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Association of inhaled corticosteroids and long-acting beta-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: a systematic review and meta-analysis



Diana M Sobieraj, Erin R Weeda, Elaine Nguyen, et al.
JAMA 2018; 319(14):1485–96.
doi: 10.1001/jama.2018.2769.

Recently, interest has grown in the use of single maintenance and reliever therapy (SMART), in which as-needed short-acting beta2-agonists (SABA) are replaced with a combined inhaled corticosteroid (ICS) and long-acting beta2-agonist (LABA) inhaler to relieve acute symptoms in patients with asthma. Diana Sobieraj and colleagues from the University of Connecticut School of Pharmacy conducted a systematic review of the evidence base for this therapeutic strategy. Sixteen randomised controlled trials were included, evaluating patients aged five years or older with persistent asthma. Most studies (14) compared SMART with ICS/LABA controller therapy, while four compared SMART with ICS maintenance alone.

In patients aged 12 years or older SMART was associated with a decreased risk of asthma exacerbations compared with the same dose of ICS monotherapy and compared with a higher comparative dose of ICS. SMART was also associated with improved forced expiratory volume in 1 second (FEV1) and decreased need for rescue medication compared with the same dose of ICS alone. No difference was seen in mortality. Additionally, in patients aged 4-11 years, SMART was associated with a reduced risk of asthma exacerbations compared with the same dose of ICS alone.

In comparison with ICS/LABA controller therapy, similar results were seen among patients aged 12 years or over. SMART was associated with a lower risk of asthma exacerbations compared with both the same dose of ICS/LABA controller and a higher dose of ICS/LABA. SMART was not associated with any changes in asthma symptom control, mortality, quality of life or lung function.

Overall, the pooled evidence base supports the use of SMART as an alternative to the use of a daily controller therapy and as-needed SABA, in patients aged 12 years and over. Evidence also suggests similar benefits in patients aged 4–11 years, but this is limited.




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