Journal of Prescribing Practice - Maintenance And Reliever Therapy (MART) for young people with asthma

Abstract

Maintenance and reliever therapy (MART) is one device, which serves as both preventer and reliever. In children and young people, the choice is more limited in terms of device and this is called Symbicort MART (SMART). One of the most common modifiable factors for optimal asthma control at any age is adherence to prescribed preventer therapy (British Thoracic Society(BTS)/Scottish Intercollegiate Guideline Network (SIGN), 2019). As young patients grow and take increasing responsibility for their own health, perfect adherence can feel impossible for the developing brain (and with this, the ability to effectively analyse risk). As health professionals, it can be easy to focus on the adherence issue as a failure to organise, and to assume all have the capacity to optimally administer a medication twice daily. What we are increasingly learning through the multiple health inequality and psychosocial workstreams is that there are families who are fundamentally less likely to achieve this, even with additional support from their health team, due to an actual or perceived inability to deal with the modifiable factors highlighted by BTS/SIGN.

When we consider family chaos in the context of a developing brain with limited abilities to create routine for itself, or to analyse risk (of not taking vs the benefit of taking medication), it is perhaps a little easier to understand why a simple task becomes difficult (Weinstein et al, 2019). When we consider further the financial, socioeconomic and psychological pressures on families who have, in the last 5 years, experienced a pandemic, pressures of balancing work and often round-the-clock childcare and then a cost of living crisis, it feels like many of our families have reached capacity on their mental load.

Anecdotally, it feels like asthma care has moved at great pace in the last decade, meaning that a large subset of our families have parents with asthma and/or atopy. They are likely to have initiated treatment when lone short-acting beta-agonists (SABA) were still recommended in the guidelines and, as is often found, feel the reliever is the medicine that ‘works’ and fear remains around inhaled steroids (Chan and Debruyne, 2000). The focus of the asthma narrative has been on reliever for some time and, despite guidelines switching to a preventer-focused approach and the health literature following suit, behaviour and perception change will be slower to catch up. We are at the tricky point of pursuing more proactive models of care with a patient population that is largely still thinking in a reactive way.

This is where MART enters the conversation. Maintenance and reliever therapy (MART) is one device that serves as both preventer and reliever. In children and young people, the choice is more limited in terms of device and this is called Symbicort MART (SMART). Symbicort (as the 100/6 preparation) is licensed in children over the age of 6 years. MART (or SMART) uses the 200/6 preparation and is licensed in children from the age of 12.

In practice, we have been using particular devices and MART therapy for some time, largely with the subset of our patient cohort that have simply not achieved optimal adherence to therapy or adequate asthma control as a result. Often, these patients have already had what feels like incredible support, multiple options, every test and frequent contact with their teams – but the plan simply does not come to fruition and we collectively scratch our heads. Historically (and certainly in the author's own clinical practice), this has been the point where we consider using breath-actuated devices and regimens like MART. We weigh up the risk–benefit model and decide that the chance of the patient receiving a therapeutic dose is better when the regimen is once per day or they are titrating to their own symptoms. If a patient is largely forgetful, when remembering to take medication when they are symptomatic, one thinks, if we take the single device option, at least they have to vote with their feet!

MART is not a new concept, and has been embedded in asthma guidelines for some years. However, the narrative is changing as we note increased focus on MART in the Global Initiative for Asthma (GINA) guidelines (2022) and the UK guidelines and literature. The National Institute for Health and Care Excellence (NICE, 2023) states, ‘If asthma is uncontrolled on a paediatric low dose of Inhaled corticosteroids (ICS) and a long-acting beta-agonist (LABA), consider changing their ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART) regimen’.

As the evidence base increases, it is becoming more apparent that this is the way forward for all appropriate patients, not just those struggling with adherence.

Rationale

MART as a regimen works because it allows for automatic self-titration. By its very nature, the patient will take more ICS doses when they are symptomatic and default to baseline (preventer therapy only) when they are well controlled. This has recently been named anti-inflammatory reliever (AIR) therapy and is a variation of MART that is newer and less established for children and young people in the UK.

Who can use MART?

Fundamentally, MART is appropriate for young people from 12 years old if they are able to use the device optimally (Box 1). This means understanding how the device works, how to inhale and how to know when it is empty. There are also more nuanced considerations, such as allergies, as some dry powder inhalers contain lactose.

Box 1.Steps to perfect dry powder inhaler technique

Prime the device*
Breathe out
With a good seal on the mouthpiece, inhale hard and fast
Hold breath for a few seconds or as long as is comfortable

*For Symbicort, patients must hold the device straight (vertically) while twisting the base back and forth to ensure optimal medication release for inhalation

Carbon footprint

Relative to pressurised metered-dose inhalers (pMDIs), consider that, overall, the lowest carbon footprint comes from good asthma control. It may not be surprising that the carbon footprint of dry powder inhaler or ‘breath-actuated’ devices is lower than a pMDI, which is more often associated with asthma in young people.

While the environmental impact of device choice is an important issue, the most significant factor contributing to the carbon footprint of individual asthma care is level of control over symptoms. Someone who uses low-carbon devices but has frequent exacerbations will generate more carbon in urgent visits, admissions and, most of all, ambulance trips (Kponee-Shovein et al, 2022; Levy et al, 2023).

Figure 1 shows the relative carbon footprint of commonly compared activities and devices with the carbon emissions associated with an asthma exacerbation. Of course, an exacerbation severe enough to warrant a call to emergency services and/or hospital admission also raises the individual's risk profile and likelihood of future exacerbation (BTS/SIGN, 2019).

Understanding effectiveness

As outlined above, MART works by self-titrating inhaled steroid alongside a short-acting bronchodilator. Therefore, we know treatment is working when patients are barely using MART and simply using their preventer doses. This means that they are not needing additional doses and that their baseline therapy is keeping lung inflammation (and therefore symptoms) at bay (GINA, 2022).

Next steps

If the patient is using MART successfully, they can simply continue with this plan for the foreseeable future. If they reach the stage where no additional doses are being used at all, and asthma control or quality of life scores remain good, a review of treatment level may be warranted: does this patient still require this level of therapy or can they be stepped down? In young people, we have restricted use of this pathway so we rarely step them down from a plan that works as it would mean they need to reconsider dual therapy, which is not always as effective or appealing.

If the patient is demonstrating potential remission and de-diagnosis may be possible, we could consider using AIR as an approach to monitor symptoms that may recur on stopping regular preventer, but have the safety net of continuing the medication that worked. If they have symptoms that recur rapidly, they will re-dose themselves with the combination device by default and continue therapy.

AIR is a newer concept that we are moving towards, but should be carefully considered. It is almost a default to a problematic approach that may have moved this young person to MART in the first instance – poor adherence.

Summary

MART has been found to be an incredibly effective treatment plan for young people with asthma – a phenomenon reflected in the newer guidelines such as GINA (2022). However, it should be considered carefully and with all-important education and discussion with the young person (plus their grown-up, depending on age).

If used appropriately, with optimal device technique and understanding of how the regimen works, it can revolutionise a young person's asthma control and, therefore, their quality of life. Any clinician working with young people will have anecdotes of adolescents who have responded incredibly well with this new regimen, not least because it also fosters a sense of independence and flexibility.

Key points

Maintenance and reliever therapy (MART) is not for everyone and health professionals must gauge appropriateness before prescribing
Technique is vital, and needs to be checked first
Practitioners must review to ensure the patient is using effectively and that it is going positively
MART should be considered carefully with education and discussion with the young person plus an adult, depending on age

CPD reflective questions

Is maintenance and reliever therapy (MART) something you can see yourself using more with young people over 12?
What challenges or barriers might you find?
What young people would you be cautious about using MART with?
What could you do to help?
How can you share this learning with your wider team?

References

Maintenance And Reliever Therapy (MART) for young people with asthma