Original articleInterventionsResponsiveness to inhaled corticosteroid treatment in patients with asthma–chronic obstructive pulmonary disease overlap syndrome
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
References (29)
- et al.
The proportional Venn diagram of obstructive lung disease: two approximations from the United States and the United Kingdom
Chest
(2003) - et al.
Increased risk of exacerbation and hospitalization in subjects with an overlap phenotype: COPD–asthma
Chest
(2014) - et al.
Spanish COPD Guidelines (GesEPOC): pharmacological treatment of stable COPD. Spanish Society of Pulmonology and Thoracic Surgery
Arch Bronconeumol
(2012) - et al.
Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
(1999) - et al.
Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
(2003) - et al.
The asthma–COPD overlap syndrome: a common clinical problem in the elderly
J Allergy
(2011) - et al.
The overlap syndrome of asthma and COPD: what are its features and how important is it?
Thorax
(2009) - et al.
Treatment options in asthma and chronic obstructive pulmonary disease overlap syndrome
Eur Respir Dis
(2011) - et al.
Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease—2007 update
Can Respir J
(2007) [COPD guideline by the Japanese Society of Respiratory Society. Guideline of diagnosis and treatment of COPD (chronic obstructive lung disease)]
Nihon Kokyuki Gakkai Zasshi
(1999)
Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma—summary report 2007
J Allergy Clin Immunol
The asthma–chronic obstructive pulmonary disease overlap syndrome: pharmacotherapeutic considerations
Expert Rev Clin Pharmacol
Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper
Eur Respir J
Direct and indirect challenges in the clinical assessment of asthma
Ann Allergy Asthma Immunol
Cited by (34)
Defining Asthma–Chronic Obstructive Pulmonary Disease Overlap
2022, Immunology and Allergy Clinics of North AmericaAsthma-Chronic Obstructive Pulmonary Disease Overlap
2020, Immunology and Allergy Clinics of North AmericaCitation Excerpt :The studies of ICS treatment in ACO are conflicting. In an observational study of 125 patients with ACO, treatment with ICS did not decrease exacerbation rates or reduce the decline in lung function caused by ACO.52 However, in a study of 127 subjects with ACO of varying severity, treatment with inhaled budesonide was shown to improve lung function, decrease sputum eosinophilia, and reduce exhaled nitric oxide (FeNO) in patients of all severity categories.53
What Is Asthma Chronic Obstructive Pulmonary Disease Overlap?
2020, Clinics in Chest MedicineEffect of Inhaled Corticosteroids on Exacerbation of Asthma-COPD Overlap According to Different Diagnostic Criteria
2020, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :However, it is generally recommended that it is important to identify patients with ACO so that ICS treatment can be initiated as soon as possible. Although several studies reported that ICS treatment was not shown to have a favorable impact on outcome in patients with ACO,22-24 there have been no large-scale studies on ICS treatment of patients with ACO that focused on exacerbation. In this study, we found that ICS treatment decreased the risk of exacerbation in patients with ACO according to the specialists' diagnoses, GINA/GOLD criteria, and updated Spanish criteria.
Disclosure: Authors have nothing to disclose.