US researchers identified sixteen randomised trials, involving 22,748 patients, from numerous databases including MEDLINE, EMBASE, the Cochrane register and the Cochrane Database of Systematic Reviews published up to November 2017.
The trials compared the use of SMART with the conventional approach of using inhaled corticosteroids ([ICS] with or without a long-acting β-agonist [LABA]) as the maintenance therapy and short-acting β-agonists as the reliever therapy, among patients 5 years or older with persistent asthma.
Further informationJAMA meta-analysis
Among patients 12 years or older (n = 22,524), the results showed that SMART was associated with a reduced risk of asthma exacerbations compared with ICS/LABA maintenance therapy when the latter was given at either the same dose (risk ratio [RR] 0.68 [95% CI 0.58–0.80]; risk difference [RD], −6.4% [95% CI −10.2% to −2.6%]) or a higher dose (RR, 0.77 [95% CI 0.60–0.98]; RD, −2.8% [95% CI −5.2% to −0.3%]).
Similar results were seen when SMART was compared with ICS alone as the maintenance therapy.
The findings are consistent with BTS/SIGN guidance on the management of asthma, which advocates the use of SMART therapy in patients whose asthma remains poorly controlled despite the regular use of an ICS. Prescribing of a combination inhaler containing both a steroid and a LABA is recommended in order to aid treatment compliance and ensure that the LABA is not taken without the steroid.
There are currently three formoterol/budesonide combination inhalers licensed for SMART in the UK: Symbicort Turbohaler (100/6 and 200/6), DuoResp Spiromax (160/4.5) and Fobumix Easyhaler (160/4.5 and 80/4.5) and one formoterol/beclometasone inhaler: Fostair (100/6).