Asthma-COPD Overlap Syndrome(ACOS)

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 Asthma and chronic obstructive pulmonary disease
(COPD) have traditionally been viewed as distinct
clinical entities.
 Recently, however, much attention has been focused
on patients with overlapping features of both asthma
and COPD : those with asthma COPD overlap
syndrome (ACOS).
6
Background

 Separating asthma from COPD in clinical practice is
difficult due to the overlapping features common to
both diseases.
 The pitfall is to presume that both conditions can not
possisbly exist in the same patient.
7
Background

 The Asthma COPD overlap syndrome (ACOS) is a
newly recognized diagnosis, one that has long been
neglected in part because clinical trials for decades
have consistently excluded patients with overlapping
asthma and COPD, using strict inclusion & exclusion
criteria.
 These criteria routinely excluded asthma patients from
COPD studies, and COPD patients from asthma
studies .
8

 A consensus ACOS description for clinical use has
recently been published by both the Global Initiative
for Asthma (GINA) and the Global Initiative for
Chronic Obstructive Lung Disease (GOLD) in 2014
 This syndrome represents an important population
with worse outcomes than asthma or COPD alone.
9

 This document provides a stepwise approach for
patients with respiratory symptoms suggestive of
chronic disease.
 It uses clinical, spirometric, and radiographic features
to help delineate if an adult patient is most likely
suffering from asthma or COPD or fulfills enough
shared features to be considered within ACOS.
10

 Patients with features of both asthma and COPD have
worse outcomes than those with asthma or COPD alone
– Frequent exacerbations
– Poor quality of life
– More rapid decline in lung function
– Higher mortality
– Greater health care utilization
 Prevalence of the ‘overlap’ syndrome varies by definition
– Reported rates are between15–55% of patients with chronic airways
disease
– Concurrent doctor-diagnosed asthma and COPD are found in 15–20%
of patients with chronic airways disease
Background
GINA 2014

16
Prevalence of obstructive airways disease in a general pulmonary
clinic and in the UC Davis Medical Center severe asthma clinics.

 Patients with ACOS have the combined risk factors of
smoking and atopy, and are generally younger than
patients with COPD.
 ACOS patients have acute exacerbations with higher
frequency and greater severity than COPD, manifest
more air-trapping, and require more healthcare
visits,despite a lower burden of cigarette smoking.
17

Reversibility of Airway Obstruction
 One of the defining characteristics of asthma is
reversible airway obstruction with bronchodilators;
however, the degree of reversibility can diminish as the
disease progresses.
 Studies indicated up to 44% and 50% airway obstruction
reversibility in COPD although COPD is traditionally
characterized by irreversible airway obstruction.
 In COPD reversibility does not decrease the risk for
exacerbation, hospitalization, or death.
18

Atopy in Asthma and COPD
 Atopy is an allergic syndrome characterized by
eczema, allergic rhinitis, and/or allergic asthma.
 Atopy is a risk factor for both asthma and COPD.
 The European Respiratory Society Study on Chronic
Obstructive Pulmonary Disease (EUROSCOPE) showed
that up to 18% of patients with COPD had atopy and that
atopic patients suffered more from cough and phlegm.
19

Bronchial Hyperresponsiveness
 Bronchial hyperresponsiveness is associated with
asthma, but is not a good diagnostic tool because it can
occur in response to both specific and nonspecific
stimulants (i.e., specific allergens or cold, dry air).
 Reports indicate there is a 60% prevalence of bronchial
hyperresponsiveness in COPD.
 Studies show that patients with COPD and bronchial
hyperresponsiveness have accelerated declines in FEV1.
 In asthma and COPD, the presence of bronchial
hyperresponsiveness indicates more severe disease.
20

Clinical expression of the asthma-COPD
overlap syndrome (ACOS).
 The ACOS usually corresponds to a smoker asthmatic
patient that develops non fully reversible airway
obstruction and/or
 a COPD individual (with or without a known history of
asthma) with a Th2 signature (increased blood and lung
eosinophilia, increased airway hyper-responsiveness,
and better response to ICS).
25

 ACOS has been defined as symptoms of increased
variability of airflow in association with incompletely
reversible airflow obstruction .
 Identifying patients with ACOS has significant therapeutic
implications particularly with the need for early use of ICS
and the avoidance of use of long-acting bronchodilators
alone in such patients.
26

 The interest in recognizing these individuals lies in
their better response to inhaled corticosteroids (ICS)
compared to those with COPD.
 This specific and differential treatment justifies the
efforts to differentiate the subgroup of patients with
ACOS from the large population of COPD patients.
 However, unlike asthma and COPD, no evidence-
based guidelines for the management of ACOS
currently exist.
27
Commentary

 Assemble the features that, when present, most favor a
diagnosis of asthma or COPD
 Compare the number of features on each side
– If the patient has ≥3 features of either asthma or COPD, there is a
strong likelihood that this is the correct diagnosis
 Consider the level of certainty around the diagnosis
– The absence of any of these typical features does not rule out either
diagnosis, e.g. absence of atopy does not rule out asthma
– When a patient has a similar number of features of
both asthma and COPD, consider the diagnosis
of ACOS
Step 2 – Syndromic diagnosis of asthma,
COPD and ACOS
GINA 2014

 A history of allergies increases the probability that
respiratory symptoms are due to asthma, but is not
essential for the diagnosis of asthma since:
1. Non-allergic asthma is a well-recognized asthma
phenotype
2. Atopy is common in the general population including in
patients who develop COPD in later years.

 Spirometry at a single visit is not always confirmatory
of a diagnosis, and results must be considered in the
context of the clinical presentation, and whether
treatment has been commenced.
 Further tests might therefore be necessary either to
confirm the diagnosis or to assess the response to
initial and subsequent treatment.

 After the results of spirometry and other investigations
are available, the provisional diagnosis from the
syndrome-based assessment must be reviewed and, if
necessary, revised.
 If the syndromic assessment suggests asthma or ACOS,
or there is significant uncertainty about the diagnosis of
COPD, it is prudent to start treatment as for asthma until
further investigation has been performed to confirm or
refute this initial position.
46

Potential for
tiotropium
Step 5Step 4Step 3Step 2Step 1
Asthma education, environmental control
As-needed rapid-
acting β2-agonists
As needed rapid-acting β2-agonist
Controller options***
Select one Select one
To Step 3 treatment,
select one or more
To Step 4 treatment,
add either
Low-dose ICS*
Low-dose ICS plus
LABA
Medium- or high-dose
ICS plus LABA
Oral
glucocorticosteroid
(lowest dose)
Leukotriene modifier**
Medium- or high-
dose ICS
Low-dose ICS plus
leukotriene modifier
Leukotriene modifier
Sustained-release
theophylline
Anti-IgE treatment
Low-dose ICS plus
sustained release
theophylline
GINA 2013

84
Drugs for
Asthma& COPD& ACOS

Beclomethasone
Budesonide
Fluticasone
Inhaled corticosteroids

LABA inhalers
LABA
DPI Diskus Serevent®
(salmeterol)
DPI Aerolizer Foradil®
(formoterol)
DPI Breezhaler Onbrez®
(indacaterol)
CLASS INHALER NAME BRAND NAME/GENERIC
NAME

Combination ICS/LABA inhalers
ICS/LABA
DPI Diskus Advair®
(Fluticasone/salmeterol)
DPI Turbuhaler Symbicort®
(Budesonide/formoterol)
DPI Ellipta Breo®
(Fluticasone/vilanterol)
CLASS INHALER
NAME
BRAND NAME/
GENERIC NAME

LAMA inhalers
LAMA
DPI HandiHaler/
SMI Respimat
Spiriva®§
(tiotropium)
DPI Breezhaler Seebri®
(glycopyrronium)*
DPI Genuair Tudorza®
(aclidinium)*
DPI Ellipta Incruse®
(umeclidinium)*
CLASS INHALER NAME BRAND NAME/
GENERIC NAME
Recently approved (since 2012).
DPI, dry powder inhaler; SMI, soft mist inhaler.
§ Spiriva® Respimat is also approved for reduction of exacerbations.

Asthma-COPD Overlap Syndrome (ACOS)

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