Maintenance and reliever treatment (MART) for asthma

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway
  • MART treatment uses the same inhaler for regular treatment and as required use - i.e. no salbutmol inhaler is prescribed
  • Formoterol has an equivalent onset of action to salbutamol. Other LABAs can’t be used
  • MART has been shown to be equivalent or better to traditional regimes with separate preventer and reliever but if patients drop themselves down to reliever only then ICS/formoterol PRN only has been shown to be as effective as regular ICS, wheras salbutamol alone has been shown to increase the risk of asthma exacerbation and death
  • PRN only dosage of ICS/formoterol is not licenced in the UK but is used widely worldwide and recommended by GINA (Global Strategy for Asthma Management and Prevention, 2021)
  • MART is only licenced for age 12 and over (and Symbicort is the only licenced inhaler for 12-18s)
  • For patients who need to step up it is possible to use 2 puffs BD of high dose inhalers (Fobumix 320/9, Fostair 200/6 etc) but the PRN inhaler should remain the lower dose ICS/formoterol. This regime is not licenced but is recommended by GINA as an option for individual patients following discussion—it should rarely be required
  • For patients who wish to step down the lowest step using Fobumix 80/4.5 is a reasonable minimal maintenance. If they wish to use PRN only there is some evidence base for it (and better than salbutamol only) but this regime is also not licenced in the UK

Step 1b—very low dose

Directions:
1 puff BD (or 2 puffs OD) plus 1 puff PRNPreparations:
Fobumix 80/4.5 DPI
Symbicort 100/6 DPI (for 12-18 year olds)

Max daily dose:
8 puffs but
12 puffs short term

Step 2a—low dose

Directions:
1 puff BD (or 2 puffs OD) plus 1 puff PRN
Preparations:
Fobumix 160/4.5 DPI Duoresp 160/4.5 DPI
Symbicort 200/6 DPI (for 12-18 year olds)

Max daily dose:
8 puffs but
12 puffs short term

Step 2b—medium dose

Directions:
2 puffs BD plus 1 puff PRN
Preparations:
Fobumix 160/4.5 DPI Duoresp 160/4.5 DPI
Symbicort 200/6 DPI (for 12-18 year olds)

Max daily dose:
8 puffs but
12 puffs short term

Step 2a

Directions:
1 puff BD plus 1 puff PRN
Preparations:
Fostair 100/6 MDI
Fostair 100/6 Nexthaler

Max daily dose:
8 puffs

Step 2b

Directions:
2 puffs BD plus 1 puff PRN
Preparations:
Fostair 100/6 MDI
Fostair 100/6 Nexthaler

Max daily dose:
8 puffs

Editorial Information

Last reviewed: 30/10/2023

Next review date: 30/10/2025

Author(s): Emily Kennedy, Dumfries and Galloway Respiratory Managed Clinical Network.

Version: 1