One Inhaler, Both Jobs: MART and the End of SABA-Only Care

A clinical brief for referring providers — part 2 of a 4-part asthma pharmacotherapy series.

Test your knowledge

How many short-acting beta2 agonist (SABA) canisters per year is the threshold associated with an increased risk of asthma death? a) ≥3/year b) ≥6/year c) ≥12/year

(Answer at the bottom — it reframes the "he just refills his albuterol" patient.)

The most consequential change in the recent guidelines

Part 1 covered the frame: low-dose inhaled corticosteroid (ICS) does 80–90% of the work, and a long-acting beta2 agonist (LABA) is never monotherapy. Now, the single most consequential change in the recent guidelines — maintenance and reliever therapy (MART), a single ICS-formoterol inhaler used for both daily control AND as-needed rescue.

Why formoterol, and only formoterol

Formoterol is the one LABA with a rapid onset (1–3 minutes) — fast enough to work as a reliever. That is what makes MART possible. Salmeterol's onset is slower (~15–20 minutes); it is a maintenance-only LABA. MART has been studied only with formoterol-containing combinations — ICS-salmeterol should never be used as reliever therapy (NAEPP 2020). One inhaler, one molecule that does both jobs.

Why it works

When symptoms worsen, the patient reaching for the inhaler automatically receives anti-inflammatory therapy alongside the bronchodilator — instead of SABA alone during exactly the window that matters. MART reduces severe exacerbations by 32–41% versus the same-dose ICS-LABA with SABA rescue, while lowering total corticosteroid exposure (NAEPP 2020; Sobieraj et al., JAMA 2018).

The 2025 numbers

A JAMA systematic review and network meta-analysis (27 randomized controlled trials, N=50,496) found ICS-formoterol reliever cut severe exacerbations by 35% versus SABA alone (relative risk [RR] 0.65; 95% confidence interval [CI] 0.60–0.72), high-certainty evidence — and it beat ICS-SABA too (RR 0.78; 95% CI 0.66–0.92) (Rayner et al., JAMA 2025).

Dosing, at the wall

Maintenance 1–2 puffs once to twice daily; rescue 1–2 additional puffs (4.5 μg formoterol/puff) every 4 hours as needed; maximum 12 total puffs/day for patients ≥12 years (NAEPP 2020). MART-eligible combinations are budesonide/formoterol and mometasone/formoterol.

The SABA-overuse danger — the reason to make the switch

SABA relieves symptoms but treats none of the underlying inflammation, and mild-appearing asthma can still flare fatally. ≥3 canisters/year is associated with increased exacerbation risk; ≥12 canisters/year with increased risk of asthma death (Papi et al., ERS 2023). Both GINA and NAEPP now hold that SABA-only treatment is no longer appropriate for any persistent asthma — an anti-inflammatory reliever should replace it wherever possible (Rayner et al., JAMA 2025).

Next in this series: the add-ons — when to reach for tiotropium (LAMA), and how to weigh montelukast after its FDA boxed warning.

The answer

c) ≥12 canisters/year is the threshold associated with increased risk of asthma death (≥3/year already flags increased exacerbation risk). A refill history is a vital sign — a patient burning through SABA is telling you the inflammation is untreated (Papi et al., ERS 2023).