II. Indications
- Moderate to Severe Persistent Asthma in age 12 years and older (preferred management)
- Moderate to Severe Persistent Asthma in age 4 to 11 years (may be considered as alternative option)
III. Background
- Uses combination Inhaled Corticosteroid with LABA products
- Limited to Formoterol (Symbicort or Dulera) due to short onset of action (5 minutes)
IV. Protocol
- Use combination agent for additional prn dose for exacerbation symptoms
- Maintenance base dosing as above
- Dose 1-2 puffs (1 puff if under age 12 years) daily or twice daily
- Use 1-2 puffs prn up to maximum based on age (additional doses above the maintenance dose)
- Indications for medical evaluation
- Red Zone Symptoms (call 911, and use rescue puffs every 1-3 minutes up to 6 puffs until EMS arrival)
- Yellow zone symptoms for 2-3 days (>4 rescue puffs/day in age <12 years, >6 rescue puffs/day if older)
- See Asthma Exacerbation
- Consider Corticosteroid burst (e.g. Prednisone 40 mg daily for 5 to 7 days)
- Consider increasing maintenance therapy
V. Efficacy
- Reduced systemic steroids, ED Visits, hospitalizations (NNT 16)
- Now a recommended protocol in the NHLBI Asthma Guidelines 2020
VI. Precautions
- Extra LABA dosing has been cautioned against in past
- Do not use with LABA agents (maintenance or rescue) other than Formoterol
- SMART Protocol has been controversial for >10 years
-
Albuterol rescue Inhaler cost is far less than the combination Corticosteroid/LABA
- Extra doses may not be covered by insurance (e.g. early medication refill)
VII. References
- (2021) Presc Lett 28(3): 14-5
- (2022) Presc Lett, August Issue, accessed online 8/2/2022
- (2010) Thorax 65(8):747-52 [PubMed]
- (2011) Drug Ther Bull 49(11):126-9 [PubMed]
- Nalin (2019) Curr Opin Allergy Clin Immunol 19(2):111-7 [PubMed]
- Cloutier (2020) J Allergy Clin Immunol 146(6):1217-20 +PMID: 33280709 [PubMed]