Symbicort® Maintenance and Reliever Therapy (SMART) and the evolution of asthma management within the GINA guidelines

Introduction: The Global Initiative for Asthma (GINA) annual report summarizes the latest evidence for asthma management. GINA recommends stepwise pharmacological treatment, advocating inhaled corticosteroids (ICS) plus rapid, long-acting beta(2)-agonists (LABA) delivered in a single inhaler for maintenance and relief at Steps 3 (moderate persistent asthma requiring 1-2 controllers plus as-needed reliever), 4 (severe persistent asthma requiring >= 2 controllers plus as-needed reliever), and 5 (higher level care and/or add-on treatment). Areas covered: Randomized controlled trials and real-world evidence demonstrate that flexibly dosed budesonide/formoterol for maintenance and relief (Symbicort (R) Maintenance And Reliever Therapy [SMART]) is associated with reductions in severe exacerbations, prolongs time to first exacerbation, and provides fast symptom relief. Expert commentary: SMART provides greater or equal levels of sustained asthma control than similar or higher fixed doses of ICS/LABA plus short-acting beta(2)-agonist (SABA) as needed or higher ICS plus SABA as needed, with lower overall ICS doses and cost. The simplified dosing strategy may improve adherence and overall asthma control but relies on patient education. Budesonide/formoterol as needed in mild asthma (patients qualifying for regular low-dose ICS) is currently under investigation in two double-blind randomized studies, SYGMA1/2 (NCT02149199/NCT02224157), comparing budesonide/formoterol as needed with budesonide plus SABA and SABA alone.