Considering MART therapy: who could benefit?

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Poor asthma control is a major problem in the UK1-3

Many factors can contribute to poorly controlled asthma – also known as ‘difficult asthma’. It can result from poor adherence to treatment (i.e. not using an inhaler enough or as prescribed), incorrect inhaler technique, other simultaneous medical issues or even a wrong diagnosis.2

Definition of poorly controlled asthma2

National Institute for Health and Care Excellence (NICE) The European Respiratory Society (ERS)
  • symptoms three or more days per week
  • need for short-acting β2-agonists (SABAs) to relieve symptoms two or more days per week
  • waking up at night due to asthma one or more nights per week. 
  

  • consistent Asthma Control Questionnaire (ACS) score >1.5, or Asthma Control Test (ACT) score <20
  • frequent exacerbations: within the past year, requiring 2 or more courses of oral corticosteroids for 3 or more days at a time
  • serious exacerbations needing hospitalisation
  • limited airflow: <80% forced expiratory volume in one second (FEV1) after stopping beta2-agonist therapy.

 

In the UK, overusing a SABA is a clear sign a patient has poor asthma control.1 SABA overuse is defined as use more than three SABA inhalers over 12 months.4,5 It is also linked to less frequent use of inhaled corticosteroids (ICS) than needed.5 Both of these are known causes of avoidable asthma exacerbations and asthma-related deaths in the UK;4 they are also related to more  primary care visits and hospital consultations.5

At 58% prevalence in moderate-to-severe asthma patients, the UK has the highest rate of SABA overuse in Europe.5 More than 80% of the total SABA prescriptions for asthma are written for SABA overusers, which is equivalent to over 9.2 million prescriptions in a year.3 A combination of ICS and a long-acting β2-agonist (LABA) may be a user-friendly option to tackle SABA overuse and improve adherence.4

Read more about tackling SABA overuse in asthma patients.

View here

Could MART help tackle poor asthma control?

Maintenance and reliever therapy (MART) describes when a patient is prescribed an ICS/LABA as a maintenance dose and in addition, as a reliever when they experience symptoms. This means a preventer and a reliever medicine are combined in the same inhaler.6

In a quality improvement programme (QIP) study in the UK (n=2,473), switching to MART to reduce SABA overuse was considered appropriate for over half (63.5%) of the asthma patients who needed a treatment change (n=633).7

MART therapy has been linked to better treatment adherence, patient satisfaction,8 and a lower risk of asthma exacerbations and hospitalisations compared with other treatment plans9,10

Other benefits of MART therapy include:6,9,11-15,17-18

For your patients  For the NHS
 

  • reassurance that LABAs are never taken without an ICS
  • simplified treatment vs multiple inhalers, which may improve adherence and tackle SABA overuse
  • lowered risk of severe asthma exacerbations (vs regimens with SABA reliever)
  • lowered risk of asthma exacerbations that need systemic steroid therapy (vs ICS or ICS with or without LABA).
  • supports NHS plans to reduce avoidable SABA prescriptions and, in turn, total carbon emissions from inhalers
  • reduced number of total used inhalers, through using combination inhalers
  • lowered costs related to hospital burden (vs other treatment plans).

Who could benefit from MART?

For every patient, successful delivery of treatment into the lungs depends on both adherence and proper use of their inhaler.14 If they don’t use their inhaler(s) properly, and in turn don’t see the benefits they expect, they could stop using them altogether. This could begin a cycle that leads to poorer health outcomes.15

The difficulties with adherence and inhaler technique become more complicated when several devices with different instructions have to be used. Even with training, errors can still happen for a few reasons, including:14,15

  • age − problems with hearing, sight, understanding and remembering instructions properly
  • low health literacy − unfamiliarity with health-related terminology can make it difficult to fully understand inhaler instructions
  • language barriers
  • physical challenges, for example poor co-ordination (e.g. pMDI vs DPIs)
  • personal preferences around devices and device types.

Concerningly, using multiple inhalers is related to more user errors, lower adherence, a higher chance of stopping inhaler use and worse health outcomes than using a single inhaler.14,15

“The use of combination inhalers should be encouraged. Where long-acting beta agonist (LABA) bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaled corticosteroid in a single combination inhaler.”1

The National Review of Asthma Deaths (NRAD), Royal College of Physicians.

In MART, the preventive and reliever medication are combined into a single device.16

Currently, MART for asthma is recommended by several guidelines.6,11,16

Guideline MART recommendation
The British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS/SIGN) Adults with a history of asthma attacks on medium dose ICS or ICS/LABA6
The Global Initiative on Asthma (GINA). Adults in Steps 3−5* of asthma treatment, and adults who:11

    • show symptoms on most days, wake at night once or more in a week due to asthma symptoms
    • have daily symptoms, wake at night once or more in a week due to asthma symptoms and have low lung function.

*Moderate to severe asthma that has been already treated for the modifiable causes of symptoms.19

Helping patients get the most from MART

It is known that patients’ own preferences and ideas about a treatment can affect how well they respond to it.15 This means that choosing the right inhaler for the right patient, and doing this in consultation with patients directly, may be as critical as the treatment itself.14

The general user experience, including how simple or convenient it is to use an inhaler, may matter to patients.15 In fact, satisfaction with an inhaler is related to:14

  • treatment adherence
  • fewer asthma exacerbations
  • fewer hospital visits
  • improved quality of life.

As satisfaction is not necessarily linked to better inhaler technique, it is extremely important to involve patients in the decision-making and ensure they understand the choice of inhaler being prescribed to them personally. It is key for people to understand how and why a device should be used correctly and why it is needed in the first place.14 This may mean discussing any fears about side effects or a treatment not working.15

Each person has their own unique characteristics and needs, and they can often overestimate their ability to use an inhaler properly.14 Joint decision-making plus education has been shown to improve patient outcomes.15

 

Additional resources

Meet the experts

Meet our panel of clinical thought-leaders who contribute to our educational content on Chiesi Air.

Meet the experts

Extrafine formulation ICS/LABA for MART in adult asthma

Fostair 100/6 maintenance and reliever therapy can be considered for adult asthma patients in need of a reliever and preventer, especially if they have a history of exacerbations and/or signs of poor control. Available in pMDI and DPI (NEXThaler®). Full indication below.

Read more about Fostair in asthma  Learn how to prescribe Fostair MART

Additional resources

  • Considering suitable patients for MART

    Considering suitable patients for MART

    June Roberts

    This video explores when and why you could consider a MART therapy.

    UK-RES-2102930 July 22
  • Considerations for MART for adult asthma

    Considerations for MART for adult asthma

    Dr Vincent McGovern

    This video provides an overview of what MART is and which patients it might be suitable for.

    UK-RES-2102930 July 22
  • Inhaler choice for patients

    Inhaler choice for patients

    Joanne King

    This video explains why inhaler choice is important for patients, and the impact this can have.

    UK-RES-2102930 July 22
View all resources

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UK-RES-2102745 - May 2022

Fostair pMDI 100/6 and Fostair NEXThaler 100/6 are both indicated in the regular treatment of asthma in adults where use of a combination product (inhaled corticosteroid and long-acting beta2-agonist) is appropriate: patients not adequately controlled with inhaled corticosteroids and ‘as needed’ inhaled short-acting beta2-agonist or, patients already adequately controlled on both inhaled corticosteroids and long-acting beta2-agonist.20,21

DPI: dry powder inhaler; ICS: inhaled corticosteroid; LABA: long-acting β2-agonist; MART: maintenance and reliever therapy; pMDI: pressurised metered dose inhaler;
SABA: short-acting β2-agonist.

 

References

    1. Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). Available at: https://www.rcplondon.ac.uk/file/868/download
    2. Primary Care Respiratory Society. Poorly controlled and severe asthma: triggers for referral for adult or paediatric specialist care – a PCRS pragmatic guide. Available at: https://www.pcrs-uk.org/sites/default/files/pcru/articles/2019-Autumn-Issue-18-SevereAsthmaReferral.pdf
    3. The pharmaceutical journal. Half of asthma patients in the UK overusing SABAs, study finds. Available at: https://pharmaceutical-journal.com/article/news/half-of-asthma-patients-in-the-uk-overusing-sabas-study-finds
    4. Janson C, et al. Adv Ther. 2020; 37: 11241135.
    5. International Primary Care Respiratory Group. SABINA: An international programme describing overuse of short-acting β2-agonists in asthma and related clinical outcomes. Available at: https://www.ipcrg.org/11601
    6. British Thoracic Society. SIGN158 British guideline on the management of asthma. Available at: https://www.sign.ac.uk/media/1383/qrg158.pdf
    7. Crooks M, et al. Eur Resp J. 2021; 58: OA80.
    8. Bakakos P, et al. J Pers Med. 2022; 12(2): 146.
    9. Papi A, et al. Lancet Respir Med. 2013; 1(1): 23-31.
    10. Papi A, et al. Allergy Asthma Clin Immunol. 2020; 16: 75.
    11. Global Initiative for Asthma. Global Initiative for Asthma (GINA). Available at: https://ginasthma.org/wp-content/uploads/2023/04/GINA-Main-Report-2021-V2-WMSA.pdf
    12. Rodriguez-Martinez CE, et al. Pharmacoeconomics. 2018; 36(10): 1165-1200.
    13. Canonica GW, et al. Ther Adv Respir Dis. 2021; 15: 17534666211042534.
    14. Usmani OS. Ther Clin Risk Manag. 2019; 15; 461-472.
    15. Kaplan A, Price D. Can Respir J. 2018; 9473051.
    16. National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management. Available at: https://www.nice.org.uk/guidance/ng80/resources/asthma- diagnosis-monitoring-and-chronic-asthma-management-pdf-1837687975621
    17. Pernigotti D, et al. BMJ Open Respir Res. 2021; 8(1): e001071.
    18. National Health Service. Annex B – Investment and Impact Fund (IIF): 2021/22 and 2022/23. Available at: https://www.england.nhs.uk/wp-content/uploads/2021/08/B0828-iii-annex-b-investment-and-impact-fund-21-22-22-23.pdf
    19. Global Initiative for Asthma. GINA 2019 Asthma recommendations about reliever medications in steps 3-5. Available at: https://ginasthma.org/gina-2019-recommendations-about-reliever-medications-in-steps-3-5/
    20. Fostair pMDI 100/6 Summary of Product Characteristics. Chiesi Limited.
    21. Fostair NEXThaler 100/6 Summary of Product Characteristics. Chiesi Limited.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Chiesi Limited on 0800 0092329 (UK) or PV.UK@Chiesi.com.