Cause of death in the SMART Trial.

In a recent issue of CHEST (January 2006),1 the Salmeterol Multicenter Asthma Research Trial (or SMART) demonstrated that the regular use of a twice-daily regimen of salmeterol in asthmatic patients was associated with an unnerving increase in respiratory-related and asthma-related deaths, combined asthmarelated deaths, or life-threatening experiences. However, surely one of the other most concerning observations was the fact that at study entry only 47% individuals in both the active treatment and placebo groups were receiving regular therapy with inhaled corticosteroids. Thus, 26,000 subjects with asthma of approximately 16 years duration with a mean peak expiratory flow of 84% predicted were randomized to receive either a placebo inhaler or a long-acting 2-agonist over a 28-week period without therapy with inhaled corticosteroids. Since guidelines2,3 advocate the early use of inhaled corticosteroids in the treatment of asthma, it is therefore incredulous to consider that the investigators felt it reasonable to enroll a majority of individuals who were being inappropriately managed in the community. Perhaps rigorous advertising campaigns are required to emphasize that therapy with inhaled corticosteroids is a long-established, effective, safe, and inexpensive treatment for the management of asthma. And perhaps clinicians and the pharmaceutical industry require reminding too.