“It is time to end our love affair with short-acting β2-agonists in asthma” (albuterol).[i] We have known for a long time that one of the key aspects of asthma is inflammation.[ii] While people with asthma may feel “relief” when they take a puff or 2 of albuterol, overreliance on albuterol “rescue” inhalers is associated with more exacerbations and worse asthma control over time.[iii]
Introducing SMART therapy
Single Maintenance and Reliever Therapy (also known as SMART) utilizes one inhaler for both maintenance dosing and reliever therapy. SMART therapy is a different approach for treating asthma. Traditionally, people with very mild, intermittent asthma or trigger-induced asthma, such as exercise-induced asthma, would just have their “rescue inhaler.” People with persistent asthma would have an inhaler for maintenance, containing a combination of an inhaled corticosteroid (ICS) and a long-acting beta agonist (LABA), and a second, albuterol “rescue” inhaler.
Now patients, regardless of their asthma status, can carry one inhaler to serve for both routine treatment and reliever therapy. The key is that the inhaler needs to be an inhaled corticosteroid (ICS) with formoterol, because formoterol is a rapid onset, long-acting beta agonist.
Why do we need this change?
Systematic reviews and meta-analyses of individuals with poor asthma control have demonstrated that people with asthma who receive some form of SMART therapy have less progression of asthma and reduced risk severe asthma events than those who are treated with other ICS/LABA inhalers plus albuterol. [iv] Use of more than 3 albuterol inhalers can signal poor asthma control and risk for severe exacerbation and death.[v]
What if I do not need to use my asthma inhaler every day?
The great thing about SMART therapy is that it can just be used as needed. Known as anti-inflamatory reliever (AIR) therapy, inhalers with the ICS/formoterol inhaler. People with exercise-induced asthma or mild intermittent asthma can literally use their inhaler just before exercise or only when they have symptoms and receive maximum benefit from both medications. Having mild asthma does not mean that a person is not at risk for severe exacerbation under the right conditions.[vi]
What do I do when I am short of breath or wheezing?
SMART therapy means that people with asthma use the same inhaler for maintenance and as needed. Treating worsening symptoms in this manner (versus albuterol alone) helps prevent the need for oral steroid therapy such as prednisone. The more we can avoid the use of oral corticosteroids, the better for overall health.
Take a Deep Breath
October is Lung Health Month. If you have asthma, consider talking to your doctor about SMART therapy. This approach to the care of people with asthma is the preferred approach recommended by the Global Initiative for Asthma (GINA). In Michigan, there is the INAHLE Initiative is working to improve asthma and COPD care in the state of Michigan by demonstrating, particularly for insurance companies, that covering the medications that allow for SMART therapy means achieving healthier patients and preventing serious illness and death.[vii] While there are barriers to this care right now, the health benefits are worth fighting for.[viii]
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Works Cited:
Alan Levine on Pxhere.com with image editing.
[i] Crooks, Michael G, and Shoaib Faruqi. “It Is Time to End Our Love Affair with Short-Acting β2-Agonists in Asthma.” ERJ open research, October 17, 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC9574554/.
[ii] Ibid.
[iii] Nannini, Luis J. “It Is Time to End Our Love Affair with Short-Acting Β2-Agonists in Asthma? Yes.” ERJ open research, February 27, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC9969308/.
[iv] Rayner, Daniel G., Dario M. Ferri, Gordon H. Guyatt, Paul M. O’Byrne, Romina Brignardello-Petersen, Farid Foroutan, Bradley Chipps, et al. “Inhaled Reliever Therapies for Asthma.” JAMA 333, no. 2 (January 14, 2025): 143. https://doi.org/10.1001/jama.2024.22700.
[v][v] White, Stacey. “Rethinking Mild Asthma in Primary Care: Real-World Lessons on as-Needed ICS-Saba Use.” European Medical Journal, July 31, 2025. https://www.emjreviews.com/en-us/amj/respiratory/article/rethinking-mild-asthma-in-primary-care-real-world-lessons-on-as-needed-ics-saba-use-s080225/.
[vi] Ibid.
[vii] “Inspiring Health Advances in Lung Care (INHALE).” INHALE. Accessed September 20, 2025. https://inhalecqi.org/.
[vii] Ibid.
Posted for Lung Health Month
October 2025
