airsupra) inhaler, you may start a maintenance (or controller) anti-inflammatory inhaler with a steroid.
• Step three: Asthma is more persistent. Step one and two treatments did not work. Start an inhaler with both a corticosteroid and a long-acting bronchodilator (aka as ICS and LABA inhalers) and Albuterol (or Airsupra) every four hours as needed.
• Step four: Start SMART therapy, which is a combination of maintenance and reliever/rescue therapy. Use ICS + LABA inhalers for maintenance and albuterol (or Airsupra) as a reliever/rescue inhaler every four hours as needed.
• Step five: Use the previous inhalers plus a long-acting muscarinic antagonist, or simply change to one of the triple therapy inhalers currently available (aka Trelegy or Breztri) that contain a corticosteroid, a long-acting muscarinic antagonist and a long-acting beta agonist.

“When you go through the five-step approach and, as a patient goes up a step in the level of medications, we also have to be thinking about what else could be happening that a step-up management strategy is not addressing ” he said. “It could be allergies, environmental exposures at home or at work, and other reasons that we need to look at. These are areas we can address to make things better.”