1. Research where it is most needed National Respiratory Strategy
Richard Beasley
Medical Research Institute of New Zealand

3. Circumstances associated with asthma deaths
Delay in seeking medical help
Lack of appreciation of severity (acute and chronic)
Inadequate use ICS and oral steroids
Over-reliance on beta agonists
Discontinuity of care
[Asthma Task Force Survey]

4. [Holt et al. Prim Care Respir J 2004]

5. [Holt et al. Prim Care Respir J 2004]

6. [Holt et al. Prim Care Respir J 2004]

7. Asthma self-management plans - questions
Individual patient requirements
Peak flow levels
Peak flow vs symptoms
Components leading to efficacy
Doubling ICS
Amount of detail
Use by patients
Other meds

8. SMART
Single combination ICS/LABA inhaler for maintenance and reliever therapy

9. [Lancet 2006]

10. BUD/F 200/6 µg bd + formoterol prn BUD/F 200/6 µg bd + terbutaline prn
BUD/F 200/6 µg bd + prn
BUD/F 200/6 µg bd + formoterol prn
BUD/F 200/6 µg bd + terbutaline prn
ICS dose reduction (baseline 750 µg per day)
Patients with beta agonist overuse excluded
Severe exacerbations: ER, HA or oral steroids
[Rabe et al. Lancet 2006]

11. [Rabe et al. Lancet 2006]

12. [NZ Med J 2008]

13. Indications
[Taylor et al. NZ Med J 2008]

14. Contraindications
[Taylor et al. NZ Med J 2008]

15. SMART Research Programme - Limitations
Excluded high risk patients
High baseline beta agonist use
Limited generalisability
Required significant bronchodilator reversibility
Excluded smokers
Step down in treatment
Inadequate maintenance ICS
No accurate measures of actual inhaler use
Inability to assess risk of adverse effects
Short term exposure
Cumulative exposure

16. [Patel et al, Lancet Resp Med 2013]

17. Questions Overuse in setting of severe exacerbation?
Delay in seeking medical review in severe exacerbations?
Improve compliance with ICS therapy?
Systemic corticosteroid exposure?
Efficacy in patients at risk of severe exacerbations?

18. Methods
A 24-week, open-label, parallel-group, randomised, controlled, trial undertaken at four primary healthcare practices and one hospital in New Zealand.

19. Design 303 asthma patients with exacerbation in previous 12 months
Randomised to SMART or Standard regime
SMART: budesonide/formoterol 200/6µg 2 actuations twice daily and 1 as required for relief
Standard: budesonide/formoterol 200/6µg 2 actuations twice daily and salbutamol 1 to 2 as required for relief
Study visits 0, 3, 10, 17, 24 weeks
Electronic monitors to measure actual inhaler use

20. Electronic medication data
Database:
282,466 actuations
2,642 monitors
49,1249 days treatment
Complete data:
95% dispensed
98% returned

21. Primary outcome variable
Proportion of subjects with at least one high-use beta agonist episode
>16 actuations/day salbutamol
>8 actuations/day bud/form
(in addition to 4 maintenance doses)
Limits of use requiring medical review defined by management plans
Bronchodilator equivalence with repeat dosing in acute asthma

27. SMART resulted in fewer days with zero actuations of ICS (non-adherence)
24 vs 34 days
RR 0.72 (0.55 to 0.95) P = 0.02

28. SMART reduced severe exacerbations
0.53 vs 0.77 per year
RR 0.54 (0.36 to 0.82), P = 0.004

30. Interpretation
The SMART regimen has a favourable risk-to-benefit profile and can be recommended for use in adults at risk of severe asthma exacerbations.

31. Asthma research priorities
Prevalence 
Morbidity 
Mortality 

32. Worldwide prevalence of clinical asthma in children
≥ 10.0%
> 5.0 – 9.9%
> 0 – 4.9%
> No standardised data available

33. Asthma Foundation research priorities
Models of care for Maori and Pacific peoples
Service evaluation of existing initiatives
Strategies to prevent respiratory conditions (COPD, lung cancer, childhood bronchiectasis)
Improve health literacy

34. Asthma Foundation research priorities
Understanding OSA
Improve diagnosis, assessment, treatment of COPD
Health psychology and respiratory disease
Effective of annual respiratory check
Indicators to measure and monitor respiratory health outcomes