Asthma-COPD Overlap Syndrome - ACOS

ASTHMA - COPD
Dr. Nino JN Doydora
Section of Pulmonary Medicine

Disclosures
Novartis
 A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to
Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.)
on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011
 A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open
label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate
to Severe COPD May–October 2011
Utsuka

Objectives:
Review GINA 2014 guidelines on Asthma
Review the GOLD 2014 guidelines on COPD
Epidemiology
Pathophysiology
Signs and symptoms
Diagnosis
Treatment
Approach to a patient with ACOS (Asthma-COPD
Overlap Syndrome) GINA 2014

CASE 1
19 year old female student
CC: 3 days cough, wheezing, SOB
Precipitated by exercise (frisbee)
Relieved by salbutamol nebulization (past 3 nights)
Self medicated with prednisone 10mg 1 dose
(+) history of asthma attacks during childhood
(+) family Hx of asthma (mother)
(+) Hx of atopy and (+) allergy to crustaceans
PE: talks in sentences with occasional wheeze

Asthma
A reversible obstructive airway disease due to bronchial muscle constriction
and airway inflammation; characterized by cough, wheezing and shortness of
breath.
Resolves spontaneously or with use of rescue meds.
Exacerbations are caused by triggers.
1 of 10 Filipino adults
3 of 10 Filipino Children

ASTHMA – levels of control
Characteristic Controlled Partly controlled Uncontrolled
Daytime symptoms:
wheezing, cough, SOB
None >2x/week >3x/week
Limitation of activities none any any
Nocturnal awakening none any any
Need for reliever meds < 2x / wk >2x/wk >2x/week

ACT – ASTHMA CONTROL TEST
< 20 – suggests poor Asthma control

Diagnostics
Spirometry – measures certain lung volumes; useful in diagnosing
obstructive lung patterns
Peak flow – screening test; measures maximum speed of expiration

Peak flow
Patient’s Peak flow showed 65% from predicted

Treatment
Non-pharmacologic
Patient education
Inhaler technique
Pulmonary Rehabilitation Program
Pharmacologic
Oral medications
Inhaled medications

t Commonly used Inhaled trreeaattmmeennttss ffoorr AAsstthhmmaa && CCOOPPDD
Short Acting Bronchodilator
Short Acting B2 Agonist agent (SABA) = Salbutamol, Terbutaline
Short Acting Anti-Muscarinic agent (SAMA) = Ipratropium Bromide
Long Acting Bronchodilator
Long Acting B2 Agonist agent (LABA) = Salmeterol, Formoterol,
indacaterol
Long Acting Anti-Muscarinic agent (LAMA) = Tioptropium
Inhaled Corticosteroid (ICS) = Fluticasone, Budesonide, beclomethasone
Combination: SABA + SAMA = Salbutamol + Ipratropium (Pulmodual)
Combination: LABA + ICS
 Salmeterol + Fluticasone (Adeflo)
 Formoterol + Budesonide

Treatment
· Patient education
· Inhaler technique and adherence to medications
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
Preferred
Controller
Choice
NONE Low Dose ICS
(Inhaled Steroid)
Low dose
ICS-LABA
(ADEFLO)
Medium/High
ICS-LABA
(ADEFLO)
Refer for add
on treatment
(anti-IgE)
Other
Controller
Options
-- LTRA or
methylxanthines
(montileukast
Or Theophylline)
Medium/High
ICS-LABA OR
Low dose
ICS/LABA + LTRA
or /+ Theophylline
High Dose
ICS-LABA +
LTRA or
Theophylline
Low dose oral
steroid
RELIEVER SABA – short acting B2-agonist (Salbutamol)

Strategies to ensure effective use of
inhaler devices
2014
CHOOSE
Most appropriate device
The medication needed
Available devices
Cost
Patient skills and patient’s choice
Ensure no physical barriers, e.g. arthritis
Avoid use of multiple different inhaler
types to avoid confusion

Strategies to ensure effective use of
inhaler devices 2014
Clinicians should be able to demonstrate correct technique for each of
the inhalers they prescribe
For MDIs - use a spacer
Improves delivery
Reduces potential
side-effects of ICS

Home meds and plans:
Inhaled corticosteroid
May add oral steroid for 3-5 days
Round the clock reliever use for a few days then give on PRN basis
If symptoms worsen :
Follow-up in 3-5 days with chest X-ray
Assess other possible causes of exacerbation
Follow-up 2 weeks – 1 month after consult
Measure peak flow on succeeding visits
6-12 months of ICS therapy

Case 2:
72 year old housewife
CC: on and off cough, wheezing, shortness of breath
Relieved by salbutamol nebulization
lately is more bothersome after hosting a birthday party
with grayish sputum, difficulty sleeping
Has consulted several doctors; has 4 inhaler devices
Passive smoker
Previously hospitalized due to asthma 3 months ago
PE: talks in phrases, (+) wheezing both lung fields

Case 2:
Inhalers:
77 female smoker
•Tiotropium handihaler LAMA
•Salbutamol MDI SABA
•Procaterol swinghaler SABA
•Formoterol + Budesonide turbohaler ICS-LABA
•Budesonide turbohaler ICS

COPD: 2014 GOLD Definition
Pink Puffer Blue Bloater
 COPD
characterized by airflow limitation that is not fully reversible
and is usually progressive
preventable and treatable
exacerbations & co-morbidities contribute to the overall
severity
© 2014 Global Initiative for Chronic Obstructive Lung Disease

CUASES of COPD
SMOKING
1 pack/day
In 10 years
Pollution
Exposure to
Hazardous
chemicals

Do we often see these COPD patients?
Pink Puffer Blue Bloater
COPD prevalence
among Filipinos > 40 yo:
2200%% Idolor et al. Respirology 2012.

Mortality comparisons with COPD
exacerbation and AMI
3
50
35
69
0 20 40 60 80
Severe
Moderate
Shock
No Shock
%
COPD Myocardial Infarction
Swedish Registry 2008, GUSTO-1 Trial 2007

How do we know they have COPD?

Acute exacerbation in COPD
Increased symptoms
Reduced lung function
Accelerate lung function
decline
Deteriorate quality of life
Increased economic cost
Increased mortality
“an acute event characterized by
worsening of respiratory symptoms
that is beyond normal day-to-day
variations and leads to a change in
medication.”
Impact of
acute
exacerabatio
ns in COPD
GOLD Strategy Document 2014 (http://www.goldcopd.org/)

Vicious Cycle of Inflammation-Oxidative Stress-
Exacerbations in COPD
Oxidative
stress
Anti-proteinase-
Proteinase
imbalance
COPD Pathology:
Exacerbations
• Cigarette smoke
• Occupational dust & fumes
• Biomass fuels
• Small airway fibrosis
• Emphysema
• Mucous hypersecretion
• Systemic
manifestations

Modified British Medical Research Council (mMRC) Dyspnea Scale

COPD Assessment Test : CAT
I never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight
When I walk up a hill or one flight When I walk up a hill or one flight
of stairs I am not breathless of stairs I am very breathless
I am not limited doing any activities at home I am very limited doing activities at home
I am confident leaving my home despite my I am not at all confident leaving my
home lung condition because of my lung condition
I sleep soundly I don't sleep soundly because of
my lung condition
I have lots of energy I have no energy at all

COPD Assessment Test : CAT
I never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight
When I walk up a hill or one flight When I walk up a hill or one flight
of stairs I am not breathless of stairs I am very breathless
I am not limited doing any activities at home I am very limited doing activities at home
I am confident leaving my home despite my I am not at all confident leaving my
home lung condition because of my lung condition
I sleep soundly I don't sleep soundly because of
my lung condition
SCORE: 35
I have lots of energy I have no energy at all

COPD treatment: 2 MAIN GOALS
Goals for treatment of stable COPD
Relieve symptoms
Improve exercise tolerance
Improve health status
And
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
REDUCE
SYMPTOMS
REDUCE
RISK
of exacerbation
Global Strategy for the Diagnosis, Management and Prevention of COPD
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014

THERAPEUTIC OPTIONS
What is the single most effective intervention
to slow the progression of COPD?
1
Home
Oxygen
2
Pulmonary
Rehab.
3
Smoking
Cessation
4
Flu
Vaccination
Evidence A

How to start Treatment*
Newly Diagnosed COPD Patient
Active Reduction of Risk Factors
1. Smoking Cessation
2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years
As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use
LABA or LAMA
 Assess : symptoms and RISK:
 Pulmonary Rehabilitation
 Long Acting Bronchodilator
 LABA alone (indacaterol) or LAMA alone (Tiotropium)
 Assess: More Symptoms low Exacerbation Risk
 Add another Long acting bronchodilator
 LABA + LAMA or LAMA + LABA
 Assess: More Symptoms, High Exacerbation Risk
 Progressive & Frequent Exacerbation
 + ICS
 LAMA + LABA + ICS
Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options
•Based on Pharmacologic first choice treatment,
GOLD 2011
• other treatment options available.

 ICS- inhaled steroid: fluticasone/budesonide/beclomethasone
 SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium
 SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)

Pharmacological Management of COPD
Patient First Choice Second Choice Alternative Choice
SABA or SAMA prn SABA and SAMA
A
LABA or LAMA
Theophylline
(Option: Doxofylline )
B
Pulmodual Dilatair
LABA or LAMA LABA and LAMA
SABA and /or SAMA
Theophylline
C
ICS +LABA or LAMA LABA and LAMA
Dilatair
PDE4 Inhibitor
SABA and/ or SAMA
Theophylline
D
ICS+ LABA and LAMA
ICS + LAMA
ICS + LABA + LAMA
ICS and LABA and PDE 4 inh
LABA + LAMA
LAMA + PDE 4 inh
Dilatair
Carbocisteine
SABA and/ or SAMA
Theophylline
Dilatair
Adeflo
Adeflo

GUIDED ASTHMA SELF-MANAGEMENT
EDUCATION AND SKILLS TRAINING
2014
Inhaler use is a skill - must be learned and
maintained
Up to 70–80% are unable to use their inhaler
correctly.
Unfortunately, many health care providers are unable
to correctly demonstrate how to use the inhalers they
prescribe
Most people with incorrect technique are unaware
that they have a problem
There is no ‘perfect’ inhaler - patients can have
problems using any inhaler device

A New Twist to
FDC ICS-LABA Inhaler
Therapy
Twist
Miat Monodose DPI

Salmeterol xinafoate/ Fluticasone
propionate (Adeflo) via Adehaler
 Passive DPI (aerolizer)
 breath actuated
 compact, portable, easy to use
 no hand-mouth coordination
required
 Inhalation by capsule loaded by the
patient
 40 capsules/ box
 Lactose carrier
 IFR > 60 lpm; no breath hold
 Protect from humidity
Sims MW. Chest 140(3):781–788, 2011.
Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011.
Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003.
50/250 mcg
50/500 mcg

Dry Powder Inhaler
Wrong Right

Case 3
55 year old, male, teacher
CC: cough, wheezing, shortness of breath 7 days
Precipitated by exposure to dust (he rides a motorbike)
Sneezing, itchy throat
Unable to sleep due to SOB, partially relieved by salbu neb
(+) history of childhood asthma
(+) 20 pack year (current) smoker
(+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with
pneumonia as outpatient.
PE: talks in sentences, (+) wheezing both lung fields

What will you give to this patient?
A. SABA (Salbutamol PRN)
B. ICS (Budesonide)
C. LAMA (Tiotropium)
D. LABA (Indacaterol)
E. ICS+LABA (Fluticasone + Salmeterol)

For a patient, count the
number of checked boxes in
each column. If 3 or more
are checked for either
asthma or COPD , that
diagnosis is suggested. But
if there are similar numbers
of checked boxes in each
column, ACOS should be
considered.

Approach to ACOS
(Asthma-COPD Overlap Syndrome)
Asthma >> ICS (Inhaled corticosteroid)
COPD >> LABA (long acting B2 agonist)
ACOS >> ICS + LABA

Approach to ACOS
(Asthma-COPD Overlap Syndrome)
At least among adults, ACOS might represent a severe form of asthma,
characterized by greater risk of hospitalizations and exacerbations
ACOS is likely the result of early asthma that has progressed to fixed
airway obstruction because airway remodeling and of its interaction
with smoking
Treatment may prevent a steeper decline of lung function among
ACOS.
De Marie Et. Al. ERS 2013 Presentation

SMOKER'S PRAYER
Heavenly Father, hear my plea,
and grant my lungs serenity.
Give me strength to kick the smoking
that's been causing all my choking.
Let my breath be fresh and clean
without a trace of nicotine.
Each ciggie I smoke so often
Adds another nail in my coffin
Guide me Lord, by Your holy means
past all those cigarette machines.
It hurts to hear My Loved ones say
kissing ya's like lickin' an ashtray.
Please oh Lord, Hear my voice,
give me will power, while I have a choice.
I ask Your help and it's no wonder
because if I don't quit, I'm six feet under.

Asthma-COPD Overlap Syndrome - ACOS

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