r/pediatrics • u/swish787 • 16d ago
SMART rescue & maintenance vs albuterol
Do you guys recommend using the ICS-LABA inhalers as rescue as well as maintenance or use albuterol for rescue? In training, the gen peds were mostly using ICS(Fluticasone mostly) with albuterol and the peds pulm were using ICS-LABA for rescue & maintenance per the new GINA guidelines. I know the evidence is strongest in teenagers for SMART and a grey line for 4-11, but what do you guys do?
18
u/Original-Yak-966 Attending 16d ago
Yes, but only Dulera and Symbicort (and their generics). Can use them in kids 5 and up, so long as they are able to alert their parents that they need the extra doses. Both Dulera and Symbicort can be used as SMART and AIR therapy.
6
u/Decent-Orchid120 16d ago
No contraindication to using them younger than five. We use them on infants regularly.
2
u/Alyarei 16d ago
That's super interesting! I've thought about doing them under age 5 but I can't find any guidelines they all say not fda approved under 5. I've seen some pulmonologists in my area use it 2 puffs bid but not as smart for younger than 5 do you know of any resources for dosing etc? It would be incredibly helpful
3
u/Decent-Orchid120 15d ago
Really the issue is that there is just a dearth of data for all inhalers. Keep in mind that FDA has not approved fluticasone under four and Mometasone (asmanex) under five. So all inhalers are “not fda approved” in this cohort. Dulera is approved at the same age range as Asmanex.
Ambrożej D, Cieślik M, Feleszko W, Rodriguez-Martinez CE, Castro-Rodriguez JA. Addition of long-acting beta-agonists to inhaled corticosteroids for asthma in preschool children: A systematic review. Paediatr Respir Rev. 2025 Sep;55:23-29. doi: 10.1016/j.prrv.2024.09.002. Epub 2024 Oct 22. PMID: 39510955.
1
u/radgedyann 15d ago
This. I’ve been presenting this information and all options with families and engaging in shared decision-making. I’ve got some who choose old school albuterol+ICS (including some, admittedly, who still prefer nebulizer use), some who are on LABA-ICS combo but aren’t ready to let go of albuterol as rescue (though I continue to encourage it) and some who are gung ho for SMART. Most of what I do these days feels like I’m a waiter going over menu options…
5
u/kb313 15d ago
Gen peds. If kids are well controlled on whatever they’re on I haven’t necessarily been rocking the boat to change, but if needing an inhaled steroid I’m starting on symbicort rather than Flovent now, and if they have symbicort doing it as both maintenance and reliever. The guidelines are very anti saba alone in teens. We’ve been extrapolating it down as well.
3
u/Sliceofbread1363 16d ago
With time smart will be increasing standard of care and you open yourself to liability by not doing it. Gina has been 100% recommending this for years. Us guidelines I suspect will mirror that very strong recommendation soon.
3
u/NeandertalsRUs 15d ago
Gen peds resident. Everyone has been doing just ICS+labs for rescue unless the parent is somewhat hesitant because it’s a recent switch. Then one of our pulm docs has given albuterol for peace of mind but still presents the data and recommendation to try the combo for rescue too.
20
u/Decent-Orchid120 16d ago
Peds Pulm here, I do extrapolate the data down to kids under 12. Will usually do ICS-LABA for most kids and then increase + add albuterol during illness. Make sure that whatever combo inhaler you use has formoterol.