Exploring Challenges in Diagnosis, Treatment of Asthma-COPD Overlap Syndrome | CHEST 2024
Two posters presented at the annual meeting of the American College of Chest Physicians, CHEST 2024, offered insights into the accurate diagnosis and appropriate treatment of ACOS.
Asthma-COPD overlap syndrome (ACOS) is a complex respiratory condition characterized by overlapping features of asthma and chronic obstructive pulmonary disease (COPD), making it difficult to diagnose and treat. Despite its growing recognition in the respiratory landscape, ACOS remains an understudied area, hindering the development of effective management strategies.
3D illustration of bronchi / Sebastian Kaulitzki - stock.adobe.com
Nonetheless, accurate diagnosis of ASOS is crucial for optimizing patient care. Two posters presented at the annual meeting of the American College of Chest Physicians, CHEST 2024, held October 6 to 9 in Boston, Massachusetts, explored the challenges of ACOS diagnosis and offered insights into appropriate treatment.
Accurate diagnosis of ACOS is crucial for effective treatment, and by identifying patients’ underlying condition, health care professionals can shape treatment plans to alleviate symptoms and minimize exacerbations, according to one case report poster.1
It has been established that patients with ACOS frequently experience severe wheezing, coughing, and excessive sputum production. However, diagnosing ACOS can be difficult due to the heterogeneity of its presentation. Additionally, treatment response patterns to biologics in individuals with ACOS and asthma are similar, suggesting that biologics might be a suitable option for patients with ACOS. To better understand which patients benefit most from specific treatments, investigators examined the case of a patient with ACOS.
A 60-year-old woman with a history of COPD, tobacco dependence, hypertension, and obesity presented to investigators. She was diagnosed with COPD in 2012 and had a 30-year smoking history of approximately half a pack per day, which she quit in August 2021.
The patient was first seen in the pulmonary clinic in early July 2022, reporting multiple prednisone courses and poor functional status. Spirometry revealed a forced expiratory volume within 1 second (FEV1) of 33% and an FEV1 over forced vital capacity (FEV1/FVC) of 58%. Following the visit, she began treatment with fluticasone propionate and salmeterol, twice daily, and tiotropium bromide.
At her one-month follow up, she reported significant symptom improvement. Repeat spirometry showed an FEV1 of 48%, suggesting a potential asthma component, and further testing revealed an IgE level of 401 IU per microliter and an absolute eosinophil count of 200 per microliter.
Investigators noted that although their patient exhibited many symptoms common to COPD, her symptoms also suggested asthma, creating diagnostic challenges. The underdiagnosis of asthma in patients with COPD and vice versa limits therapeutic benefits for patients. Additionally, few studies have focused on anti-IgE therapy for ACOS in biologic therapy, but investigators found it notable that beginning anti-IgE therapy helped improved the patient’s symptoms.
“Research efforts are directed toward understanding the complex mechanisms that influence treatment responses in the diverse phenotypes of asthma and COPD,” concluded investigators. “By identifying the unique characteristics of patients who respond optimally to specific treatments, health care professionals can customize interventions, potentially leading to more effective therapeutic strategies for managing asthma and COPD.”
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Another poster presented at the meeting discussed the potential for misdiagnosis in patients with ACOS, emphasizing that inappropriate management of the condition can be dangerous.2 Investigators said the study serves as a reminder to carefully evaluate patients’ spirometry results to ensure appropriate diagnoses.
Although diagnosing ACOS comes with its own distinct challenges, early recognition is important, as the recommended treatment regimen for the condition differs from that of COPD. Depending on the severity, patients with COPD may be treated with a long acting beta agonist (LABA) inhaler. However, the Salmeterol Multicenter Asthma Research Trial found that patients with asthma treated with LABA alone had a higher risk of respiratory-related deaths.
Given the asthma-like features of ACOS, the Global Initiative for Chronic Obstructive Lung Disease strongly discourages LABA monotherapy. Instead, inhaled corticosteroids (ICS) are regarded as the mainstay of treatment, with LABA or long acting muscarines antagonists added if necessary. The current study aimed to explore the potential for misdiagnosis and subsequent inappropriate treatment in patients with ACOS.
Investigators enrolled 284 patients with a history of COPD diagnosed between 2020 and 2021 at a Veterans Affairs Medical Center pulmonology clinic. Repeat spirometry confirmed an FEV1/FVC ratio of less than 70% before bronchodilator administration in all 284 patients. Eosinophil counts were also recorded at the time of spirometry evaluation.
Among the 284 patients with a prior COPD diagnosis and pre-bronchodilator FEV1/FVC ratio below 70%, 17 exhibited an FEV1 increase of over 12% and a volume increase greater than 400 mL after bronchodilator administration, but maintained an FEV1/FVC less than 70%. These patients demonstrated characteristics of both asthma and COPD, meeting the criteria for ACOS but having been misdiagnosed with COPD. Within this subgroup, 7 patients had eosinophil counts of more than 300 cells per microliter.
This retrospective observational study highlights the potential for misdiagnosis in patients with ACOS. Investigators noted that recent research suggests that patients with COPD and eosinophil counts greater than 300 cells per microliter benefit the most from ICS therapy, although only 7 of the 17 patients that met the criteria for ACOS had eosinophil counts above this threshold. “More research is needed to determine if all patients with ACOS benefit from ICS of if there are similar eosinophil cut-offs to that of COPD,” they concluded.
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