The paper by Chapman et al1 reviewing single maintenance and reliever therapy (SMART) in asthma is important in highlighting some of the inadequacies of existing research evaluating this treatment method.

The authors also claim that SMART fails to achieve adequate asthma control as measured by GINA criteria and provide a table detailing seven studies and associated control indices.

While these outcomes are far from ideal, the authors fail to point out that they were no worse than the comparator arm, which varied across the studies from conventional inhaled steroid therapy to fixed dose combination inhaled steroid/long-acting beta-agonist inhalers in high dose (ie, ‘optimal therapy’). This inadequate control therefore reflects the severity of disease in the trial subject group rather than being a specific deficiency of SMART therapy.

It is disingenuous to claim that SMART fails to achieve adequate asthma control without pointing out that in this patient group standard, ‘optimal’, therapy does no better.