What is the first-line treatment for patients with Chronic Obstructive Pulmonary Disease (COPD) and overlapping asthma?

First-Line Treatment for COPD with Overlapping Asthma

For patients with COPD and overlapping asthma (ACOS), inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) combination therapy is recommended as first-line treatment. 1

Understanding Asthma-COPD Overlap Syndrome (ACOS)

ACOS is characterized by:

• Persistent airflow limitation with significant reversibility
• Features of both asthma and COPD
• Often presents with eosinophilic inflammation
• Affects approximately 20% of patients with obstructive airway diseases

Treatment Algorithm

First-Line Treatment:

• ICS/LABA combination therapy
  • Examples: fluticasone/salmeterol or budesonide/formoterol 1, 2
  • Rationale: Targets both eosinophilic inflammation (ICS) and bronchoconstriction (LABA)
  • Clinical remark: "ICS/LABA combination therapy is preferred to LAMA/LABA dual therapy in individuals who have COPD with concomitant asthma" 3

For Patients with Inadequate Response to ICS/LABA:

• Add LAMA to create triple therapy (ICS/LABA/LAMA)
  • Indicated for patients with persistent symptoms or exacerbations
  • The Spanish guidelines specifically recommend triple therapy for ACOS as disease severity increases 1
  • The Canadian Thoracic Society recommends triple therapy for patients at high risk of exacerbations with moderate to high symptom burden 3, 1

For Patients with Frequent Exacerbations Despite Triple Therapy:

Consider add-on options:

• Prophylactic macrolides
• PDE-4 inhibitors (particularly with chronic bronchitis)
• Mucolytic agents

Evidence Strength and Considerations

The recommendation for ICS/LABA as first-line therapy is supported by:

• Multiple national guidelines including the Spanish COPD consensus, Japanese Respiratory Society, and Australian Asthma Management Handbook 1
• The American Thoracic Society's recommendation for an asthma-dominant treatment approach for ACOS 1
• The Canadian Thoracic Society's explicit preference for ICS/LABA over LAMA/LABA in COPD patients with concomitant asthma 3

Safety and Monitoring

• Pneumonia risk: ICS use may increase pneumonia risk in COPD patients; monitor accordingly 3, 1
• Dose adjustment: Adjust ICS dose based on symptoms, lung function, and eosinophil counts 1
• Oral candidiasis: Monitor for oral thrush; advise patients to rinse mouth after inhalation 2
• Long-term effects: Monitor for potential glaucoma and cataracts with prolonged ICS use 2

Common Pitfalls to Avoid

1. Undertreatment with bronchodilators alone: Relying solely on LAMA/LABA therapy without ICS in ACOS patients may leave eosinophilic inflammation untreated
2. ICS monotherapy: ICS should only be administered as part of combination therapy, not as monotherapy 3
3. Overreliance on bronchodilator reversibility: Diagnosis and treatment decisions should not be based solely on bronchodilator reversibility 1
4. Inadequate ICS dosing: Too low ICS doses can lead to uncontrolled asthmatic components 1

This approach aligns with the most recent guidelines and emphasizes the importance of addressing both the inflammatory and bronchoconstrictive components of ACOS for optimal patient outcomes.