National asthma guidelines published in 2020 recommend that most patients with moderate-to-severe asthma would benefit from using one inhaler that includes both a long-term anti-inflammatory medicine and quick-relief medicine. This treatment is called SMART (or MART), which stands for Single Maintenance and Reliever Therapy. Studies show that using a single inhaler reduces the risk of asthma flare-ups by about 30%, compared to using one daily maintenance inhaler plus a separate, quick-relief inhaler as needed. However, only a small number of the 25 million people with asthma in the U.S. are prescribed and use SMART.
One of the main reasons for this is cost, according to James Krings, MD, an Assistant Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at Washington University in the St. Louis School of Medicine. With an American Lung Association Public Health and Public Policy Research Award, Dr. Krings and his team are attempting to increase Medicaid payors’ awareness of SMART to increase the number of people who benefit from this form of treatment. Medicaid is the focus of the study because asthma affects more patients covered by Medicaid programs compared to those covered by private insurance.
What is SMART?
SMART is a treatment where patients use one inhaler that includes both an inhaled corticosteroid (ICS) and a specific long-acting bronchodilator (LABA), called formoterol. This is how one inhaler can provide everyday maintenance control and as needed relief treatments. The ICS helps reduce inflammation in the airways, while the LABA (formoterol) has a rapid onset to reduce symptoms by relaxing the smooth muscles in the airways.
SMART has been shown to reduce emergency room visits and hospitalizations, while improving asthma control and quality of life. The improvements in asthma control and quality of life also result in an improved risk of mortality. With only one inhaler, it’s easier for patients to keep track of their medicines and use them as directed by their doctor.
“Research from the American Lung Association has shown that many state Medicaid programs don’t optimally cover SMART despite being guideline-recommended,” Dr. Krings said. His team previously found that the main reason doctors don’t prescribe it is due to lack of insurance coverage and high out-of-pocket costs for patients.
To address this, Dr. Kring and his team will do two things. First, they will partner with health economics investigators to figure out how much it costs Medicaid to cover SMART inhalers, compared to covering a maintenance inhaler plus a separate quick-relief inhaler. “This type of cost analysis has never been done before in the U.S,” he explained. Although SMART inhalers may cost Medicaid a bit more up front, they help avoid costly emergency room visits, hospital stays and doctor appointments, which could save money in the long run.
The second part of the study will involve sharing the results with state Medicaid pharmacy directors, who decide which medications are covered. “The medications that Medicaid decides to put on its formulary are what people will generally get,” Dr. Krings said. “We want to show Medicaid pharmacy directors that covering SMART will save them money, in addition to improving asthma patients’ outcomes.” After distributing the cost data analysis, Dr. Krings’ team will check how much Medicaid pharmacy directors know about SMART.
“The potential impact of this grant could be big,” Dr. Krings said. “It could improve access to evidence-based and guideline-recommended asthma care for those covered by state Medicaid programs. We believe that if more people are prescribed SMART, they will have better asthma outcomes.”
Learn more by taking Asthma Basics in English or Spanish or call our Helpline at 1-800-LUNG-USA.
Blog last updated: March 7, 2025
