SMART - is it practical in the United States?

Purpose of reviewThe 2020 focused updates to the asthma management guidelines by the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group advocate for inhaled corticosteroid (ICS)-formoterol combinations as single maintenance and reliever therapy (SMART) for patients with persistent asthma. We review the rationale, the evidence supporting SMART use in asthma, and barriers limiting its wide adoption in the United States.Recent findingsA growing body of evidence supports the use of SMART over the conventional use of controller medicaments with an as-needed short-acting β₂agonist for rescue therapy for the purpose of reducing the risk of asthma exacerbation and maintaining asthma control in adolescents and adults with persistent disease. Lack of US Food and Drug Administration approval, inconsistent insurance coverage, and limited options of ICS-formoterol combination available for use as SMART represent obstacles to wider integration of SMART in clinical practice.SummarySMART represents a paradigm shift in asthma management. By identifying and addressing the current and anticipated barriers to implementing SMART, its adoption by providers is likely to increase in the United States.