What inhalers are used for Maintenance And Reliever Therapy (MART)?

Inhalers Used for MART Therapy

For MART (Maintenance And Reliever Therapy) in asthma, budesonide-formoterol is the primary inhaler combination used, as it contains both an inhaled corticosteroid (ICS) and a rapid-onset long-acting beta-agonist (LABA) that can function as both maintenance and rescue medication. 1, 2

Approved Combinations for MART

Primary Options:

• Budesonide-formoterol (most evidence-based option)

  • Dosing: 160/4.5 μg, 1-2 inhalations once or twice daily for maintenance
  • Same inhaler used as needed for symptom relief
  • Maximum daily limit: 8 puffs for children 5-11 years, 10-12 puffs for adults/adolescents 2, 3

• Beclomethasone-formoterol (alternative option with supporting evidence) 3

Key Requirements for MART Inhalers

1. Contains formoterol specifically - essential due to its rapid onset of action (similar to short-acting beta-agonists)

   • Salmeterol-containing combinations (like fluticasone/salmeterol) CANNOT be used for MART due to slower onset 2, 3

2. Available as a single inhaler - simplifies management and potentially improves adherence 4

3. Delivers consistent dosing - particularly important since the same device is used for both maintenance and rescue 4

Clinical Evidence and Recommendations

The 2020 National Asthma Education and Prevention Program (NAEPP) Expert Panel strongly recommends ICS-formoterol in a single inhaler as both daily controller and reliever therapy for patients aged 4 years and older with moderate to severe persistent asthma. This recommendation is based on high-certainty evidence showing superior outcomes compared to:

• Higher-dose ICS with SABA for rescue
• Same-dose ICS-LABA with SABA for rescue 1

Similarly, the 2019 Global Initiative for Asthma (GINA) guidelines recommend as-needed low-dose ICS-formoterol as the preferred reliever for patients prescribed maintenance and reliever therapy 1.

Practical Implementation

1. Patient education is crucial:

   • Explain that the same inhaler serves two purposes (daily maintenance and as-needed relief)
   • Emphasize maximum daily dose limits
   • Clarify that increasing use (more than 2 days/week) indicates inadequate control 2

2. Monitoring:

   • Assess symptom control after 2-4 weeks of initiating therapy
   • Consider stepping down if control is maintained for ≥3 months 2

Important Caveats

• MART therapy is currently an off-label use in the United States 2
• Most clinical evidence is based on budesonide-formoterol specifically 3
• Not extensively studied in children under 5 years old 2
• Insurance coverage may be problematic as some insurers may not cover two canisters of the same medication 2
• Electronic monitoring studies have not conclusively determined whether the benefits of MART come from additional ICS at pivotal times or from patients using the combination for self-treatment of exacerbations 5

Device Considerations

The effectiveness of MART therapy depends partly on the inhaler device used. An ideal inhaler should provide consistent dosing regardless of inspiration rate, be easy to use, and be comfortable for patients to carry and use in public 4. Dry powder inhalers (DPIs) are commonly used for MART therapy and may have lower carbon footprint compared to metered dose inhalers (MDIs) 1.

By using a single inhaler for both maintenance and relief, MART therapy offers a simplified approach that may improve adherence while providing better asthma control and reducing exacerbation risk compared to traditional treatment regimens.