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Pediatric asthma is the most common chronic disease in childhood. It is a frequent cause of school absenteeism and results in more hospitalization days than any other pediatric chronic disease. In 2022, the Centers for Disease Control and Prevention (CDC) estimated that there are 4.5 million children with asthma in the United States. Each year, 1 of 6 children with asthma visit the emergency department for asthma symptoms, and 1 of 20 are hospitalized for asthma. In 2013, 13.8 million school days were missed among children with asthma, and about half of these children missed 1 or more school days due to the disease. In 2022, there were a total of 145 deaths due to asthma in children younger than 18 years old.Asthma is often hard to diagnose and has no cure. Symptoms can consist of wheezing, shortness of breath, chest tightness, and coughing, resulting in sleep disturbance and fatigue. Asthma triggers can include viral illnesses, exercise or exertion, cold air, allergens, strong emotions, and odors. Pediatricians must treat asthma appropriately to maximize symptomatic control and protect their patients’ developing lungs. Treatment plans for children with asthma consist of education, frequent symptom monitoring, and a tailored medication plan that addresses symptom fluctuation. Single maintenance and reliever therapy (SMART) involves the dynamic use of a combination of an inhaled corticosteroid (ICS) and a long-acting β-agonist (LABA) for both daily maintenance and acute rescue treatment of asthma. SMART has been shown to be an effective approach to treating school-aged children with asthma.The standard recommended therapy for children and adolescents with asthma has consisted of an ICS, a leukotriene modifier, and/or the combination of an ICS and a LABA for daily maintenance therapy among patients classified as having persistent asthma based on asthma impairment and risk. Use of a short-acting β2 agonist (SABA) has been recommended for treatment of acute asthma symptoms and a systemic corticosteroid, particularly an oral corticosteroid (OCS), for acute exacerbation. ICSs modulate transcription of inflammatory molecules in the airway, thus exerting an anti-inflammatory effect. Systemic corticosteroids work similarly but are administered orally or intramuscularly, leading to higher concentrations in the blood and lungs. SABAs relax smooth muscle in the airways, relieving obstruction, with a quick onset of action and duration of about 4 hours. SABAs have been the inhaler of choice for quick relief of symptoms for over 50 years. However, SABAs do not treat inflammation and do not prevent future exacerbations. Use of SABAs without controller medication has been associated with increased health care use and greater annual systemic corticosteroid exposure. There is no evidence for the safety or efficacy of using a SABA alone as treatment. Studies have shown that regular use of a SABA, even for only 1 to 2 weeks, is associated with increased airway hyperresponsiveness, reduced bronchodilator effect, increased allergic response, and increased blood eosinophil levels. These deleterious effects can counterproductively cause greater patient overuse of SABAs, which is associated with increased number of exacerbations, increased mortality rates, and higher annual OCS exposure. Although effective during acute flares, OCS use can cause a wide range of side effects including but not limited to sleep disturbance, weight gain, growth suppression, mood changes, metabolic disturbances, hypertension, and osteoporosis. Even as few as 4 to 5 courses of OCS over a lifetime can increase risk of osteoporosis, diabetes, cataracts, heart failure, and pneumonia.LABAs are a class of bronchodilator, similar to SABAs, but with a longer duration of action of approximately 12 hours. Some LABAs such as salmeterol and formoterol also have a quick onset of action similar to SABAs. Although both salmeterol and formoterol have similarly long durations of effect, formoterol has a faster onset of action (within minutes) compared with salmeterol. Beginning in 2003, the Food and Drug Administration (FDA) issued a black box warning for LABAs due to concerns for asthma-related serious adverse outcomes associated with LABA monotherapy. However, clinical trials completed in both adults and children with asthma between 2011 and 2017 show no significant increase in risk of asthma-related serious adverse outcomes when a LABA is used with an ICS. In 2017, the FDA removed the black box warning from combined LABA-ICS products.SMART or maintenance and reliever therapy (MART) is the use of a combination ICS and fast-acting LABA in a single inhaler for both MART. Currently, 2 ICS-formoterol inhalers are available, budesonide-formoterol and mometasone-formoterol. However, the current recommendations of both the Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEEP) are only for budesonide-formoterol based on the availability of clinical trial data for this combination medication. The 2020 NAEEP update recommended SMART and/or MART therapy in children ages 4 years or older, with moderate to severe persistent asthma. Studies suggest that SMART and/or MART may be more effective than the traditional, standard use of ICS and ICS-LABA for maintenance therapy only and SABA for rescue treatment. Studies in children ages 12 years or older showed that SMART and/or MART compared with ICS and ICS-LABA for maintenance therapy resulted in reduced overall corticosteroid exposure. Multiple post hoc analyses have confirmed that SMART and/or MART reduces the number of exacerbations and results in a lower cumulative daily ICS exposure. Three large, randomized control trials comparing use of SMART vs higher-dose ICS showed that SMART resulted in fewer asthma exacerbations and overall number of doses of ICS and OCS. In children aged 4 to 11 years old, evidence suggests that SMART vs high-dose ICS may lower the risk of growth suppression.In comparison with traditional therapy, SMART and/or MART allows a more flexible, personalized, and dynamic titration of ICS anti-inflammatory treatment along with a fast onset but long duration of smooth muscle relaxation during periods of increased airway inflammation and asthma symptoms. Studies suggest that with a decreased number of asthma exacerbations, there is decreased disease burden on patients and families, less health care use due to fewer urgent health care and emergency department visits, and decreased systemic corticosteroid use. SMART and/or MART may also allow simplification of asthma regimens, with families only using one inhaler for a child’s overall asthma treatment. However, education is necessary to teach families and patients the proper use of SMART and/or MART, especially given the regimen is directly counter to previous recommendations that stressed that ICSs should only be used for maintenance and that it was not a rescue treatment. Lastly, SMART and/or MART makes stepping down on therapy simpler than with traditional therapy because patients can easily step back up by administering more puffs if a step-down therapy does not provide adequate symptom control.Although use of SMART and/or MART is supported by both GINA and NAEEP, US-based pediatricians face several challenges when implementing SMART and/or MART. Budesonide-formoterol is FDA approved for daily maintenance use but not for SMART and/or MART. However, ICS-LABA for SMART and/or MART is approved in over 120 countries, including the United Kingdom, Australia, and New Zealand. Lack of FDA approval for this indication may result in poor insurance coverage and prohibitive cost for American families. Furthermore, even with insurance coverage, the number of inhalers covered per month might be less than the number needed by a patient in any given month when used for SMART and/or MART.In summary, SMART and/or MART have been shown to decrease the risk of severe asthma exacerbations, which can decrease disease burden on patients and families, decrease health care use, and reduce the lifetime number of OCS courses for children. Although SMART therapy presents challenges, it is essential that pediatricians discuss the option of SMART therapy with their patients aged 4 years and older who meet current guideline criteria to improve asthma care.Comment: As the 17th century British physician and writer Dr Thomas Fuller said, “All things are difficult before they are easy.” This aphorism holds especially true about adopting new medical recommendations. The FDA first approved use of ICSs for persistent asthma in 1996. After that, clinicians spent over 2 decades convincing patients and their families that routine ICS use is essential to ward off asthma exacerbations. The message was sometimes a tough sell because ICS inhalers did not offer immediate symptomatic relief despite looking almost identical to albuterol inhalers. That only made us clinicians even more determined to educate our patients with asthma and families on the important difference between controller and rescue medications. Thank goodness SMART is not only better for asthma control but also more intuitive for adherence. Nonetheless, after spending so many years explaining the difference between controllers and rescue medications, it seems that we clinicians may have become reluctant to let go of the distinction despite new evidence. In a 2024 study, only 14.5% of adult patients with moderate to severe asthma were prescribed SMART. Before we can realize population-scale improvements in childhood asthma outcomes, we first need to get the message across to all pediatric clinicians and insurers that SMART is now considered best practice.Linda Y. Fu, MD, MSAssociate Editor, In Brief