What is the recommended dose of Symbicort (budesonide/formoterol) MART (Maintenance And Reliever Therapy) as a reliever?

Maximum Puffs of Symbicort 200/6 MART as Reliever Therapy

For patients aged 12 years and older using Symbicort (budesonide/formoterol) 200/6 as Maintenance And Reliever Therapy (MART), the maximum recommended number of puffs for relief is up to 10 puffs per day total (including maintenance doses). 1

Understanding Symbicort MART Dosing

Recommended Dosing Schedule:

• Maintenance dose: Typically 1-2 puffs twice daily (depending on asthma severity)
• Reliever dose: 1 puff as needed for symptom relief
• Maximum daily limit: Up to 10 total puffs per day (including maintenance doses) for patients ≥12 years 1
• Children aged 5-11 years: Up to 8 puffs per day total when using MART 1

Key Considerations for MART Therapy:

1. Formoterol component: The rapid onset of action of formoterol makes it suitable for both maintenance and reliever therapy, unlike salmeterol which has a delayed onset 1

2. Safety concerns:

   • Exceeding the maximum recommended daily dose increases risk of adverse effects
   • The formoterol component has dose-dependent side effects (tremor, palpitations)
   • Maximum daily dose is established to limit formoterol exposure

3. Regulatory status:

   • MART is currently an off-label use in some regions 1
   • Studies were primarily performed with budesonide/formoterol 1

Clinical Evidence and Guideline Support

The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 4 recommends ICS-formoterol as both maintenance and reliever therapy for steps 3 and 4 in asthma management for patients ≥12 years old 1. This approach has been shown to:

• Reduce the risk of severe asthma exacerbations compared to conventional regimens
• Provide similar or better daily asthma control than higher fixed maintenance doses
• Achieve improved efficacy with a lower overall corticosteroid exposure 2

Differences Between Guidelines

It's important to note that guidelines differ slightly in their recommendations:

• NAEPP: Recommends SMART for steps 3 and 4 (moderate asthma) but not for step 5 1
• GINA: Recommends SMART for steps 3-5 and advocates using ICS/formoterol instead of SABA as reliever therapy for all patients ≥12 years 1

Practical Implementation

When implementing MART therapy:

• Educate patients that their Symbicort inhaler replaces their rescue inhaler
• Instruct patients to use Symbicort for both daily maintenance and symptom relief
• Emphasize the maximum daily limit of 10 puffs total
• Monitor frequency of reliever use - increasing use may indicate inadequate control
• Consider treatment step-up if patient regularly approaches maximum daily limit

Common Pitfalls to Avoid

1. Using salmeterol-containing products for MART: Only formoterol has a rapid enough onset for reliever use 1

2. Exceeding maximum daily dose: Patients should be clearly instructed on the 10-puff daily maximum to avoid formoterol overdose

3. Inadequate patient education: Patients may be confused by using the same inhaler for both maintenance and relief

4. Insurance coverage issues: Some insurance plans may not cover two inhalers of the same medication 1

By following these guidelines and ensuring proper patient education, Symbicort MART can be an effective strategy for managing moderate to severe persistent asthma.