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BMJ. 2007 September 22; 335(7620): 577.
PMCID: PMC1989002
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Way forward is not obvious at asthma crossroads

Syed F Hussain, consultant respiratory physician

Barnes argues that using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control.1 Several studies support the use of budesonide/formoterol in the SMART (Symbicort (budesonide/formoterol) maintenance and reliever therapy) regimen.2 3 They have shown longer time to first exacerbation, reduced rate of severe exacerbations, and less inhaled corticosteroid dose, although with similar improvement in symptoms, peak flow rates, and quality of life in some studies. The concept looks promising, but some areas of concern remain.

The main concern is that all the above studies were conducted by the manufacturing firm (study design, data interpretation, data analysis, and publication). Three matching studies from the rival manufacturers of fluticasone/salmeterol have shown the opposite effect—stable dosing reducing exacerbation rate and improving symptom free days compared with the SMART regimen.4

Secondly, in all SMART studies patients needing more than 10 as needed inhalations were excluded, and this will have implication on therapy of patients with frequent symptoms.

Thirdly, there is no convincing evidence that in patients who are well controlled with stable dose inhaler therapy a change to the SMART regimen will be a smart or cost effective move.

In my own limited clinical experience I have found the SMART regimen useful in poorly compliant patients and patients at the milder end of persistent asthma. Of greater interest was the paper in New England Journal of Medicine and debate on once daily asthma maintenance therapy compared with twice daily regimens.5 Certainly, asthma treatment is at a crossroads awaiting a change of direction.


Competing interests: SFH has received sponsorships for organising a CME programme, participating in conferences, and speaking from Astra Zeneca, GSK, and MSD.


1. Barnes PJ. Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control. BMJ 2007;335:513 (8 September.) [PMC free article] [PubMed]
2. Rabe KF, Atienza T, Magyar P, et al. Effect of budesonide in combination with formoterol for reliever therapy in asthma exacerbations: a randomised controlled, double-blind study. Lancet 2006;368:744-53. [PubMed]
3. Kuna P, Peters MJ, Manjra AI, et al. Effect of budesonide/formoterol maintenance and reliever therapy on asthma exacerbations. Int J Clin Pract 2007;61:725-36. [PMC free article] [PubMed]
4. Price DB, Williams AE, Yoxall S. Salmeterol/fluticasone stable-dose treatment compared with formoterol/budesonide adjustable maintenance dosing: impact on health-related quality of life. Respir Res 2007;8:46. [PMC free article] [PubMed]
5. American Lung Association Asthma Clinical Research Centers, Peters SP, Anthonisen N, Castro M, et al. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-39. [PubMed]

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