What are the recommended brand names and generic names (e.g. Flovent (fluticasone), Serevent (salmeterol), Ventolin (albuterol), Spiriva (tiotropium), Xolair (omalizumab), Nucala (mepolizumab)) for a smart protocol in asthma management?

Brand Names for SMART Protocol in Asthma Management

The recommended SMART (Single Maintenance And Reliever Therapy) protocol for asthma primarily utilizes budesonide/formoterol (Symbicort) as both maintenance and reliever therapy, as this combination has the most evidence supporting its use in this approach.

SMART Protocol Medications

Primary SMART Combination:

• Budesonide/formoterol (Symbicort) - The most studied combination for SMART protocol with extensive clinical evidence 1, 2
  • Used for both daily maintenance and as-needed symptom relief
  • Formoterol component provides rapid onset of action necessary for symptom relief 1
  • Maximum recommended daily dose: up to 8 puffs/day for ages 5-11, up to 10 puffs/day for ages ≥12 1

Alternative ICS/LABA Combinations:

• Beclomethasone/formoterol (Fostair) - Has evidence supporting SMART approach 2
• Mometasone/formoterol (Dulera) - Limited evidence for SMART approach but contains formoterol 1

Important Note: Salmeterol-containing combinations like fluticasone/salmeterol (Advair) should NOT be used for SMART protocol due to salmeterol's slower onset of action 1

Step-wise Medication Options by Asthma Severity

Quick-Relief Medications:

• Albuterol (Ventolin, ProAir, Proventil) - Short-acting beta2-agonist for symptom relief 1
• Levalbuterol (Xopenex) - Alternative short-acting beta2-agonist 1
• Ipratropium bromide (Atrovent) - Anticholinergic for additional bronchodilation during exacerbations 1

Controller Medications by Step:

1. Step 1 (Intermittent Asthma):

   • As-needed SABA only (e.g., Ventolin) 1
   • Alternative: ICS/formoterol (Symbicort) as needed 1

2. Step 2 (Mild Persistent):

   • Preferred: Low-dose ICS (e.g., Flovent/fluticasone, QVAR/beclomethasone, Pulmicort/budesonide) 1
   • Alternatives: Leukotriene modifiers (Singulair/montelukast, Accolate/zafirlukast) 1

3. Step 3 (Moderate Persistent):

   • Preferred: Low-dose ICS/LABA (Symbicort, Advair) or medium-dose ICS 1
   • Alternative: Low-dose ICS plus leukotriene modifier (Singulair) 1

4. Step 4 (Moderate-Severe Persistent):

   • Preferred: Medium-dose ICS/LABA (Symbicort, Advair) 1
   • Alternative: Medium-dose ICS plus leukotriene modifier or theophylline 1

5. Step 5 (Severe Persistent):

   • Preferred: High-dose ICS/LABA 1
   • Consider adding Tiotropium (Spiriva) 1
   • Consider adding anti-IgE therapy (Xolair/omalizumab) for allergic asthma 1

6. Step 6 (Very Severe Persistent):

   • High-dose ICS/LABA plus oral corticosteroids 1
   • Consider biologics:
     • Omalizumab (Xolair) for allergic asthma 1
     • Mepolizumab (Nucala) for eosinophilic asthma 3

Clinical Pearls for SMART Protocol

• Formoterol is essential for SMART protocol due to its rapid onset of action; salmeterol is too slow-acting 1
• Most SMART studies used budesonide/formoterol 160/4.5 μg (delivered dose) 2
• SMART protocol is currently an off-label use in the United States 1
• The approach reduces exacerbation risk while lowering overall ICS exposure 2
• Patient education is critical when implementing SMART protocol to ensure proper use 2

Common Pitfalls to Avoid

• Never use LABA monotherapy for asthma control - always combine with ICS due to increased risk of severe exacerbations and death 1
• Avoid frequent or chronic use of SABA before exercise as this may mask poorly controlled persistent asthma 1
• Don't substitute other ICS/LABA combinations for SMART protocol without evidence supporting their use 1, 2
• Remember that combination therapy with ICS/LABA is superior to adding montelukast to ICS therapy for most patients 4