Treatment for Asthma-COPD Overlap Syndrome (ACOS)
For patients with Asthma-COPD overlap syndrome, inhaled corticosteroids (ICS) plus long-acting beta-agonist (LABA) combination therapy is the recommended first-line treatment, with the addition of a long-acting muscarinic antagonist (LAMA) as disease severity increases. 1
Diagnostic Considerations
Before initiating treatment, confirming the diagnosis of ACOS is essential. Several guideline-based diagnostic criteria exist:
Spanish Consensus Criteria: Two major criteria (FEV₁ increase ≥15% and ≥400 mL, sputum eosinophilia, history of asthma) or one major plus two minor criteria (elevated IgE, atopy history, bronchodilator response ≥12% and ≥200 mL) 2
Czech Guidelines: Two major criteria or one major plus two minor criteria, with major criteria including strong bronchodilator test positivity, bronchoconstrictor test positivity, elevated FeNO, and history of asthma 2
It's important to note that bronchodilator reversibility alone is not sufficient for diagnosis, as it can be present in both conditions and doesn't reliably predict treatment response 2.
Treatment Algorithm
Step 1: Initial Treatment
- First-line therapy: ICS/LABA combination 2, 1
- This approach is recommended by multiple guidelines including the Spanish COPD consensus, Japanese Respiratory Society, and Australian Asthma Management Handbook 2
- ICS targets the eosinophilic inflammation common in ACOS while LABA addresses bronchoconstriction
Step 2: Inadequate Response to Initial Treatment
- Add LAMA (triple therapy: ICS/LABA/LAMA) 2
Step 3: Further Management
- Adjust ICS dose based on symptoms, lung function, and sputum eosinophilia 2
- Consider prophylactic macrolides, PDE-4 inhibitors, or mucolytic agents for patients with frequent exacerbations 2
Medication Selection
ICS/LABA Options:
- Fluticasone/salmeterol (Wixela Inhub®) - available in various strengths (100/50,250/50, or 500/50 mcg) 3
- Budesonide/formoterol
- Beclomethasone/formoterol
LAMA Options:
- Tiotropium
- Umeclidinium
- Glycopyrronium
Special Considerations
Pneumonia Risk: ICS therapy increases pneumonia risk in COPD patients, particularly in older patients and those with more severe disease 3, 4. Monitor patients for signs and symptoms of pneumonia.
Eosinophil Levels: Higher blood eosinophil counts may predict better response to ICS therapy 4. Consider checking eosinophil levels to guide treatment decisions.
Candidiasis: Advise patients to rinse their mouth with water without swallowing after ICS inhalation to reduce the risk of oral candidiasis 3.
Comorbidities: ACOS patients often have increased comorbidities compared to either asthma or COPD alone, which may require additional management strategies 1.
Evidence Strength and Limitations
The recommendation for ICS/LABA as initial therapy is consistently supported across multiple guidelines 2, 1. The Spanish guidelines provide the most detailed approach specifically for ACOS 2.
The evidence for triple therapy in ACOS specifically is less robust, but extrapolated from COPD guidelines showing mortality benefits in high-risk patients 2.
Common Pitfalls to Avoid
Using LABA monotherapy: This is contraindicated in asthma and ACOS due to increased risk of asthma-related events including death 3, 5.
Relying solely on bronchodilator reversibility for diagnosis or treatment decisions 2.
Inadequate ICS dosing: Unlike in pure COPD, patients with ACOS require adequate ICS dosing to control the asthmatic component of their disease 1.
Failure to monitor for pneumonia: Regular assessment for pneumonia symptoms is essential in patients on ICS therapy 3, 4.
Not considering eosinophil levels: These may help identify patients most likely to benefit from ICS therapy 4.