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We thank our colleagues who have forwarded questions and comments to the editors of Thorax, thereby engaging in a discussion of asthma strategy we believe to be long overdue. We must leave the editors of Thorax to respond to comments directed to their principles and policies, but suspect that our review was regarded by the editors and reviewers as a summary of single maintenance and reliever therapy (SMART) outcomes from a traditional yet unexplored perspective that might spark discussion in an important area. In doing so, we believe that the journal has behaved responsibly by encouraging scientific debate. The tenets of single maintenance and reliever therapy of asthma have represented a marked departure from contemporary asthma management perspectives. These include the following: (1) that a reactive and bronchodilator-driven strategy of asthma care is superior to the prevention of asthma symptoms and disability as long as a small aliquot of inhaled corticosteroid is inhaled at times of acute wheezing and breathlessness; (2) that comprehensive asthma control is no longer needed to evaluate asthma treatment and it is sufficient to measure the time between severe exacerbations; and (3) that rising sputum and biopsy markers of inflammation are of no concern in the choice of maintenance strategies. Until the present correspondence, the absence of discussion and debate concerning these proposals has puzzled us.
Dr Peters and Professor Jenkins have entitled their letter ‘Critical appraisal of Symbicort maintenance and reliever treatment misrepresents clinical evidence’.1 We had used the acronym SMART to represent ‘single maintenance and reliever therapy’ to engage in a broad discussion of asthma management principles and not a review of a specific pharmacotherapy; that will be the intended meaning …