Original article
Interventions
Responsiveness to inhaled corticosteroid treatment in patients with asthma–chronic obstructive pulmonary disease overlap syndrome

https://doi.org/10.1016/j.anai.2014.08.021Get rights and content

Abstract

Background

Inhaled corticosteroid (ICS) is recommended in the management of patients with asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS), but its effectiveness has not been clearly proved.

Objective

To evaluate whether ICS has effects on outcomes of ACOS.

Methods

In this observational 12-year retrospective cohort study involving 125 patients with ACOS from Seoul National University Hospital, the annual rate of decrease in forced expiration volume in 1 second, the incidence rate of severe exacerbation, and overall mortality in an ICS-treated group were compared with those in a non-ICS–treated group.

Results

Of 125 patients with ACOS, 90 and 35 were categorized to the ICS and non-ICS treatment groups, respectively. There were no significant differences between the 2 groups in the annual rate of decrease in forced expiration volume in 1 second (9.61 mL/year in ICS treatment group vs 15.68 mL/year in non-ICS treatment group, P = .598). Compared with the non-ICS treatment group, the ICS treatment group did not show a decrease in the risk of severe exacerbation (adjusted incidence rate ratio 1.24, 95% confidence interval 0.44–3.46). Time to death also did not differ between the 2 groups. Even when analyses with propensity score matching were performed, the results were similar.

Conclusion

In the management of ACOS, the use of ICS was not significantly associated with improvements in the annual rate of decrease in forced expiration volume in 1 second, the incidence of severe exacerbations, and overall mortality compared with the non-ICS treatment group.

Introduction

Asthma–chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) occurs when patients with COPD and a history of cigarette smoking have an asthmatic component, although ACOS has not been clearly defined.[1], [2] The definition of ACOS has been simplified into patterns of abnormal airway physiology, which in conjunction with symptoms can be used to facilitate clinical recognition.3 It could be accepted that at a physiologic level, patients with ACOS have 2 characteristics. One is an incompletely reversible airflow obstruction that can be defined by a postbronchodilator forced expiratory volume for 1 second (FEV1) to forced vital capacity (FVC) ratio of less than 70%. The other is an increased variability of airflow obstruction, which can be determined by increased bronchodilator responsiveness or bronchial hyperresponsiveness demonstrated by a bronchial challenge test.3

Clinicians are often faced with ACOS, and the prevalence is reported as up to 25% in adults with obstructive airway diseases.2 In the Proyecto Latino-Americano de Investigación en Obstrucción Pulmonar (PLATINO) study of obstructive lung diseases, including asthma, COPD, and ACOS, ACOS was reported in 11.6% of cases. Furthermore, patients with ACOS had more respiratory symptoms, worse lung function, and greater use of respiratory medications, more hospitalizations, and more exacerbations.4 However, treatment is based on extrapolation of data derived from studies in patients with asthma or COPD alone owing to a lack of studies in those with coexisting asthma and COPD.[2], [5] Spanish and Canadian guidelines have suggested that inhaled corticosteroid (ICS) treatment could be justified in the management of COPD combined with asthma,[6], [7] and the Japanese Respiratory Society has recommended that ICS should be used in cases of COPD complicated by asthma, regardless of the severity of COPD.8 ICS is the most potent and effective anti-inflammatory medication in the management of asthma, and its clinical effects include improvement in prevention of exacerbations, hospitalizations, deaths from asthma, and possibly the attenuation of lung function loss in adults.9 Conversely, ICS treatment is controversial in COPD, and only medium doses of ICS in fixed combination (ICS plus a long-acting β2 agonist [LABA] inhaler) are approved by the US Food and Drug Administration to control symptoms and decrease acute exacerbations.10 The American Thoracic Society and the European Respiratory Society also recommend the addition of ICS to a LABA or long-acting muscarinic antagonist, but only when the FEV1 is less than 50% predicted or the patient has experienced an acute exacerbation in the past year.11 The effectiveness of ICS in ACOS has not been investigated in a plenary study, and no sufficiently powered studies have been published demonstrating the role of ICS in ACOS.

The present study examined the effects of ICS in patients with ACOS by measuring the rate of decrease in lung function, the incidence rate of severe exacerbation, and overall mortality.

Section snippets

Study Subjects

An observational retrospective cohort study of patients with ACOS was conducted by analyzing data from Seoul National University Hospital (Seoul, Republic of Korea) from February 2000 through February 2012. ACOS was defined as a postbronchodilator FEV1/FVC less than 0.70 and a positive bronchodilator response or positive airway hyperresponsiveness. A positive bronchodilator response was defined as an increase in FEV1 by at least 200 mL and 12% after inhalation of 200 μg of salbutamol. Airway

Results

In total, 331 patients with COPD were screened, each having undergone at least 2 postbronchodilator spirometric assessments with bronchodilator reversibility testing during the study period. Of these, 125 patients who met the inclusion criteria of an ACOS diagnosis were identified, of whom 90 had a record of at least 1 ICS or ICS–LABA combination prescription and 35 were treated only with another medication, such as a LABA, a short-acting β2 agonist, a short-acting muscarinic antagonist, or

Discussion

In this study, no beneficial effects of ICS treatment were found in patients with ACOS with regard to mortality, decreasing lung function, and exacerbation.

Various COPD guidelines have proposed that ICS should be preferentially considered for use in the management of ACOS. Spanish COPD guidelines have classified patients with ACOS as a mixed COPD–asthma phenotype group and have suggested that ICS associated with a long-acting bronchodilator could be the first option in ACOS.6 Japanese COPD

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    Disclosure: Authors have nothing to disclose.

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