Single Maintenance and Reliever Therapy (SMART) for Asthma

SMART is a type of therapy to help control moderate to severe asthma in children that are at least 4 years old. With SMART, your child will use 1 inhaler each day that has 2 medicines in it rather than 2 separate inhalers. Brand names include Symbicort® (budesonide/formoterol) and Dulera® (mometasone/formoterol). 

These medicines help control and relieve asthma symptoms:

  • Corticosteroid (inhaled steroids) – This medicine helps control asthma symptoms, like swelling (inflammation) in the airway, and prevents asthma flare-ups. It may take 2 to 3 weeks for some symptoms to get better. Your child still needs this medicine when their symptoms get worse. 
  • Bronchodilator – This medicine helps relieve asthma flare-ups and keeps the airway open. It is usually used as a rescue inhaler like albuterol. With SMART, your child will use extra doses with the same inhaler for fast relief with flare-ups.

Warnings

  • If your child is allergic to the ingredients in these medicines, they should not take them. Call the doctor or health care provider right away.
  • Asthma is a disease that always changes. If asthma symptoms seem to be getting worse, call your child’s doctor or health care provider.

How to Give This Medicine

  • Controller therapy; Dosing is usually 1 to 2 puffs done two times (twice) each day. Each puff is 1 dose. For example, if your child takes 2 puffs for controller therapy each day, they will be taking a total of 4 puffs in one day.
  • Reliever therapy; Each inhaler puff is 1 dose. Dosing is based on your child’s age:
    • 4 to 11 years old: 1 puff as needed. Repeat if symptoms don’t get better. Your child cannot take more than 8 puffs each day. This includes their controller doses.
    • 12 years and older: 1 puff as needed. Repeat if symptoms don’t get better. Your child cannot take more than 12 puffs each day. This includes their controller doses.
  • Most inhalers come with a spacer device to help your child get their full dose of medicine (Picture 1).
  • Read the label carefully to make sure you’re giving your child the right dose. Give the exact dose ordered, even if they’re feeling fine. Do not change doses or stop the medicine without talking to their doctor or health care provider.
  • If your child has a metered-dose inhaler or liquid for a nebulizer, shake the medicine before giving it.
  • If your child has a dry powder inhaler, do not shake the medicine before giving.
  • Stay with your child until they have used the right dose of medicine.
  • After each dose, have your child rinse their mouth with water or brush their teeth to wash out the steroid medicine. This will help prevent thrush and sore throats.
  • Keep a record of how many doses are left and when the medicine is given.
  • Get this prescription refilled at least 5 days before the last dose is given. This is very important.

If You Forget a Dose

  • If your child takes 1 controller dose each day, give this medicine as soon as possible.
  • If your child takes 2 controller doses each day, give this medicine as soon as possible. Do not give their next controller dose until at least 4 hours later. Do not double their next controller dose.
  • After missing a dose, go back to your child’s regular dosing schedule. For questions, ask your child’s doctor, health care provider, or pharmacist.

Contact your doctor or health care provider, or get emergency care if:

  • You exceed your maximum number of puffs per day or
  • Your child needs 6 reliever doses for a single event if 12 years and older or
  • More than 4 reliever doses for a single event for if 4 to 11 years old or
  • You are not getting any relief from the extra puffs.

Drug Interactions

  • Your child should not smoke or vape or be around people that do while taking this medicine. Smoking and vaping can make asthma symptoms worse. This includes tobacco products, medicinal or recreational marijuana, THC, and CBD products.
  • Tell your child’s doctor, health care provider, and pharmacist about any other medicine or herbal supplements they take. Some water pills (diuretics) and medicines for diabetes may affect how inhalers control asthma.

Possible Side Effects

  • Sore throat
  • Thrush (white spots in the mouth)
  • Dry mouth
  • Hoarse voice

What to Do About Side Effects

  • If your child gets a skin rash, call your child’s doctor or health care provider.
  • Your child should brush their teeth or drink water after each dose. This will help prevent thrush and a sore throat.

Special Note for Pregnancy

  • If a patient thinks they may be pregnant, they must tell the doctor or health care provider before taking this or any other medicine.
  • If a patient is breast/chest feeding, they must tell their doctor or health care provider before taking this or any other medicine.

When to Call the Doctor

Call your child’s doctor or health care provider if they are:

  • Having a severe asthma attack.
  • Exposed to chickenpox or shingles.
  • Having any side effects that continue or are very bothersome.

When to Call for 911

Call 911 for emergency help if your child:

  • Has any of these signs of an allergic reaction:
    • Trouble breathing
    • Swelling of the tongue
    • Swelling of the hands, feet, or ankles
  • Is not getting better during an asthma flare-up.
  • Has lips or fingernails that are turning blue or gray.

Medicine Storage

  • Store all medicine out of the reach of children and pets.
  • Keep the inhaler tightly closed and store it in a dark, dry place away from heat or direct sunlight. Do not keep it in a bathroom or above any sinks. It will not work as well if kept in a light or humid place.
  • Do not put this medicine in a refrigerator. Store it at room temperature.
  • Do not use this medicine after the expiration date on the container.
  • Check the label on your child’s medicine. It may have directions to throw it away after being open for 30 to 60 days, even if the medicine is not gone.

Medicine Safety

  • Tell the doctor or health care provider and pharmacist if your child has an allergic reaction to any medicine.
  • If you carry medicine in your purse, keep it in its original bottle. Keep your purse out of the reach of children and pets.
  • This medicine is prescribed for your child only. Do not give it to anyone else.
  • Take all your child’s medicines with you in the original bottles when they see a doctor or health care provider, go to an emergency room, or are admitted to the hospital. This helps providers who may not know them.
  • Learn the name, spelling, and dose of this medicine. Teach your child if they are old enough. You will need to know this information when you call their doctor, health care provider, or pharmacist.
  • If your child takes too much of this medicine, or if someone else takes this medicine, call the Central Ohio Poison Center at 1 (800) 222-1222 [TTY (614) 228-2272]. They will tell you what to do.
  • When going to the dentist, tell them what medicines your child takes and why.
  • Tell your child’s teacher, school nurse, coach, babysitter, and others that they’re taking this medicine and what side effects to watch for.
  • This medicine comes with a patient information sheet. Make sure the pharmacist gives it to you and that you read it. Call your child’s doctor, health care provider, or pharmacist with any questions.

Follow-up

  • Your child will have regular follow-up visits with their doctor or health care provider every  3 to 6 months.
  • Bring any questions you have and a record of your child’s asthma flare-ups and possible triggers to their visits.
  • Call the doctor or health care provider if you can’t keep an appointment.

 

Helping Hands™ Patient Education Materials

Helping Hands™ are easy-to-read guides about different illnesses, therapies, surgeries, and more. They’re created by the Patient Education team at Nationwide Children’s Hospital and are reviewed and approved by clinical staff, like nurses, doctors, pharmacists, and psychologists. Nationwide Children's Hospital is not responsible for misuse of information in patient education materials, including Helping Hands.

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