What are common Long-Acting Beta-Agonist (LABA) + Inhaled Corticosteroid (ICS) combinations licensed in the UK for Maintenance and Reliever Therapy (MART) in asthma?

Common LABA + ICS Combinations Licensed for MART in Asthma in the UK

The most common LABA + ICS combinations licensed for Maintenance and Reliever Therapy (MART) in the UK are budesonide/formoterol formulations, particularly Symbicort, which is the primary combination approved for this approach.

Licensed MART Combinations in the UK

Primary MART Option

• Budesonide/formoterol (Symbicort):
  • The primary and most established combination for MART
  • Available in various strengths (100/6,200/6 mcg)
  • Used for both maintenance and as-needed relief
  • Formoterol component provides rapid onset of action (1-3 minutes) making it suitable for symptom relief

Key Features of MART Therapy

• MART allows patients to use the same inhaler for both daily maintenance therapy and symptom relief
• This approach is particularly beneficial because:
  • It ensures patients receive additional anti-inflammatory medication (ICS) when experiencing symptoms
  • It reduces the risk of SABA overuse
  • It simplifies the treatment regimen with a single inhaler

Clinical Evidence Supporting MART

The Global Initiative for Asthma (GINA) recommends as-required ICS + LABA inhaler containing formoterol as first-line therapy to ensure underlying airway inflammation is controlled as well as symptoms 1. This approach has several advantages:

• Simplifies therapy
• Reduces SABA overuse
• Reduces overall steroid dose
• Reduces risk of severe exacerbations

Studies have shown that budesonide/formoterol maintenance and reliever therapy:

• Prolongs time to first severe exacerbation compared to fixed-dose regimens 2
• Reduces the risk of hospitalizations/emergency room visits by 37% compared to salmeterol/fluticasone propionate fixed maintenance-dose treatment 2

Important Considerations

Why Formoterol-Based Combinations?

Formoterol is the preferred LABA for MART because:

• It has a rapid onset of action (similar to SABAs)
• It provides sustained bronchodilation (12+ hours)
• Other LABAs like salmeterol and vilanterol have a slower onset, making them unsuitable for as-needed symptom relief

Safety Considerations

• LABAs should never be used as monotherapy for asthma control due to increased risk of severe exacerbations 3
• The FDA has issued a Black Box warning for all LABAs due to increased risk of severe exacerbations in some patients 3
• When used in combination with ICS, this risk is mitigated

Alternative Options

While not specifically licensed for MART in the UK:

• Fluticasone furoate/vilanterol (Relvar Ellipta) is a once-daily ICS/LABA combination, but it's not suitable for MART due to vilanterol's slower onset of action 4, 5
• Fluticasone propionate/salmeterol (Seretide) is widely used for maintenance therapy but not for MART due to salmeterol's slower onset 2

Practical Application

For patients requiring step-up from ICS monotherapy:

1. Consider budesonide/formoterol MART if:

   • Patient has inadequate control on medium-dose ICS alone
   • Patient has experienced exacerbations despite regular ICS use
   • Patient struggles with adherence to multiple inhalers

2. Typical dosing for budesonide/formoterol MART:

   • Maintenance: 1-2 inhalations twice daily
   • Relief: 1 inhalation as needed (maximum of 8 inhalations per day including maintenance doses)

In conclusion, budesonide/formoterol is the primary LABA + ICS combination licensed for MART in the UK, with strong evidence supporting its efficacy in reducing exacerbations and improving asthma control.