Breathing a sigh of relief: A new therapy for asthma management

May 29, 2024

People with asthma now have a way to manage their symptoms that is easier and more effective than traditional therapeutics.

Woman with chronic asthma using inhaler while hiking in the desert

SMART offers a combined approach in one inhaler, reducing reliance on emergency department visits and optimizing long-term prevention and treatment.

It involves using only one inhaler to simultaneously deliver two types of medications in what is called SMART therapy, or single maintenance and reliever therapy, and it is endorsed by national boards and global organizations for moderate to severe asthma. 

The Healthy Dose asked board-certified allergist Tara Carr, MD, a member of the University of Arizona Health Sciences Asthma and Airway Disease Research Center and an associate professor of Medicine at the College of Medicine—Tucson who sees patients at the Allergy and Immunology Clinic at Banner – University Medical Center Tucson, what people need to know about SMART therapy.  

How is asthma usually treated?

Asthma is a chronic disorder that affects the airways in the lungs. While scientists still haven’t found the underlying cause of asthma, we know that people with asthma have inflamed airways. These inflamed airways produce extra mucus, and the muscles that line the airways can spasm and tighten. All of this can narrow and block the path for air entering or leaving the lungs. 

When we treat asthma, it is important to treat the inflammation. This soothes the airways so they are less likely to clamp down, but at some point, bronchial spasms will happen. This is often caused by triggers like pollen, an illness or bad air quality. When this occurs, people need another medication to open their airways.

Traditionally, people with asthma are prescribed one maintenance inhaler for daily doses of an anti-inflammatory medicine and then one rescue, or reliever, inhaler to open the airways when needed. 

How is SMART different?

With SMART, people with moderate to severe asthma typically use one inhaler with both medications twice a day, and then additionally if needed. An anti-inflammatory corticosteroid serves as an ongoing preventive treatment, and a long-acting beta-agonist functions as a quick relief therapy when people are having symptoms.

Research shows it is effective at reducing the use of systemic (injections and pills) corticosteroids over time and emergency department visits to treat asthma exacerbations. We think the dose of anti-inflammatory, which patients wouldn’t get if they were reaching for a regular reliever inhaler, is an important part of what makes this therapy so effective. 

The National Asthma Education and Prevention Program included SMART in its latest treatment recommendations for moderate to severe asthma, and it is really changing the way we treat patients.

3d Illustration of asthma symptoms in lungs

Traditional asthma treatment focuses on managing inflammation in the airways with daily maintenance inhalers, supplemented by reliever inhalers for sudden symptom relief.

Are there additional benefits of SMART?

With SMART, you only have one inhaler. When you use the inhaler, you are getting airway-opening relief and a dose of anti-inflammatory. Research shows this reduces the likelihood of your symptoms progressing to an asthma attack. It makes you feel better faster, and it is much easier for people to deal with one inhaler instead of two. It reduces confusion and improves adherence. 

Is SMART only for moderate to severe asthma? 

SMART is approved by the Food and Drug Administration for the treatment of moderate to severe asthma, and this is really where it shines. For mild asthma, there is a similar treatment called AIR, or anti-inflammatory reliever therapy. AIR also uses one inhaler and combines the same types of medications. In this case, patients only use the inhaler when symptoms occur. This has been shown to reduce the exposure to medications over time as well. 

Woman walks past blooming creosote bush

Improving someone's breathing enables them to exercise, maintain their overall health, and resume enjoying their favorite activities.

Does SMART face any challenges?  

The side effects for SMART are the same side effects someone would be exposed to if they took these two medications separately. With SMART dosing, you end up using a little more inhaled steroid and inhaled reliever so some people might be more likely to deal with thrush and jitteriness, which are common side effects of those medications. But, it reduces the likelihood of ending up needing steroids by pill or injection (systemic) for an asthma exacerbation- which have more significant side effects in the short and long term- so fewer side effects overall.

Anytime there is a change in paradigm or changing guidelines, there can be a delay in the uptake. SMART requires an inhaler that can accommodate doses of both medications. One challenge is getting those inhalers built with enough regularity that they are widely available. Another challenge is getting insurance companies to update their policies to cover SMART inhalers the same way they would two separate inhalers. 

What would you like everyone to know? 

I’ve seen what can happen when a person finds an effective treatment for their asthma symptoms. By helping someone breathe better, you allow them to exercise and maintain their general health. You get them back to doing the activities they enjoy, and it is just an overall improvement to their quality of life. SMART is an exciting new option to consider, and I encourage people to talk to their doctors about it. 

About the Author

Tara Carr, MD, is a board-certified allergist and immunologist. Carr specializes in allergic rhinitis and asthma and sees patients in conjunction with the Sinus and Allergy Center of the University of Arizona Department of Otolaryngology. She is also president of the Tucson Asthma Society, secretary-treasurer of the Arizona Allergy and Asthma Society and member of the University of Arizona Health Science’s Asthma & Airway Disease Research Center.