Single maintenance and reliever therapy (SMART) has been recommended as a preferred option for moderate to severe persistent asthma since updated national guidelines were released in 2020. But adoption of this paradigm shift has been far from universal across the large group of stakeholders, which includes not only patients and their caretakers but also primary care providers, schools, and insurance carriers.
“Despite the advantages of a single inhaler for both maintenance and relief, there are a number of practical issues which have impacted implementation of SMART, not the least of which include discrepancies between labeling of [inhaled corticosteroid (ICS)-long-acting β2-agonist (LABA)] drugs for quick relief vs guideline recommendations, age limitations, insurance and formulary issues, and need for reeducation,” said Mary Cataletto, MD, FCCP, Pediatric Pulmonologist at New York University Langone Health.
Experts will explore these issues during SMART Therapy and Allergy Immunotherapy in GINA/EPR-4 Guidelines for Asthma Control: Pros and Cons, Sunday from 8:15 am to 9:15 am, in Room 315 of the convention center. Session Co-Chair, Jerry Krishnan, MD, FCCP, University of Illinois, Chicago, and Shahid Sheikh, MD, FCCP, Nationwide Children’s Hospital, will debate the evidence supporting implementation of SMART; address the current challenges; and look at those 2020 National Heart, Lung, and Blood Institute (NHLBI) Expert Panel 4 (EPR-4) guidelines in relation to Global Initiative for Asthma (GINA) recommendations.
A second debate between Dr. Cataletto and S. Shahzad Mustafa, MD, University of Rochester, will address the pros and cons of allergen immunotherapy (AIT) for atopic asthma as recommended in those same guidelines.
“Allergen immunotherapy is the only disease-modifying therapy for allergic disease,” said Dr. Cataletto, who is also a Session Co-Chair. “It has a long history of use in allergic diseases, especially rhinitis. The NHLBI Expert Panel provided subcutaneous immunotherapy (SCIT) with a conditional recommendation for atopic asthma in those ages 5 years and older with mild to moderate allergic asthma as an adjunct to standard asthma treatment.”
This guideline was issued with the recommendation that asthma is controlled during each phase of immunotherapy, as the risk of systemic side effects, including anaphylaxis, may be higher in those with severe or uncontrolled asthma. SCIT involves a high level of commitment, as it requires pretreatment evaluation and testing as well as in-person visits over an extended period of time, usually 3 to 5 years. While adverse systemic effects are rare, they can include anaphylaxis and death. Therefore, SCIT should be administered in a medical setting by trained staff and with equipment to identify, monitor, and treat anaphylaxis, Dr. Cataletto said.
EPR-4 issued a conditional recommendation against sublingual immunotherapy for persistent allergic asthma. It may, however, be useful in improving comorbid allergic rhinoconjunctivitis and help to improve quality of life outcomes.
“It is our goal to improve attendees’ knowledge of both the science and the real-world application of SMART and AIT in the appropriate individuals with asthma,” Dr. Cataletto said. “Working through the pros and cons can promote improved clinical outcomes with evidence-based guideline care.”