What is the recommended regimen for patients on SMART (Single inhaler Maintenance And Reliever Therapy) therapy using Symbicort (budesonide and formoterol)?

SMART Therapy Regimen for Patients Using Symbicort (Budesonide/Formoterol)

For patients on SMART therapy using Symbicort, the recommended regimen is to use budesonide/formoterol as both maintenance therapy (1-2 inhalations once or twice daily) and as a reliever (1 inhalation as needed for symptoms), with a maximum of 8-12 total inhalations per day depending on age. 1, 2

Dosing Guidelines by Age Group

Adults and Adolescents (≥12 years):

• Maintenance dose:
  • Step 3: Budesonide/formoterol 160/4.5 μg, 1 inhalation once or twice daily
  • Step 4: Budesonide/formoterol 160/4.5 μg, 2 inhalations twice daily
• Reliever dose: 1 inhalation of the same inhaler as needed for symptom relief
• Maximum daily limit: Up to 12 total inhalations in any single day (delivering 54 μg formoterol) 2

Children (5-11 years):

• Maintenance dose: Budesonide/formoterol 80/4.5 μg, 1-2 inhalations daily
• Reliever dose: 1 inhalation of the same inhaler as needed
• Maximum daily limit: Up to 8 puffs per day 1, 3

Implementation Instructions

1. Explain the concept: Teach patients that their Symbicort inhaler serves two purposes:

   • Regular scheduled use (maintenance)
   • As-needed use for symptom relief (replacing SABA inhalers)

2. Provide clear instructions:

   • Take your prescribed maintenance dose(s) every day
   • When experiencing symptoms, take 1 additional puff of Symbicort
   • Wait a few minutes to see if symptoms improve
   • If symptoms persist, another puff may be taken
   • Never exceed the maximum daily limit

3. Create a written asthma action plan that clearly outlines:

   • Daily maintenance schedule
   • When to take additional doses
   • Maximum daily doses
   • When to seek medical attention 2

Key Clinical Considerations

• Formoterol is essential: SMART therapy requires formoterol specifically due to its rapid onset of action (similar to SABAs). Salmeterol-containing combinations cannot be used for SMART due to slower onset 1

• Evidence base: Most clinical trials used budesonide/formoterol, though other ICS-formoterol combinations may be effective 1

• Efficacy benefits: SMART therapy reduces severe exacerbations compared to fixed-dose regimens while using lower overall corticosteroid exposure 4

• Off-label use: Be aware that SMART is currently an off-label use in the United States, despite the boxed warning regarding asthma-related death being removed from ICS/LABA labels 1

• Monitoring: Assess symptom control after 2-4 weeks of initiating therapy. Consider stepping down if control is maintained for at least 3 months 5

Common Pitfalls to Avoid

1. Using the wrong combination: Only formoterol-containing combinations should be used for SMART therapy, not salmeterol-containing products 1

2. Inadequate patient education: Patients may be confused about using the same inhaler for both maintenance and relief. Clear instructions are essential 2

3. Insurance barriers: Some insurance plans may not cover two canisters of the same ICS/LABA at once. This reimbursement issue may need to be addressed 1

4. Overreliance on reliever use: Increasing use of the reliever function (more than 2 days per week) generally indicates inadequate control and may require stepping up maintenance therapy 1

5. Poor inhaler technique: Ensure proper inhaler technique is demonstrated and regularly checked at follow-up visits

By following these guidelines, patients can effectively use Symbicort in a SMART regimen to achieve better asthma control with reduced risk of exacerbations.