What is the recommended Maintenance and Reliever Therapy (MART) regimen, including initial dosing and step‑up strategy, for a patient aged 12 years or older with persistent asthma that is not controlled on low‑dose daily inhaled corticosteroid (ICS) alone?

MART Regimen for Patients ≥12 Years with Uncontrolled Asthma on Low-Dose ICS

For patients aged 12 years and older with persistent asthma not controlled on low-dose ICS alone, use ICS-formoterol (budesonide-formoterol) as both daily maintenance and as-needed reliever therapy (MART/SMART regimen), which reduces severe exacerbations by 21-39% compared to traditional fixed-dose ICS-LABA plus SABA approaches. 1, 2

Initial MART Dosing Strategy

• Start with budesonide-formoterol as a single inhaler for both maintenance and reliever therapy 1
• The maintenance dose should be appropriate for moderate to severe persistent asthma (typically budesonide 200-400 mcg/formoterol 6-12 mcg per inhalation, taken twice daily as maintenance) 3, 2
• Patients use the same inhaler for quick relief when symptoms occur, taking 1-2 additional inhalations as needed 4, 3
• This approach is conditionally recommended with high certainty of evidence for patients ≥12 years 1

Why MART Works Better

The MART regimen achieves superior outcomes at a lower overall corticosteroid burden compared to traditional approaches: 3, 2

• Reduces severe exacerbations by 21-39% versus fixed higher-dose ICS-LABA plus SABA 2
• Provides similar or better daily asthma control while using less total ICS dose 3, 2
• Addresses the critical problem of poor adherence by ensuring patients receive ICS every time they use their reliever 4, 5
• Simplifies management by using a single inhaler for both maintenance and relief 4, 6

Step-Up Strategy Within MART

If asthma remains uncontrolled on MART after 2-6 weeks of verified adherence and proper technique: 7

• First verify adherence, proper inhaler technique, environmental control measures, and address comorbid conditions before escalating 7
• Add a long-acting muscarinic antagonist (LAMA) to the existing ICS-formoterol regimen (triple therapy), which reduces exacerbation risk (RR 0.67,95% CI 0.48-0.92) 1, 7
• Continue using ICS-formoterol as both maintenance and reliever while adding LAMA as a separate daily controller 7
• Reassess asthma control at 2-6 weeks after adding LAMA 7

Critical Implementation Details

Formoterol is essential for MART—other LABAs cannot be used this way: 3, 6

• Only budesonide-formoterol should be used for SMART implementation, as formoterol has rapid onset of action (within 1-3 minutes) necessary for symptom relief 3, 6
• Salmeterol-containing combinations cannot be used as reliever therapy due to slow onset of action 6
• The rapid-acting property of formoterol allows it to function as both maintenance LABA and quick-relief medication 3

Common Pitfalls to Avoid

• Never use LABA as monotherapy—it must always be combined with ICS to avoid increased risk of severe exacerbations and asthma-related deaths 7, 8
• Do not add LAMA to ICS alone (without LABA first)—this is conditionally recommended against in patients ≥12 years 1
• Using SABA more than 2 days per week for symptom relief indicates inadequate control and confirms need for treatment intensification 7
• Ensure patients understand they use the same inhaler for both scheduled maintenance doses and as-needed relief—this is not a traditional "controller plus rescue" approach 4, 6

Alternative for Mild Persistent Asthma

For patients ≥12 years with only mild persistent asthma (not moderate-severe), two equally acceptable options exist: 1

• Daily low-dose ICS with as-needed SABA for quick relief (traditional approach)
• As-needed ICS and SABA used concomitantly (conditional recommendation, moderate certainty of evidence) 1

However, once asthma severity reaches moderate to severe persistent levels requiring step 3-4 therapy, MART becomes the preferred approach 1, 6