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but monoclonal antibodies approved for asthma can also be used&#44; although real-world data on benralizumab is limited&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 54-year-old man ex-smoker with a 60 pack-year history&#44; diagnosed with COPD and receiving triple inhalation therapy at a COPD clinic&#46; He has undergone four surgeries for nasal polyposis&#44; had PAO in all follow-ups&#44; a positive skin test for dog and cat epithelia&#44; and 6&#37; blood eosinophilia &#40;historically always above 460<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;&#956;l&#41;&#46; He had dyspnea with mMRC grade 1&#44; wheezing since age 30&#44; 5&#8211;6 exacerbations per year in recent years treated with antibiotics and oral corticosteroids&#44; including two hospitalizations in the last year&#46; He was referred to our asthma clinic&#44; where an obstructive spirometry with a negative bronchodilator test &#40;FEV1&#47;FVC&#58; 45&#37;&#44; FEV1&#58; 48&#37;&#41;&#44; FeNO 99<span class="elsevierStyleHsp" style=""></span>ppb&#44; IgE 259&#44; and eosinophilia of 8&#46;7&#37; &#40;700<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;&#956;l&#41; were observed&#46; He was diagnosed with ACO&#44; inhalation therapy was adjusted&#44; and due to persistent poor control&#44; benralizumab treatment was initiated&#46; Over the three years of follow-up after starting benralizumab&#44; he reported significant clinical improvement &#40;ACT 23&#41;&#44; requiring only one course of antibiotics and oral corticosteroids&#46; Additionally&#44; his nasal polyposis improved&#44; with no further surgeries needed&#46; FeNO decreased to 24&#44; and he still has PAO&#44; but with an FEV1 &#62;80&#37;&#46; See <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Given the clinical features consistent with asthma&#44; recurrent nasal polyposis&#44; frequent exacerbations despite appropriate treatment&#44; and elevated T2 markers&#44; along with COPD-related features such as a 60 pack-year smoking history and PAO&#44; the patient was diagnosed with ACO according to the SEPAR consensus criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The lack of a standardized and universally accepted definition of ACO makes diagnosis complex&#44; often leading to underdiagnosis&#46; Furthermore&#44; treatment options are limited as there are no specific biomarkers or standardized therapies&#46; Clinical trials for biologic drugs in severe asthma excluded smokers&#44; while COPD trials excluded patients with asthma features&#44; leaving ACO patients unrepresented&#46; This has resulted in ACO patients being less likely to receive biologics compared to those with severe asthma&#46; Thus&#44; real-world studies on the use of biologics in ACO are essential&#44; though currently limited&#46; 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Clinical Letter
Asthma-COPD Overlap – A Gateway to Biological Treatment
Alicia Padilla-Galo
Corresponding author
aliciapadillagalo@gmail.com

Corresponding author.
, Marina Rubio Moreno, Borja Valencia Azcona
Servicio de Neumología, Hospital Universitario Costa del Sol, Spain
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but monoclonal antibodies approved for asthma can also be used&#44; although real-world data on benralizumab is limited&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 54-year-old man ex-smoker with a 60 pack-year history&#44; diagnosed with COPD and receiving triple inhalation therapy at a COPD clinic&#46; He has undergone four surgeries for nasal polyposis&#44; had PAO in all follow-ups&#44; a positive skin test for dog and cat epithelia&#44; and 6&#37; blood eosinophilia &#40;historically always above 460<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;&#956;l&#41;&#46; He had dyspnea with mMRC grade 1&#44; wheezing since age 30&#44; 5&#8211;6 exacerbations per year in recent years treated with antibiotics and oral corticosteroids&#44; including two hospitalizations in the last year&#46; He was referred to our asthma clinic&#44; where an obstructive spirometry with a negative bronchodilator test &#40;FEV1&#47;FVC&#58; 45&#37;&#44; FEV1&#58; 48&#37;&#41;&#44; FeNO 99<span class="elsevierStyleHsp" style=""></span>ppb&#44; IgE 259&#44; and eosinophilia of 8&#46;7&#37; &#40;700<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;&#956;l&#41; were observed&#46; He was diagnosed with ACO&#44; inhalation therapy was adjusted&#44; and due to persistent poor control&#44; benralizumab treatment was initiated&#46; Over the three years of follow-up after starting benralizumab&#44; he reported significant clinical improvement &#40;ACT 23&#41;&#44; requiring only one course of antibiotics and oral corticosteroids&#46; Additionally&#44; his nasal polyposis improved&#44; with no further surgeries needed&#46; FeNO decreased to 24&#44; and he still has PAO&#44; but with an FEV1 &#62;80&#37;&#46; See <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Given the clinical features consistent with asthma&#44; recurrent nasal polyposis&#44; frequent exacerbations despite appropriate treatment&#44; and elevated T2 markers&#44; along with COPD-related features such as a 60 pack-year smoking history and PAO&#44; the patient was diagnosed with ACO according to the SEPAR consensus criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The lack of a standardized and universally accepted definition of ACO makes diagnosis complex&#44; often leading to underdiagnosis&#46; Furthermore&#44; treatment options are limited as there are no specific biomarkers or standardized therapies&#46; Clinical trials for biologic drugs in severe asthma excluded smokers&#44; while COPD trials excluded patients with asthma features&#44; leaving ACO patients unrepresented&#46; This has resulted in ACO patients being less likely to receive biologics compared to those with severe asthma&#46; Thus&#44; real-world studies on the use of biologics in ACO are essential&#44; though currently limited&#46; The main real-world studies in ACO<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3&#44;4</span></a> focused on omalizumab&#44; mepolizumab&#44; reslizumab&#44; and dupilumab&#46; A recent study with benralizumab&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> using insurance database records in the US&#44; lacked clinical or spirometric criteria&#44; introducing potential selection bias&#46; Nevertheless&#44; all real-world studies confirm biologics&#8217; effectiveness in ACO&#46; This case highlights the clinical improvement and remarkable lung function response with benralizumab&#44; emphasizing the need for accurate diagnosis and specific precision medicine treatments&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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