From the Guidelines
Maintenance and Reliever Therapy (MART) is recommended for adults with moderate to severe asthma who need better symptom control despite using standard inhaled corticosteroid (ICS) therapy. The MART approach uses a single inhaler containing both a corticosteroid (anti-inflammatory) and a fast-acting bronchodilator, allowing patients to use the same device for both daily maintenance and as-needed symptom relief.
Key Points
- Commonly prescribed MART combinations include budesonide/formoterol (such as Symbicort) and beclomethasone/formoterol (such as Foster) 1.
- A typical regimen involves 1-2 inhalations twice daily as maintenance plus additional inhalations as needed for symptom relief, not exceeding 8 total inhalations daily (12 inhalations maximum for severe cases).
- MART is particularly effective because it delivers additional anti-inflammatory medication during symptom flares, addressing both the immediate bronchospasm and underlying inflammation simultaneously.
- This approach has been shown to reduce exacerbations, improve symptom control, and often requires lower cumulative steroid doses compared to conventional therapy, as supported by a network meta-analysis that ranked combined inhaled corticosteroids and long acting β-agonists as maintenance and reliever treatment as one of the most effective strategies for preventing severe exacerbations of asthma 1.
Patient Education
- Patients should be educated on proper inhaler technique.
- The importance of regular maintenance dosing should be emphasized.
- Patients should know when to seek medical attention if symptoms worsen despite increased reliever use.
Recommendations
- In individuals aged 12 y and older with moderate to severe persistent asthma, the expert panel conditionally recommends ICS-formoterol in a single inhaler used as both daily controller and reliever therapy, as opposed to higher-dose ICS-LABA as daily controller therapy and SABA for quick-relief therapy 1.
- The use of MART has been associated with improved outcomes in terms of reducing exacerbations and improving symptom control, making it a preferred treatment option for adults with moderate to severe asthma 1.
From the Research
Maintenance And Reliever Therapy (MART) for Asthma in Adults
- The recommended approach for MART in adults is to use a combination of an inhaled corticosteroid and a long-acting beta2 agonist, such as formoterol, in a single inhaler for both controller and reliever treatments 2, 3, 4.
- This approach is preferred for adults and adolescents because of its effectiveness in reducing severe exacerbations 2.
- The Global Initiative for Asthma (GINA) 2019/2020 recommends an anti-inflammatory rescue/reliever approach for adult and adolescent patients, based on the combination of an inhaled corticosteroid with a rapid onset β2-agonist such as formoterol 3.
- The National Asthma Education and Prevention Program recommends formoterol in combination with an ICS in a single inhaler (single maintenance and reliever therapy) as the preferred therapy for moderate persistent asthma 4.
Key Considerations
- Asthma severity and level of control should be assessed at diagnosis and evaluated at subsequent visits using validated tools such as the Asthma Control Test or the asthma APGAR tools 2.
- Short-acting beta2 agonists are preferred asthma reliever medications, but should not be used alone as a reliever due to safety concerns 3.
- Controller medications consist of inhaled corticosteroids, long-acting beta2 agonists, long-acting muscarinic antagonists, and leukotriene receptor antagonists, and should be added in a stepwise fashion according to guideline-directed therapy recommendations 2, 5, 4.