What is the difference in treatment between Chronic Obstructive Pulmonary Disease (COPD) and asthma?

Treatment Differences Between COPD and Asthma

The key difference in treatment between COPD and asthma is that inhaled corticosteroids (ICS) are first-line therapy for asthma, while bronchodilators are first-line for COPD, with ICS added only in specific circumstances. 1

Diagnostic Differences

Understanding the diagnostic differences is essential for appropriate treatment:

• COPD:

  • Characterized by persistent airflow limitation that is not fully reversible 1
  • Post-bronchodilator FEV1/FVC ratio less than 0.70 confirms persistent airflow limitation 1
  • Typically develops after age 40 in patients with significant smoking history or occupational exposures 1
  • Minimal reversibility with bronchodilators 1
  • Evidence of emphysema on imaging and decreased diffusing capacity are common 1

• Asthma:

  • Characterized by variable airflow limitation that is often reversible either spontaneously or with therapy 2
  • Marked improvement on spirometry with bronchodilators or glucocorticosteroids 1
  • Often associated with atopy and allergic conditions 1
  • May begin at any age, often in childhood 1
  • Airway hyperresponsiveness to various stimuli is common 1

Treatment Approach for COPD

• First-line therapy: Long-acting bronchodilators

  • Long-acting muscarinic antagonists (LAMAs) such as tiotropium 3
  • Long-acting beta-agonists (LABAs) 1
  • Can be used as monotherapy or in combination depending on symptom severity 1

• Second-line/Add-on therapy:

  • Combination LAMA/LABA for patients with persistent symptoms 1
  • Add ICS only for patients with:
    • Frequent exacerbations despite optimal bronchodilator therapy 1
    • Blood or sputum eosinophilia 1
    • History of asthma or features of asthma-COPD overlap 1

• Exacerbation management:

  • Short-acting bronchodilators for symptom relief 1
  • Antibiotics if increased sputum purulence and volume 1
  • Systemic corticosteroids for moderate to severe exacerbations 1

Treatment Approach for Asthma

• First-line therapy: Anti-inflammatory treatment

  • Inhaled corticosteroids (ICS) as controller medication 1, 4
  • Short-acting beta-agonists (SABA) as needed for symptom relief 2

• Second-line/Add-on therapy:

  • ICS/LABA combination for persistent symptoms 4
  • Higher dose ICS or add-on therapies (leukotriene modifiers, tiotropium) for difficult-to-control asthma 1

• Exacerbation management:

  • Increased dose of ICS or short course of systemic corticosteroids 1
  • Bronchodilators for symptom relief 2

Asthma-COPD Overlap

• Patients with features of both conditions require special consideration:
  • Typically require ICS as part of their treatment regimen 1
  • Often need combination therapy with ICS/LABA plus LAMA in more severe cases 1
  • Diagnostic criteria include:
    • Strong bronchodilator response (FEV1 >15% and >400 mL) 1
    • Sputum eosinophilia ≥3% 1
    • History of asthma 1
    • Elevated total IgE and history of atopy 1

Common Pitfalls in Management

• Misdiagnosis: Up to 30% of patients with doctor-diagnosed asthma and 87% with doctor-diagnosed COPD may have incorrect diagnoses 5

  • Always confirm diagnosis with spirometry before initiating treatment 6, 5

• Underuse of spirometry: Only about 55% of patients with respiratory diagnoses have ever had spirometry 6

  • Perform pre- and post-bronchodilator spirometry to distinguish between the conditions 7

• Inappropriate ICS use:

  • Overuse in COPD: About 71% of COPD patients may be inappropriately treated with ICS 5
  • Underuse in asthma: Approximately 12% of asthma patients may not receive needed ICS 5

• Failure to recognize overlap: Missing features of both conditions can lead to suboptimal treatment 1, 7

  • Consider overlap when patients have mixed features or respond poorly to standard treatment 1

Treatment Algorithm

1. Confirm diagnosis with spirometry:

   • Post-bronchodilator FEV1/FVC <0.70 with minimal reversibility (<12%) suggests COPD 1
   • Significant reversibility (>12% and >200mL) suggests asthma 1, 7

2. For confirmed COPD:

   • Start with LAMA or LABA 1
   • Add second long-acting bronchodilator if symptoms persist 1
   • Add ICS only if frequent exacerbations or features of asthma overlap 1

3. For confirmed asthma:

   • Start with ICS as controller medication 1, 4
   • Add LABA if symptoms persist 4
   • Adjust ICS dose based on symptom control 1

4. For asthma-COPD overlap:

   • Start with ICS/LABA combination 1
   • Add LAMA if symptoms persist 1
   • Monitor closely and adjust therapy based on symptoms and exacerbations 1

Remember that proper diagnosis is the foundation of effective treatment, and spirometry is essential for distinguishing between these conditions 2, 6, 7.