Asthma–COPD overlap: identification and optimal treatment

Abstract

Asthma and chronic obstructive pulmonary disease (COPD) are both highly prevalent conditions that can coexist in the same individual: the so-called ‘asthma -COPD overlap’ (ACO). Its prevalence and prognosis vary widely depending on how ACO is defined in each publication, the severity of bronchial obstruction of patients included and the treatment they are receiving. Although there is a lack of evidence about the biology of ACO, the overlap of both diseases should express a mixture of a Th1 inflammatory pattern (characteristic of COPD) and a Th2 signature (characteristic of asthma). In this review we support a novel algorithm for ACO diagnosis proposed by the Spanish Respiratory Society (SEPAR), based on a sequential evaluation that considers: (a) the presence of chronic airflow limitation in a smoker or ex-smoker patient ⩾35 years old; (b) a current diagnosis of asthma; and (c) the existence of a very positive bronchodilator test (PBT; ⩾15% and ⩾400 ml) or the presence of eosinophilia in blood (⩾300 eosinophils/μl). This algorithm can identify those patients who may benefit from a treatment with inhaled corticosteroids (ICSs) and maybe from biological drugs in a near future. In addition, it is easily applicable in clinical practice. The major disadvantage is that it groups patients with very different characteristics under the ACO’s umbrella. In view of this heterogeneity, we recommend a strategy of defining specific and measurable therapeutic objectives for every single patient and identifying the traits that can be treated to achieve those objectives.

Chronic obstructive pulmonary disease - diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society

“…The simplified current Spanish Respiratory Society consensus defines ACO as: (a) the presence of chronic airflow limitation in a smoker or ex-smoker (more than 10 pack-years) patient ≥35 years old; (b) with current diagnosis of asthma; and/or (c) the presence of a strongly positive bronchodilator test (≥15% and ≥400 mL) or the presence of eosinophilia in peripheral blood (≥300 eosinophils/μL) (ref. [103][104][105] ).…”

Asthma–COPD–Bronchiectasis combination: an unstudied triplet

“…Even if the coexistence of asthma and chronic obstructive pulmonary disease (COPD), known as asthma-COPD overlap (ACO), is progressively more approached for studies in recent years, if one should try to find out what does the existence of bronchiectasis in the above-mentioned ACO patients involve, he or she would be deeply disappointed by the low number of articles addressing this subject. The so-called ACO is a common overlap whose prevalence and prognosis are highly dependent on various factors such as the moment of diagnosis, the therapeutic intervention, or the severity of the obstruction (1). This is heavily influenced also by the lack of evidence about the pathophysiology of ACO and the mixture of the inflammatory patterns (T Helper cells type 1 (TH1), characteristic for COPD and T Helper cells type 2 (TH2), specific for asthma).…”

A New Perspective on Bronchial Asthma and Chronic Obstructive Pulmonary Disease Overlap: Potential Diagnostic Criteria

“…This includes updating diagnostic criteria for ACO, identifying diagnostic significance of the markers of pathologies combination at different stages of disease course, developing indications for medication administration at certain stages of disease course, specifying medication dose, etc. [8,9,10].…”

“…It is shown that among patients with bronchial asthma, particularly among smokers, there are individuals with predominantly neutrophilic inflammation, rapid decrease in pulmonary ventilation or poorer response to bronchodilator or inhaled glucocorticosteroid (ICS) therapy [6,7,8]. It is also believed that the possibility of ACO formation in patients with asthma may be associated with risk factors for constantly progressing airflow limitation, such as childhood asthma, long-term asthma with no ICS intake, first asthma manifestations in adulthood, severe or treatment-resistant asthma [8,9,10]. According to the latest findings, ACO formation in patients with previously verified asthma may reach 29% [9].…”