Budesonide/Formoterol (Symbicort combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its - real life effectiveness in treating Malaysian patients with moderate to severe asthma in whom despite on combined inhaled corticosteroids and long acting 2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age : 49 (36-65) years; FEV1 : 41 (21-74)% predicted] were identified from medical records of an urban based university hospital chest clinic and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short acting 2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART pproach. In SMART group, rescue treatment requirement (p < 0.001) and FEV1 [median difference = 2.5%, p = 0.015; mean difference : 90 ml, p = 0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p = 0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p = 0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1,400μg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate to severe asthma in Malaysian setting.