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Asthma COPD overlap Syndrome

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by

Mudher Al-khairalla

on 6 October 2013

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Transcript of Asthma COPD overlap Syndrome

Asthma COPD overlap Syndrome
(ACOS)

ACOS
Poorly recognised
Trial exclusion
TORCH & UPLIFT
Description
“Asthmatic Bronchitis” (ATS 1962)
Recent attempts to define this phenotype

Definition
Difficult!
Variable responses to Rx
Corticosteroid resistance burden
Vague

Conclusion
Smokers
Atopy
Younger
Definition?
“Logical” extrapolation of Rx from existing evidence?
Emerging therapies should be endo-type specific?

ACOS
Younger
age
group
Exacerbations
“airflow obstruction that is not completely reversible accompanied by symptoms or signs of an increased reversibility of the obstruction”
Miravitlles et al Primaria 2012

By
Mudher Al-khairalla

“patients with COPD and prominent asthmatic component' or as asthma that complicates COPD”
Major and Minor Criteria

Soler-Cataluña JJ, Cosío B, Izquierdo JL et al.
Consensus document on the overlap phenotype COPD-asthma in COPD. Arch.
Bronconeumol. 48(9), 331–337 (2012)

“a physician diagnosis of asthma and COPD in the same patient, history or evidence of atopy, for example, hay fever, elevated total IgE, age 40 years or more, smoking >10 pack-years, postbronchodilator FEV1 <80% predicted and FEV1/FVC <70%. A ≥15% increase in FEV1 or ≥12% and ≥200 ml increase in FEV1 postbronchodilator treatment with albuterol would be a minor criteria.”
Samuel Louie et al: Expert Rev Clin Pharmacol. 2013;6(2):197-219

Prevalence of obstructive airway disease in the University of California Davis Medical Center general pulmonary clinics.*p= 0.0009; **p < 0.0001; ***p < 0.0001 by Fisher's exact test. 'Other' represents a combination of bronchitis, bronchiectasis,
bronchiolitis and/or cystic fibrosis cases.ACOS: Asthma–chronic obstructive pulmonary disease overlap syndrome; COPD: Chronic obstructive pulmonary disease; NS: Not significant.Adapted with permission from [2].

Prevalence of obstructive airway disease in the University of California Davis Medical Center severe asthma clinics.*p = 0.0009; **p < 0.0001; ***p < 0.0001 by Fisher's exact test. 'Other' represents a combination of bronchitis,
bronchiectasis, bronchiolitis and/or cystic fibrosis cases.ACOS: Asthma–chronic obstructive pulmonary disease overlap syndrome;
COPD: Chronic obstructive pulmonary disease.Adapted with permission from [2].

Expert Rev Clin Pharmacol. 2013;6(2):197-219

Risk Factors
>10 pack-years of smoking
Prevalence of smoking in adults with Asthma?
Emphysema in COPD & ACOS on CT
No difference (Hardin et al Respir. Res. 12, 127 (2011))
FEV1 decline 2nd to small airways inflammation?
Impaired therapeutic response to ICS in Asthmatics who smoke (Thomson NC et al Eur. Respir. J. 24(5), 822–833 (2004))
A1ATD? ↑Asthma (Eden et al Am. J. Respir. Crit. Care Med. 156(1), 68–74 (1997))

"Clinical Trials are lacking"
"Need more evidence"
Treatment
LABA + ICS
LAMA
Theophylline or Roflumilast

Principles of treatment similar to Asthma and COPD
QoL
Reduce Morbidity and Mortality

Miravitlles M, Soler-Cataluña JJ, Calle M et al. [Spanish COPD Guidelines (GesEPOC): pharmacological treatment of stable COPD]. Aten. Primaria 44(7), 425–437 (2012).


NNT
To prevent one exacerbation/hospitalisation
And another 14 studies. NNT 2-45 (References at request!)

All were Asthma or COPD studies!
Narrow vs Broad spectrum drugs?!
Narrow: LTRAs, MAB (Omalizumab) > Asthma

Broad: Bronchodilators, Corticosteroids, theophyllines and antibiotics

Discussion Points
Need to screen for ACOS?
Old and new therapeutic options
Mainly for Asthma or COPD in studies
Is it OK to extrapolate & apply to ACOS?
Omalizumab? Immunosuppression?
Which clinic? Asthma or COPD?
Less strict exclusion criteria in studies “real world patients”
Leukotriene Antagonists as First-Line or Add-on Asthma-Controller Therapy NEJM Price et al. N Engl J Med 2011; 364:1695-1707
ICS resistance
Workup and treatment pathway for ACOS... Should it be similar to severe Asthma?

15-25%
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