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February 2020

GINA clarifies MART recommendations

Misinterpretation by some clinicians of the 2019 Global Initiative for Asthma (GINA) recommendations for patients on combination inhaled corticosteroids/long acting b2-agonists (ICS/LABA) has prompted the organisation to issue clarification.

In the GINA 2019 treatment algorithm for adults and adolescents, Steps 3-5 show the medication options for patients with moderate to severe asthma in whom modifiable causes of symptoms or exacerbations have been addressed. In these patients, low-dose ICS-formoterol is the preferred reliever only for patients who are prescribed maintenance and reliever therapy with ICS-formoterol.

GINA does not recommend use of ICS-formoterol as the reliever for patients taking combination ICS-LABA medications with a different LABA. For these patients, their as-needed reliever inhaler should be a short-acting b2-agonist (SABA).

The maintenance and reliever regimen (sometimes called ‘MART’ or ‘SMART’) is approved in many countries for use with low dose beclometasone-formoterol or low dose budesonide-formoterol. With this regimen, the patient receives ICS-formoterol as their regular twice-daily or once-daily maintenance treatment, and takes additional doses of a low-dose ICS-formoterol for relief of symptoms, instead of as-needed short-acting b2-agonist.

GINA states: ‘In adult and adolescent patients with ≥1 exacerbation in the previous year, the ICS-formoterol maintenance and reliever regimen significantly reduces exacerbations and provides similar levels of asthma control at relatively low doses of ICS, compared with a fixed dose of ICS-LABA as maintenance treatment or a higher dose of ICS, both with as-needed SABA. Low dose ICS-formoterol is the preferred reliever for patients prescribed the maintenance and reliever treatment regimen. It should not be used as the reliever for patients taking combination ICS-LABA medications with a different LABA.’

GINA Alert.