Chest
Volume 155, Issue 1, January 2019, Pages 168-177
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Recent Advances in Chest Medicine
Clinical Approach to the Therapy of Asthma-COPD Overlap

https://doi.org/10.1016/j.chest.2018.07.028Get rights and content

Over the last few years, there has been a renewed interest in patients with characteristics of both asthma and COPD. Although the precise definition of asthma-COPD overlap (ACO) is still controversial, patients with overlapping features are frequently encountered in clinical practice, and may indeed have worse clinical outcomes and increased health-care utilization than those with asthma or COPD. Therefore, there is a critical need to set a framework for the therapeutic approach of such patients. There are key distinctions in the therapy between asthma and COPD, particularly regarding the initial choice of therapy. However, there is considerable overlap in the use of existing medications for both diseases. Furthermore, novel therapies approved for asthma, such as monoclonal antibodies, may have a role in patients with COPD and ACO. The use of biomarkers, such as peripheral blood eosinophils, exhaled nitric oxide, and serum IgE, may help in selecting appropriate therapies for ACO. In this review, we provide an overview of available treatments for both asthma and COPD and explore their potential role in the treatment of patients with ACO.

Section snippets

Why Has ACO Become a Renewed Focus of Interest?

Asthma and COPD have been recognized now for centuries. The potential for overlap has been well described, and the concept that asthma and COPD share common origins was conceived more than half a century ago.15 Why then has there been an increased interest in this subgroup of patients in recent years? This may reflect an increased attention to disease phenotyping because precision medicine approaches require more refined understanding of disease heterogeneity. Along with this is the combination

Management Strategies for Asthma, COPD, and ACO

The Global Strategy for Asthma Management and Prevention and the Global Strategy for the Diagnosis, Management, and Prevention of COPD19 provided approaches for the diagnosis and management of ACO. However, these approaches were based mainly on expert opinion rather than patient outcomes data, reflecting an overall need for well-designed studies that address the management of this population. Nevertheless, these strategies provide a starting point for clinicians who encounter these patients in

Contrasting Therapies of Asthma and COPD in Mild/Moderate Disease

Inhaled medications are the foundation of therapy for both asthma and COPD. The treatment of these diseases uses a stepwise or escalation approach based on symptoms and exacerbations.22, 23 However, there is a key distinction between both treatment algorithms: specifically, the introduction of inhaled corticosteroids (ICSs) (Fig 1). In asthma, ICSs are introduced early in the treatment for patients who are symptomatic. ICSs decrease the risk of severe exacerbations, improve asthma control, and

Contrasting Therapies of Asthma and COPD in Severe Disease

Both severe asthma and COPD are characterized by worsening respiratory symptoms, frequent exacerbations and increased health-care utilization.47, 48 In these advanced stages, the treatment may require triple therapy with ICS, LABA, and LAMA (Fig 1). In COPD, triple therapy has been shown to improve lung function and exacerbation rates without increasing adverse events compared with dual therapy and placebo.49, 50, 51 For instance, a recent study by Vestbo et al52 showed that triple therapy

Role of Biomarkers in ACO

The use of biomarkers to identify patients who may benefit from therapy is well established in asthma.55, 56 In COPD, this method has accumulating evidence of benefits.60, 61 Although this approach might appear to be particularly useful to identify the ACO population, to date there is no biomarker that best encompasses the biologic mechanisms of this overlap. In fact, evidence suggests that ACO is a heterogeneous group encompassing several phenotypes of disease, including both eosinophilic and

Therapeutic Guidance

In patients with ACO who remain symptomatic despite inhaled therapies, an in-depth evaluation is required to determine the presence of treatable traits, which may aid in the diagnosis and provide therapeutic guidance.46 Further work is needed to help clinicians select the most appropriate therapy. Predictors of response in chronic airways disease is an area of intense research. Elevated serum levels of IgE, exhaled fraction of nitric oxide, and peripheral blood eosinophilia not only provide

Conclusions

There is still much to learn about the spectrum of ACO. Because asthma and COPD are inherently heterogeneous, future studies that include well-characterized and richly phenotyped cohorts of patients with features of both asthma and COPD, with varying degrees of severity and exacerbation history, are needed to better study disease interactions, risk factors, and prognostic makers.89 A gap clearly exists in the evidence for therapy in ACO, particularly in severe disease. Nevertheless, in clinical

Acknowledgments

Authors contributions: D. J. M. is the guarantor of this article. D. J. M. and F. J. M. contributed to conception, manuscript writing, and manuscript review. M. H. and S. A. C. contributed to manuscript writing and manuscript review. N. A. H., S. G. A, A. A., J. I. P., and M. K. H. contributed to interpretation of data and critical revisions. C. P. H. contributed to interpretation of data and critical revisions.

Financial/nonfinancial disclosures: The authors have reported to CHEST the

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