Single inhaler asthma therapy better at preventing attacks than recommended treatment

These findings challenge national and international medical guidelines, particularly in the USA, where this approach has yet to be approved.

Despite effective drug treatment options, most adults with asthma fail to achieve good control of symptoms. In these patients, medical guidelines recommend prescribing a corticosteroid (ICS) plus rapid-onset long-acting β2 agonist (LABA) combination inhaler to achieve control along with a second short-acting β2 agonist (SABA) inhaler for rescue use, to treat symptoms. In contrast, SMART uses just a single ICS/LABA inhaler for both preventive and relief treatment.

The first study of 1714 adults with moderate persistent asthma from 14 European countries found that those treated with the SMART beclometasone/formoterol combination had a significantly reduced risk of severe asthma attacks and hospitalisation or urgent medical care compared to current best practice.

The authors say, "We believe that the additional cost of inhaled corticosteroid and rapid-onset, long-acting β2 agonist combination (29 Eurocents per patient per day) is justifiable because of the significant reduction in severe exacerbations, and specifically hospital admissions, known to have a huge effect on health-care costs in asthma."

Previous studies have reported that higher doses of corticosteroids do not improve symptoms for all patients and can have substantial side effects, while LABAs have come under scrutiny for their risk of worsening asthma symptoms that could result in hospitalisation.

By contrast, the first non-pharmaceutical industry sponsored study of its kind involving 303 adults (16󈞭 years) at increased risk of flare-ups and high use of reliever medication, reported that the SMART budesonide/formoterol regimen reduced the risk of severe asthma exacerbations without increasing the risk of beta-agonist overuse or increasing long-term corticosteroid exposure.

With the help of electronic monitoring of medication use, the team of researchers from New Zealand found that the number of days of high use, marked overuse, and, extreme overuse of beta-agonists were about 40% lower in the group taking SMART compared to the group given standard treatment. They also discovered that although patients prescribed SMART had a greater average daily exposure to ICS, they had similar overall systemic corticosteroid exposure because of lower oral corticosteroid exposure use due to reduced severe attacks.

Writing in a linked Comment, René Aalbers from Martini Hospital in the Netherlands says, "We now have four options for a patient-tailored strategy of inhaled corticosteroid and a LABA… Despite these options for treatment, we should start with a post-hoc analysis of the substantial patients' data files from previous controlled trials with SMART and undertake real-life studies, including electronic monitoring because we still do not know which patients will benefit most from which of these four treatment options."

The Lancet Respiratory Medicine launches on Monday 4 March, 2013, publishing timely news, views, research, and reviews in respiratory medicine and critical care. The new journal will be the fourth Lancet specialty journal and will offer fast track publication of selected research papers which can be published online within 8 weeks of submission. The Lancet Respiratory Medicine will cover a wide breadth and diversity of topics of interest to clinicians, specialists, and researchers in the field of respiratory and critical care medicine. See http://www.thelancet.com/respiratory for more details.