A 30-year-old woman has asthma not well controlled on a low-dose ICS and montelukast. What is the next step in her treatment?

• A. Switch to MART
• B. Increase ICS dose
• C. Add oxygen
• D. Start oral steroids

Answer: (A)

When asthma remains uncontrolled on a low-dose inhaled corticosteroid plus montelukast, the goal is to boost anti-inflammatory control while ensuring effective relief during symptoms. Switching to a maintenance-and-reliever strategy with an ICS-formoterol inhaler (MART) achieves this in one step.

MART uses the same inhaler for daily maintenance and for relief as-needed. This means you get anti-inflammatory corticosteroid delivery whenever you use it, including during symptoms when inflammation is often worse, while formoterol provides fast-acting bronchodilation. Because the ICS dose is effectively higher during symptom-driven use, MART has been shown to reduce exacerbations and improve overall control compared with a fixed ICS dose plus a separate rescue inhaler. The regimen also simplifies treatment, which can improve adherence.

In practice, this approach is particularly appropriate for patients like this, who need better control but may benefit from a simpler, more responsive plan. Of course, it requires proper technique and access to an ICS-formoterol inhaler, and alternatives exist if MART isn’t suitable (for example, stepping up ICS dose with a separate LABA-containing regimen or other controller add-ons).