Management of Asthma with ICS and LABAs: Different treatment strategies

In recent years considerable insight has been gained in the optimal management of adult asthma. In asthma patients who have persistent symptoms despite the daily use of (a low dose) inhaled corticosteroids (ICS), adding a long- acting β 2 -agonist to ICS improves asthma control and decreases the number of exacerbations. Currently two different LABAs are available, ie formoterol and salmeterol. The most important difference between both LABAs is a more rapid onset of action of formoterol (2-5 minutes) when compared to salmeterol (15-30 minutes). Partly based on these pharmacological differences, two major different approaches have been put forward to asthma management. The fi rst approach (Gaining Optimal Asthma Control) is promoted by the producers of fl uticasone/salmeterol and recommends to step up ICS to the dose needed to achieve optimal asthma control in order to keep the patient symptom free and to prevent exacerbations. The second approach is promoted by the producers of budesonide/formoterol and recommends a low maintenance dose which can be adjusted up or down according to the clinical control of asthma. Initially, a treatment strategy with Adjustable Main- tenance Dosing with budesonide/formoterol was introduced. At a later time, this concept was changed to the Symbicort Maintenance And Reliever Therapy (SMART) approach. The aim of this manuscript is to review the current literature on the management of asthma with ICS and LABAs and to discuss the different treatment strategies.