Kate Johnson

November 08, 2014

ATLANTA — Clinicians should consider a wider concept of obstructive airway disease, in which either asthma or chronic obstructive pulmonary disease (COPD) predominates, said speakers here at the opening plenary of the American College of Allergy, Asthma & Immunology (ACAAI) 2014 Annual Meeting.

"I think we're beginning to enter a new era," said William Busse, MD, professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison. "There are clearly overlaps between the two conditions, and recognizing this is important and will lead to the best care that patients can have."

A consensus description of asthma–COPD overlap syndrome (ACOS) — recently published by both the Global Initiative for Asthma and the Global Initiative for Chronic Obstructive Lung Disease — states that "faced with a differential diagnosis equally balanced between asthma and COPD (i.e. ACOS), the default position should be to start treatment accordingly for asthma."

Blurring the lines between the two conditions calls for new collaboration between allergists and pulmonologists, said Reynold Panettieri, MD, a pulmonologist and professor of medicine at the University of Pennsylvania in Philadelphia.

"This is a time for interaction; we don't have two camps," said Dr Panettieri. "As we take care of more COPD patients, I think allergists, for the first time, are needed to help us as pulmonologists treat the disease. I think it's a very important time, bringing allergy and pulmonology back together to help patients with the global concept of airway disease. In my practice, we have airflow obstruction associated with and without cigarette smoke, not asthma or COPD."

Allergists are also asking new questions about the diagnosis and management of COPD.

Dave Gupta, MD, and allergist-immunologist from Lansing, Michigan, told Medscape Medical News that treating patients with severe smoking-related lung disease and those who are on oxygen is not necessarily part of their training.

"The reality is we're already seeing these patients," he said. "We're treating obstructive lung disease, whether it's smoking-related COPD or asthma. As allergists, we're open to it, but from a practical standpoint, there needs to be more instruction. We look to our national organizations like the ACAAI for guidance."

After the presentation, Dr Gupta asked the panelists what should be expected of allergists who take on patients with COPD or overlap syndrome.

"What is practical for us? What is expected of us? When you talk about collaboration with pulmonology, when is it appropriate for us to manage these patients? And when should we be sharing it with our pulmonology colleagues? We still need more guidance," he said.

Although a simplified 6-minute walk test and even prescriptions for supplemental oxygen were discussed after the presentation, advice from the panel about specific pharmacotherapy for overlap syndrome remained elusive.

"If symptoms are more predominantly asthma, the treatment will be more traditional for asthma — anti-inflammatories," said Dr Busse. "And if they're more predominantly COPD, it's going to be bronchodilators."

However, there is growing concern about the use of inhaled corticosteroids in patients with COPD in light of emerging evidence suggesting they can increase the risk for pneumonia in this population.

"The issue is steroids; it's the biggest question," said Dr Gupta. "As allergists, we are very comfortable with anti-inflammatories. We're still going to prescribe those, at least at low doses, unless we're given clear instructions about when it might increase risk in some patients," he explained. "If someone has obvious smoking-related lung disease without much history of asthma, then we might skip the steroids or try low-dose steroids and focus on the bronchodilators, but in the overlap patients, whether or not we include steroids is still unclear. This is all going to depend on the research; this is an emerging field."

"It's important that we begin to take a step back, look at the multiple faces that exist with the disease, and realize that it's not just pure asthma, not just pure COPD, but may be complicated by many other aspects," said Dr Busse. "This is going to be important as far as outcomes are concerned, and it's going to add excitement to our treatment. I think it's going to expand the effectiveness with which we deal with our patients."

American College of Allergy, Asthma & Immunology (ACAAI) 2014. Presented November 8, 2014.

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