GOLD 2021 Strategy Report: Implications for Asthma–COPD Overlap

Abstract

In its 2021 strategy report, the Global Initiative for Chronic Obstructive Lung Disease states: “we no longer refer to asthma-COPD overlap (ACO), instead we emphasize that asthma and COPD are different disorders, although they may […] coexist in an individual patient. If a concurrent diagnosis of asthma is suspected, pharmacotherapy should primarily follow asthma guidelines, but pharmacological and non-pharmacological approaches may also be needed for their COPD.” What does this mean for the treating physician? In this review, we explore the implications of this new guidance on treating patients with chronic obstructive pulmonary disease, arguing for a personalized approach to treatment.

Individual trajectory-based care for COPD: getting closer, but not there yet

“…Accordingly, the most recent GOLD document no longer refers to ACO as a particular entity, emphasizing that COPD and asthma are mostly different disorders to be managed accordingly [ 1 ]. In practice, prescribing ICS simply because of some putative past asthma history (or post-bronchodilator reversibility) is not desirable as it can lead to unjustified corticosteroid-based therapy and potential ICS-associated adverse events [ 46 ].…”

Functional Predictors Discriminating Asthma–COPD Overlap (ACO) from Chronic Obstructive Pulmonary Disease (COPD)

“…11,13,[17][18][19][20] Although some consensus documents contain precise classification criteria for ACO, 21,22 there is still a lack of an internationally accepted definition of ACO and, in consequence, research into ACO has been. 23 Some physicians and researchers still consider ACO to be a specific syndrome, 24 whereas other physicians and researchers see ACO as a theoretical construct with no clear biological grounds. 25 However, in no longer referring to the term ACO but, instead, increasing emphasis on individual treatment approaches tailored to COPD and/or asthma, a focus on precision medicine in these patients should be adopted.…”

Unraveling the Pathogenesis of Asthma and Chronic Obstructive Pulmonary Disease Overlap: Focusing on Epigenetic Mechanisms

“…Patients with ACO have increased disease severity, live a poorer quality of life, and incur higher healthcare costs when compared with patients with asthma or COPD alone [ 2 , 3 ]. The frequency of ACO-related hospitalization increases, the medical utilization rate increases, and the survival time is shortened compared with simple asthma and COPD [ 4 , 5 ]. Patients with ACO based on late onset asthma had the most rapid decline in lung function with a forced expiration volume at 1 s (FEV1) decline of 49.6 mL/year, compared with 39.5 mL/year in COPD alone, 34.5 mL/year in asthma alone, and 27.3 mL/year in ACO patients based on early onset asthma [ 6 , 7 , 8 , 9 ].…”

“…ACO also had increased bronchial wall thickening, increased airway remodeling, and increased airway hyper-responsiveness compared with asthma and COPD patients [ 11 , 12 ]. ACO likely encompasses a wide spectrum of phenotypes, e.g., COPD with eosinophilia and partially reversible airflow limitation, severe asthma with neutrophilia and fixed airflow limitation, or elderly non-smokers with long-standing asthma and irreversible airflow limitation [ 3 , 4 , 13 ]. Although there is no universally accepted definition of ACO at present, it is recommended that ACO be defined based on the presence of persistent airflow limitation (post-bronchodilator FEV1/forced vital capacity (FVC) ratio < 70%) in symptomatic individuals 40 years of age and older, a well-documented history of asthma, probably before 40 years of age, and a significant exposure history to cigarette or biomass smoke, accompanied by one of the hyper-responsive features, including atopy, allergic rhinitis, eosinophilia, and positive bronchodilator response [ 14 ].…”