Asthma affects approximately 8 percent of all adults. The main goals of asthma management are to minimize symptoms and to prevent acute exacerbations through patient education, avoidance of exposures and pharmacotherapy. The use of medications, including inhalers, leukotriene receptor antagonists, oral glucocorticoids and newer biologic agents, are based on severity of symptoms and are escalated in a stepwise fashion.
Traditionally, patients with intermittent asthma symptoms were treated with short-acting β2 agonists (SABA) alone for rescue therapy. The use of inhaled corticosteroids (ICS) as maintenance therapy was reserved for cases where symptoms were inadequately controlled. Despite the apparent low symptomatic burden, up to 30 percent of asthma deaths are in people with infrequent symptoms. Further evidence suggested SABA overuse and ICS underuse were associated with a higher risk of acute exacerbations and that rapid increase of ICS doses in the setting of worsening asthma control showed fewer severe asthma exacerbations.
In response to these findings, 2022 Global Initiative for Asthma (GINA) guidelines now recommends 2 therapeutic tracks. The preferred Track 1 recommends a combination of inhaled corticosteroid and formoterol as needed as first-line therapy for symptom relief, also known as single maintenance and reliever therapy (SMART).
Of long-acting β2 agonists, only formeterol should be used as it has both a rapid onset and long duration of action as a bronchodilator. Alternatively, the more traditional Track 2 recommends the use of intermittent or scheduled ICS for patients on SABA as relief therapy. Current evidence shows a reduction in risk for severe exacerbations with the use ICS-formeterol combination therapy compared to SABA alone, as well as a similar or greater reduction in severe exacerbations compared to daily ICS.
“The use of SMART augments anti-inflammatory coverage, especially during times of increased symptoms,” says Jiesu Sun, MD, MPH, a board-certified pulmonary and critical care medicine physician on the medical staff at Baylor University Medical Center (Baylor Dallas), part of Baylor Scott & White Health. “Whenever a patient uses their rescue inhaler, they also receive some glucocorticoids for improved long-term control. This may be especially beneficial in patients who are not as compliant and may skip their maintenance inhalers when feeling well. At the same time, the use of a single inhaler for both maintenance and rescue therapy may improve adherence.”
While treatments for asthma continue to advance, many diseases can mimic asthma or may coexist with asthma, increasing its severity. At the Martha Foster Lung Care Center at Baylor Dallas, a multidisciplinary team works with patients to provide accurate diagnoses and appropriate treatment plans. Successful management of asthma relies on a partnership between clinicians and patients and emphasis is placed on direct one-on-one patient education to empower patients in the management of their disease.
