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In Dec. 2020, the National Heart, Lung and Blood Institute (NHLBI) updated the clinical asthma guidelines. You may be wondering how that affects your child’s asthma treatment plan.

One change from the guidelines is a treatment method called single maintenance and reliever therapy, or simply SMART. With SMART, an inhaler that contains two medicines – a inhaled corticosteroid (ICS) and a long-acting beta agonist (LABA) – can be used for both asthma quick-relief and control.

Studies show using these specific combination inhalers improve asthma control. Only one inhaler is used instead of two. This may be an easier treatment plan for your child to follow.

What Is SMART?

SMART uses a combination inhaler in one of two ways:

  1. As a daily controller medicine to prevent symptoms AND as a quick-relief medicine that your child takes when they have asthma symptoms, or
  2. As a quick-relief medicine that your child takes when they have asthma symptoms


When using SMART, your child may not need a separate quick-relief medicine (albuterol). If you want to know more about SMART, talk with your child’s doctor.

Which Medicines Are Available for SMART?

Currently, the guidelines recommend the asthma combination medicine of budesonide and formoterol (SYMBICORT®) for SMART. It contains an ICS that reduces the swelling in the lungs. It also has a LABA that also works quickly to open the airways. The LABA also keeps the muscles around the airways from tightening.

A different combination medicine, DULERA®, may also be used for SMART. DULERA® contains mometasone and formoterol. SYMBICORT® and DULERA® are only available as brand name inhalers. Generic inhalers and liquid for nebulizers for these medicines are not available at this time.

Formoterol is a long-acting medicine, but it also starts working very quickly, just like albuterol. Formoterol can open the airways within 15 minutes or so and keep them open for up to 12 hours.

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What Doses Are Recommended Under SMART?

For children who are 4 to 11 years and older with moderate-to-severe asthma, the recommendation is to use the combination inhaler as needed for sudden symptoms. Up to eight puffs can be taken in one day.

For children and adults 12 years and older with moderate-to-severe asthma, the recommendation is to use the combination inhaler (ICS and formoterol) both daily as a control medicine and as needed, up to 12 puffs in one day to relieve sudden symptoms.

Your child’s Asthma Action Plan should be updated by their doctor whenever they change your child’s medicines.

Can My Child Stay on Their Current Daily Asthma Medicines?

Yes, per the updated guidelines. If your child’s asthma is currently well-controlled by taking a daily controller medicine and a separate quick-relief medicine (albuterol), they can stay on that treatment plan. Talk with your child’s doctor about the best treatment plan for your child.

What Are the Challenges to Using SMART?

To date, the Food and Drug Administration (FDA) has only approved the combination inhalers used in SMART to be used as daily controller medicines. They are not approved to be used as needed or for quick relief. If your child’s doctor prescribes SMART, this will be considered “off label.” This means it may not be covered by your insurance company. Work with your child’s doctor and insurance company to get the medicines for SMART covered by your insurance plan.

How Can I Learn More About the New Asthma Guidelines?

If you want to learn more about SMART and the new guidelines, talk with your child’s doctor. You can also read AAFA’s summary of “The 2020 Focused Updates to the Asthma Management Guidelines: A Report from The National Asthma Education and Prevention Program Expert Panel Working Group.

Medical Review: March 2022 by Benjamin Ortiz, MD, FAAP

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