Initial Treatment for Patients with Both COPD and Asthma
For patients with both COPD and asthma (asthma-COPD overlap), triple therapy with LAMA/LABA/ICS in a single inhaler is the recommended initial treatment to reduce mortality and exacerbation risk.
Understanding Asthma-COPD Overlap
Asthma-COPD overlap represents a distinct clinical phenotype where patients exhibit features of both conditions. These patients typically experience:
- More frequent and severe exacerbations
- Poorer quality of life
- More rapid decline in lung function
- Higher mortality risk
Diagnostic Considerations
Before initiating treatment, confirm the diagnosis of asthma-COPD overlap by identifying features of both conditions:
Major criteria (at least 2 required):
- Strong bronchodilator response (FEV₁ increase >15% and >400 mL)
- Sputum eosinophilia (≥3%)
- History of asthma
Minor criteria (can supplement diagnosis):
- Elevated total IgE
- History of atopy
- Positive bronchodilator response on multiple occasions (FEV₁ >12% and >200 mL)
Treatment Algorithm
First-line therapy: LAMA/LABA/ICS triple therapy in a single inhaler 1, 2
- Reduces mortality risk
- Decreases exacerbation frequency
- Improves lung function
- Addresses both inflammatory and bronchoconstrictive components
If single inhaler triple therapy is unavailable:
For acute symptom relief:
Medication Options and Dosing
Triple Therapy Options:
- Fluticasone/umeclidinium/vilanterol
- Beclomethasone/formoterol/glycopyrronium
- Budesonide/glycopyrrolate/formoterol
ICS/LABA Options:
- Fluticasone propionate/salmeterol (Wixela Inhub): 250/50 mcg twice daily 3
- Budesonide/formoterol: 160/4.5 mcg twice daily
LAMA Options:
- Tiotropium (Spiriva): 18 mcg once daily 5
- Umeclidinium: 62.5 mcg once daily
- Glycopyrrolate: 15.6 mcg twice daily
Monitoring and Follow-up
- Assess symptom control, exacerbation frequency, and lung function regularly
- Monitor for adverse effects:
Important Considerations
- Do not use LABA monotherapy in patients with asthma components due to increased risk of asthma-related events including death 2, 6
- Do not use ICS monotherapy in COPD component as it's less effective than combination therapy 2
- Inhaler technique is crucial for medication effectiveness - demonstrate and check regularly 2
- Blood eosinophil count may help predict response to ICS component 1
Non-pharmacological Management
- Smoking cessation (most important intervention to slow disease progression)
- Pulmonary rehabilitation
- Annual influenza and pneumococcal vaccinations
- Oxygen therapy if indicated
The Canadian Thoracic Society guidelines (2023) specifically recommend that ICS/LABA combination therapy should be used in individuals with concomitant asthma and COPD, with triple therapy being preferred for those at high risk of exacerbations 1. This approach addresses both the inflammatory component predominant in asthma and the bronchodilation needs in COPD 6, 7.