Join me for a trip down memory lane.

In yesteryear (2018), humankind was distinctly divided into two parties.

Those with asthma, and those without.

If you were lucky, a simple blue cap inhaler would allow you to blend in with wider society.
But if that didn’t do the trick, you were cast out.
Condemned.
Separated from the healthy and the normal.

Escorted to a dingy side room called Allergy Clinic - a sort of pathway purgatory.

And there, your pilgrimage began.

Through the 7 Circles of Hell, politely referred to by NICE as: The chronic asthma management pathway.

Every time you coughed, wheezed or fell short of breath, you were labelled uncontrolled.
Circle 1: SABA
Circle 2: SABA + ICS
Circle 3: SABA + ICS + LTRA
Circle 4: SABA + ICS + LABA +/- LTRA

On and on and on. Deeper in the belly of the beast.

But one day, a saviour emerged.
Not from a stable in Bethlehem but instead from the front pages of …
The SYGMA trials.

In this multinational, phase 3 double-blind RCT, these researchers asked if there was a better way…

The trial aimed to determine if MART therapy(ICS/LABA) was more effective at controlling asthma than standard SABA or SABA + ICS management.

3,849 patients aged 12+ with mild asthma were randomly assigned to one of three groups:

As-Needed SABA: Placebo twice daily + terbutaline as needed.

As-Needed MART: Placebo twice daily + budesonide-formoterol as needed.

ICS Maintenance: Budesonide twice daily + terbutaline as needed.

Then these patients were followed for 52 weeks (that’s one year).

The primary outcome?

Simply: Out of 52, how many weeks were truly well-controlled? No symptoms, no exacerbations, no descent into the next circle.

What did they find?

Ultimately, severe exacerbations were significantly lower in the MART group compared to SABA alone.

Severe Exacerbations: Whilst SABA alone was 0.2% a year, MART therapy was 0.07% a year, a reduction of 64%. ICS <aintenance came in at 0.09%, showing no significant difference to MART

Symptom Control: MART was also significantly superior to SABA alone(34.4% vs 31.1%) but inferior to ICS Maintainance at 44.4%

Steroid Exposure: whilst not being clinically better in terms of symptom control, MART therapy exposed participants to a measly 17% of the total steroids that ICS Maintenance did.

And with that, the covenant was broken. The Gates of Wheeze Hell were permanently closed.

This evidence led GINA (Global Initiative for Asthma) to fundamentally change recommendations in 2019, moving from the old stepwise approach to the new and improved MART pathway:

Circle 1: ICS Maintenance

Circle 2: Low Dose MART

Circle 3: Moderate Dose MART

Circle 4: Send em’ to the specialists

Much better 😊