• Asthma genetics
• asthma guidelines
• asthma pharmacology

We write to raise some of a number of serious concerns about the recent paper ‘Single maintenance and reliever therapy (SMART) of asthma: a critical appraisal’.1 We believe that it is written in a misleading fashion and contains important errors of fact, presentation and inference.

Tabulated data for symptoms, reliever use and exacerbations are presented only for patients randomly assigned to SMART. The lead author had access to the analysis by Bateman et al2 that included full comparative data, as he wrote an accompanying editorial3 and cited it in the present paper. It is unscientific, knowing that symptoms and reliever use outcomes are remarkably similar for fixed-dose and SMART, to not present all the data. It is worse then to imply that fixed-dose, even at the highest approved and marketed doses, achieved target levels of control in the populations studied.

The Cochrane review by Cates and Lasserson,4 limited to comparisons of SMART compared with inhaled corticosteroid monotherapy, is wrongly invoked to support the contention that SMART does not reduce exacerbations compared with current best practice. Furthermore, the Cochrane authors' conclusions are selectively edited, removing their definition of current best practice and the qualifying phrase ‘although results of five large trials are awaiting full publication’. Chapman and his co-authors are clearly aware of these data. Another Cochrane review that did examine SMART compared with fixed-dose combination therapy, concluding that SMART reduces severe exacerbations requiring oral corticosteroids but not hospitalisation, is not mentioned.5

Suggesting that SMART is proved to be associated with concerning airway inflammation is similarly disingenuous and is inconsistent with key messages constructed by the authors.6 It is misleading to omit to say that eosinophil counts were in the range of control, that there was no difference in the number of patients who would have been eligible, per protocol, for a maintenance dose increase or decrease, and that fixed-dose combination treatment did not achieve greater improvement in any other asthma endpoint despite more than double the inhaled corticosteroid dose.

This paper purports to be a critical analysis and is published under ‘Review’ in the table of contents. The authors could have presented a balanced description of peer-reviewed evidence, robustly discussing the pros and cons of different medication regimens in clinical practice, but did not. Misrepresentation of scientific evidence is of grave concern. The appropriate response is for the paper to be retracted.