Asthma Management Handbook

Management considerations for patients with asthma-COPD overlap

Recommendations

For patients with asthma-COPD overlap, prescribe long-term inhaled corticosteroids (at a low dose, if possible, or at the lowest effective dose) to reduce the risk of asthma flare-ups.

  • Monitor closely for lower respiratory tract infections, and advise patients to get medical advice immediately if they develop symptoms of a lower respiratory tract infection.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Abramson et al. 20121

For patients with asthma-COPD overlap, consider treatment with both an inhaled corticosteroid and a long-acting bronchodilator, as (either of):

  • combination inhaled corticosteroid/long-acting beta2 agonist in a single inhaler (or separate inhalers if the preferred combination is not available in a single inhaler)
  • concomitant treatment with an inhaled corticosteroid and a long-acting muscarinic antagonist (anticholinergic) agent such as tiotropium.

Note: The use of separate inhalers for concomitant treatment with an inhaled corticosteroid and a long-acting bronchodilator (long-acting beta2-agonist or long-acting muscarinic antagonist) in patients with asthma should be avoided if possible, even if the person also has COPD. If no combination product is available for the desired combination, carefully explain to the patient that it is very important that they continue taking the inhaled corticosteroid. 

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Abramson et al. 20121

In addition to prescribing inhaled corticosteroids in combination with long-acting bronchodilators, manage coexisting asthma and COPD according to the individual’s clinical features, comorbidities and response to treatment.

  • Do not prescribe a long-acting bronchodilator (beta2 agonist or muscarinic antagonist) without an inhaled corticosteroid in these patients.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • McDonald et al. 20122
  • McDonald et al. 20113

More information

Coexisting asthma and COPD

There is a subgroup of patients with longstanding asthma who do not demonstrate reversible airflow limitation.42 Asthma that begins later in life often shows a component of irreversible or incompletely reversible airflow limitation (also called ‘fixed airway obstruction’), due to airway remodelling and stiffening of the chest wall.5 The same may be seen in patients with a history of severe asthma in childhood.

Correspondingly, there is a subgroup of patients with COPD who demonstrate significant (though incomplete) bronchodilator response and meet the diagnostic criteria for variable airflow limitation in asthma.42 Most patients with COPD show some reversibility of airflow limitation with bronchodilators,1 and the degree of reversibility can vary from visit to visit.6

Overlap of asthma and COPD is fairly common among older patients attending primary care:

  • In a Dutch analysis of GP patient lists, approximately 10% of patients using an inhaled medication had both COPD and asthma as assessed by an independent pulmonologist.7
  • In a Belgian survey of 26 GPs, 30% of patients with asthma and 38% with COPD had their diagnosis changed to the combination of asthma and COPD following re-examination.7
  • In a New Zealand population study, over 50% of people older than 50 years with airflow limitation showed some degree of overlap of asthma and COPD.8

COPD is an important comorbidity and can lead to under-diagnosis of asthma in older people.9

In older people, COPD and asthma can be difficult to distinguish because both disorders have similar manifestations despite potentially different causes and underlying abnormalities.9

Current Australian guidelines for the diagnosis and management of COPD recommend referral to a specialist respiratory outpatient service for patients with a clinical diagnosis of COPD in whom asthma cannot be excluded.1

Risk factors for coexisting asthma and COPD include ageing, longstanding asthma, and smoking. The coexistence of incompletely reversible airflow limitation (characteristic of COPD) and increased airflow variability (characteristic of asthma) is common among people with respiratory symptoms aged 65 years and over, and even among those over 50 years.94 

The coexistence of asthma and COPD in older patients is not always due to cigarette smoking.5 In some people, persistent airflow limitation may develop as a complication of long-term asthma.97

Close
Is it asthma, COPD or both?

The main symptoms of chronic obstructive pulmonary disease (COPD) are breathlessness, cough and sputum production. Chest tightness, wheezing and airway irritability are also common. Patients often attribute breathlessness to ageing or poor cardiopulmonary fitness.1

The definitions of asthma and COPD overlap, and asthma and COPD frequently coexist in people aged 65 years and over.9 Comorbid COPD is often misdiagnosed as asthma in older people,9  and vice versa.

For information on diagnosis and management of COPD, refer to the COPD-X Concise Guide for Primary Care.10

The Global Initiative for Asthma (GINA) and Global Initiative Obstructive Lung Disease (GOLD) recommend the following stepwise approach for adults presenting with respiratory symptoms:11

  1. Identify whether the patient has clinical features of, or is at risk of, chronic airway disease. This may be suggested by the clinical history and physical examination.
  2. Identify features that favour a diagnosis of typical asthma or typical COPD. If several features of both are present, asthma-COPD overlap is likely.
  3. Perform spirometry to confirm airflow limitation.
  4. Start treatment, selected according to whether the assessment favoured the single diagnosis of asthma, the single diagnosis of COPD, or asthma-COPD overlap.
  5. Refer for specialist assessment and other investigations, if necessary.

 

Close
Management of coexisting asthma and COPD
  • Long-acting beta2 agonists or long-acting muscarinic antagonists should not be prescribed without an inhaled corticosteroid in patients who have both asthma and COPD, or who have COPD with some features of asthma.

  • For patients with both asthma and COPD, treatment should always include inhaled corticosteroids to reduce the risk of flare-ups.

Coexisting asthma and COPD should be managed according to the individual’s clinical features and response to treatment, and monitored by comprehensive ongoing assessment.2

Although back-titration of pharmacological treatment is a core principle of asthma management, there is insufficient evidence about the role of back-titration in patients with coexisting asthma and COPD. However, treatment decisions should always balance potential benefits with potential risks of treatment.

Pulmonary rehabilitation is effective for people with symptomatic COPD.112 Pulmonary rehabilitation is also effective for people with asthma who experience persistent breathlessness, those who are physically inactive, and those with anxiety or depression.13

Supervised exercise training may help improve asthma symptoms and quality of life in people with coexisting asthma and COPD, even in older people.14

Comorbid medical conditions are common among people with coexisting asthma and COPD. Comorbidities should be assessed and managed individually.23

Assessment and management of asthma self-management skills must take into consideration comorbidity associated with COPD or ageing (e.g. impaired cognition, reduced manual dexterity and impaired vision).23

Close
Pneumonia risk with inhaled corticosteroids in patients with COPD

In people with COPD, the risk of pneumonia is increased by the use of regular inhaled corticosteroids.15161718 Most of the available evidence is from patients treated with fluticasone propionate.1819202122, 23 Increased pneumonia rates have also been observed in studies of patients with COPD using fluticasone furoate/vilanterol.24 The higher dose of fluticasone furoate/vilanterol (Breo Ellipta 200/25 mcg) is not indicated for patients with COPD.

Increased risk of pneumonia with inhaled corticosteroids has not been established in patients with asthma.24, 25 However, the risk of pneumonia in patients with co-existing asthma and COPD is unknown, so caution is advised, particularly if high doses are being considered.

Close
Definition of variable expiratory airflow limitation

Most of the tests for variable expiratory airflow limitation are based on showing variability in FEV1. While reduced FEV1 may be seen with many other lung diseases (or due to poor spirometric technique), a reduced ratio of FEV1 to FVC indicates airflow limitation.26 Normal FEV1/FVC values derived from population studies vary,2728 but are usually greater than:27

  • 0.85 in people aged up to 19 years
  • 0.80 in people aged 20–39 years
  • 0.75 in people aged 40–59 years
  • 0.70 in people aged 60–80 years.

In children, it is less useful to define expiratory airflow limitation according to a specific cut-off for FEV1/FVC ratio, because normal values in children change considerably with age.28

Some spirometers provide predicted normal values specific to age group. If these are available, a FEV1/FVC ratio less than the lower limit of normal (i.e. less than the 5th percentile of normal population) indicates airflow limitation.

Variable expiratory airflow limitation (beyond the range seen in healthy populations) can be documented if any of the following are recorded:

  • a clinically important increase in FEV1 (change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children) 10–15 minutes after administration of bronchodilator
  • clinically important variation in lung function (at least 20% change in FEV1) when measured repeatedly over time (e.g. spirometry on separate visits)
  • a clinically important reduction in lung function (decrease in FEV1 of at least 200 mL and 12% from baseline on spirometry, or decrease in peak expiratory flow rate by at least 20%) after exercise (formal laboratory-based exercise challenge testing uses different criteria for exercise-induced bronchoconstriction)
  • a clinically important increase in lung function (at least 200 mL and 12% from baseline) after a trial of 4 or more weeks of treatment with an inhaled corticosteroid
  • clinically important variation in peak expiratory flow (diurnal variability of more than 10%)
  • a clinically important reduction in lung function (15–20%, depending on the test) during a test for airway hyperresponsiveness (exercise challenge test or bronchial provocation test) measured by a respiratory function laboratory.

Notes

Patients referred to a respiratory function laboratory may be asked not to take certain medicines within a few hours to days before a spirometry visit.

A clinically important increase or decrease in lung function is defined as a change in FEV1 of at least 200 mL and 12% from baseline for adults, or at least 12% from baseline for children, or a change in peak expiratory flow rate of at least 20% on the same meter.2926 A clinically important increase in FVC after administering bronchodilator may also indicate reversible airflow limitation, but FVC is a less reliable measure in primary care because FVC may vary due to factors such as variation in inspiratory volume or expiratory time.

The finding of ‘normal’ lung function during symptoms reduces the probability that a patient has asthma, but a clinically important improvement in response to bronchodilator or inhaled corticosteroid can occur in patients whose baseline value is within the predicted normal range.

The greater the variation in lung function, the more certain is the diagnosis of asthma. However, people with longstanding asthma may develop fixed airflow limitation.

Reversibility in airflow limitation may not be detected if the person is already taking a long-acting beta2 agonist or inhaled corticosteroid.

Airflow limitation can be transient and does not necessarily mean that the person has asthma (e.g. when recorded during a severe acute infection of the respiratory tract). Ideally, airflow limitation should be confirmed when the patient does not have a respiratory tract infection. Reduction in lung function during a respiratory tract infection with improvement in lung function after its resolution, commonly occurs in people with asthma, but can also be seen in patients with COPD or in healthy people without either asthma or COPD.30,31

Close

References

  1. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  2. McDonald VM, Higgins I, Gibson PG. Managing older patients with coexistent asthma and chronic obstructive pulmonary disease. Drugs Aging. 2013; 30: 1-17. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23229768
  3. McDonald VM, Simpson JL, Higgins I, Gibson PG. Multidimensional assessment of older people with asthma and COPD: clinical management and health status. Age Ageing. 2011; 41: 42-49. Available from: http://ageing.oxfordjournals.org/content/40/1/42.long
  4. Gibson PG, Simpson JS. The overlap syndrome of asthma and COPD: what are its features and how important is it?. Thorax. 2009; 64: 728-735. Available from: http://thorax.bmj.com/content/64/8/728.full
  5. Reed CE. Asthma in the elderly: diagnosis and management. J Allergy Clin Immunol. 2010; 126: 681-7; quiz 688-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20673985
  6. Albert P, Agusti A, Edwards L, et al. Bronchodilator responsiveness as a phenotypic characteristic of established chronic obstructive pulmonary disease. Thorax. 2012; 67: 701-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22696176
  7. van der Molen T. Co-morbidities of COPD in primary care: frequency, relation to COPD, and treatment consequences. Prim Care Resp J. 2010; 19: 326-334. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20842323
  8. Weatherall M, Travers J, Shirtcliffe PM, et al. Distinct clinical phenotypes of airways disease defined by cluster analysis. Eur Respir J. 2009; 34: 812-818. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19357143
  9. Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010; 376: 803-813. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20816547
  10. Abramson M, Frith P, Yang I, et al. COPD-X Concise Guide for Primary Care. Lung Foundation Australia, Brisbane, 2016. Available from: http://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/
  11. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2016. Available from: http://ginasthma.org/
  12. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of COPD. GOLD, 2013. Available from: http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html
  13. Coventry PA, Hind D. Comprehensive pulmonary rehabilitation for anxiety and depression in adults with chronic obstructive pulmonary disease: Systematic review and meta-analysis. J Psychosom Res. 2007; 63: 551-65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17980230
  14. Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life following exercise training in older adults with moderate/severe persistent asthma. Respiration. 2011; 81: 302-10. Available from: http://www.karger.com/Article/FullText/315142
  15. Singh S, Amin AV, Loke YK. Long-term use of inhaled corticosteroids and the risk of pneumonia in chronic obstructive pulmonary disease: a meta-analysis. Arch Intern Med. 2009; 169: 219-29. Available from: http://archinte.jamanetwork.com/article.aspx?articleid=414788
  16. Spencer S, Karner C, Cates CJ, Evans DJ. Inhaled corticosteroids versus long-acting beta(2)-agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011; Issue 12: CD007033. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007033.pub3/full
  17. Drummond MB, Dasenbrook EC, Pitz MW, et al. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis. JAMA. 2008; 300: 2407-16. Available from: http://jama.jamanetwork.com/article.aspx?articleid=182942
  18. Nannini LJ, Lasserson TJ, Poole P. Combined corticosteroid and long-acting beta(2)-agonist in one inhaler versus long-acting beta(2)-agonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012; Issue 9: CD006829. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006829.pub2/full
  19. Janson C, Larsson K, Lisspers KH, et al. Pneumonia and pneumonia related mortality in patients with COPD treated with fixed combinations of inhaled corticosteroid and long acting beta2 agonist: observational matched cohort study (PATHOS). BMJ. 2013; 346: f3306. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666306/
  20. Sin DD, Tashkin D, Zhang X, et al. Budesonide and the risk of pneumonia: a meta-analysis of individual patient data. Lancet. 2009; 374: 712-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19716963
  21. Halpin DM, Gray J, Edwards SJ, et al. Budesonide/formoterol vs. salmeterol/fluticasone in COPD: a systematic review and adjusted indirect comparison of pneumonia in randomised controlled trials. Int J Clin Pract. 2011; 65: 764-74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21676119
  22. Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013; 68: 1029-36. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812880/
  23. Nannini LJ, Poole P, Milan SJ, et al. Combined corticosteroid and long-acting beta2-agonist in one inhaler versus placebo for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2013; Issue 11: CD003794. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003794.pub4/full
  24. GlaxoSmithKline Australia Pty Ltd. Product Information: Breo (fluticasone furoate; vilanterol) Ellipta. Therapeutic Goods Administration, Canberra, 2014. Available from: https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf
  25. O'Byrne PM, Pedersen S, Carlsson LG, et al. Risks of pneumonia in patients with asthma taking inhaled corticosteroids. Am J Respir Crit Care Med. 2011; 183: 589-95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20889908
  26. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from: http://erj.ersjournals.com/content/26/5/948
  27. National Heart Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. Full report 2007. US Department of Health and Human Services National Institutes of Health, Bethesda, 2007. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report
  28. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. Eur Respir J. 2012; 40: 1324-43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22743675
  29. Levy ML, Quanjer PH, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J. 2009; 18: 130-147. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19684995
  30. Collier AM, Pimmel RL, Hasselblad V, et al. Spirometric changes in normal children with upper respiratory infections. Am Rev Respir Dis. 1978; 117: 47-53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/619724
  31. Melbye H, Kongerud J, Vorland L. Reversible airflow limitation in adults with respiratory infection. Eur Respir J. 1994; 7: 1239-1245. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7925901