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How can Patients With Asthma-COPD Overlap Syndrome in Clinical Practice be Identified?
¿Cómo podemos identificar a los pacientes con fenotipo mixto asma-EPOC (ACOS) en la práctica clínica?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "59" "paginaFinal" => "60" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miriam Barrecheguren, Cristina Esquinas, Marc Miravitlles" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Miriam" "apellidos" => "Barrecheguren" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Cristina" "apellidos" => "Esquinas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:4 [ "nombre" => "Marc" "apellidos" => "Miravitlles" "email" => array:1 [ 0 => "mmiravitlles@vhebron.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Ciber de Enfermedades Respiratorias (CIBERES), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Cómo podemos identificar a los pacientes con fenotipo mixto asma-EPOC (ACOS) en la práctica clínica?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In a recent consensus meeting of 26 Spanish specialists, 85% of the participants were in agreement about the existence of a mixed COPD-asthma phenotype, known as asthma-COPD overlap syndrome (ACOS). However, there was less agreement on the characteristics that defined this phenotype and how it can be identified in routine clinical practice.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The need for an agreement on the significance of ACOS led to the first consensus meeting aimed at defining ACOS as a COPD phenotype. This was necessary in view of the emerging body of evidence on COPD patients with asthmatic characteristics who respond better to treatment with inhaled corticosteroids (ICS). In this meeting, major and minor criteria for the diagnosis of ACOS were defined<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>; however, subsequent studies have shown that these criteria were excessively restrictive, and that they applied to only a small proportion of patients who may have ACOS.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Compared to the excessively restrictive criteria of the Spanish consensus, the recent criteria from the Global Initiative for Asthma (GINA) and the Global Initiative for Obstructive Lung Disease (GOLD) appear imprecise and ambiguous. These organizations provide a list of characteristics associated with asthma and another list of characteristics associated with COPD. Doctors are expected to tick the characteristics which apply to the patient, and if the number of ticks in each list is similar, the patient probably has ACOS.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> There is no indication of how many ticks are required, and all ticks have the same weight, even though not all characteristics have the same value when identifying asthma or COPD. Returning to the opinion of the Spanish experts, we find that the most relevant ACOS diagnostic criteria were: prior diagnosis of asthma in a COPD patient (according to 88% of experts); significant tobacco consumption (73%); and post-bronchodilator FEV1/FVC<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.7 (69%).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In contrast, other characteristics listed in the GINA-GOLD document, such as respiratory symptoms or daily variability in these symptoms,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> did not appear among the criteria proposed by the Spanish consensus group.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">From the perspective of COPD, a diagnosis of ACOS is based on the presence of asthmatic characteristics in COPD patients. In contrast, from an asthma perspective, the identification of COPD is not so clear: an asthma patient cannot be diagnosed as having ACOS simply because they have incomplete reversibility of airflow obstruction (post-bronchodilator FEV1/FVC<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.7). If that patient has never smoked, they should be classified as having chronic, severe or not completely reversible asthma, but asthma nevertheless. Similarly, neutrophilic asthma would still be asthma, not ACOS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In any case, a prerequisite for diagnosis of ACOS is an overlap between COPD and asthma, and we must therefore be able to identify COPD and asthma in a patient with this possible diagnosis. The most common type of ACOS patient is an asthmatic who is, or who used to be a heavy smoker, who has developed incomplete reversibility of airflow obstruction. In this case, smoking does not cure the asthma, rather it is an added risk factor for the development of incomplete reversibility of airflow obstruction with underlying asthmatic inflammation. Another common pattern is the smoker with COPD who has characteristics reminiscent of asthma, such as reversible airflow obstruction, signs of atopy, rhinitis and/or elevated peripheral eosinophilia.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> This patient may also be a smoker with asthma, perhaps mild or previously undiagnosed. Despite these considerations, it is curious that 31% of participants in the Spanish consensus meeting did not view incomplete reversibility of airway obstruction as an essential criterion for the diagnosis of ACOS.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">From a clinical point of view, the identification of ACOS in patients previously labelled asthmatic has no impact on management, since these patients should be treated as for asthma. In contrast, in COPD, a diagnosis of ACOS will require the immediate introduction of ICs (combined with long-acting bronchodilators). This is a very significant difference with respect to other COPD patients, and for this reason, ACOS was included as one of the clinically relevant phenotypes in the Spanish COPD guidelines (GesEPOC).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Consensus is growing on the limited efficacy of ICS in COPD, and the need for identifying responders to avoid overtreatment has been recognized.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> ACOS patients respond well to ICS, as they typically present predominantly eosinophilic inflammation, and bronchial eosinophilic inflammation in COPD has been shown to be an excellent predictor of good response to ICS. However, the difficulty involved in analyzing eosinophils in sputum in daily practice has sparked interest in the potential of peripheral eosinophilia as a predictor of ICS response. A post hoc analysis of the results of 2 clinical trials found that the efficacy of an ICS (fluticasone furoate) plus a bronchodilator (vilanterol) in reducing COPD exacerbations had a dose–response relationship with the concentration of eosinophils in blood.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Confirmation of these findings in specifically designed prospective studies could herald the end of ACOS, which, being replaced by “eosinophilic COPD” as an identifier of patients with COPD who respond to ICS, would become obsolete. Until such time, our advice is to always ask COPD patients about any history of asthma (or asthmatic symptoms), since this may be a useful indication of the need to include the diagnosis of a possible ACOS in the evaluation of the patient.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interest with regard to this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Barrecheguren M, Esquinas C, Miravitlles M. ¿Cómo podemos identificar a los pacientes con fenotipo mixto asma-EPOC (ACOS) en la práctica clínica?. Arch Bronconeumol. 2016;52:59–60.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What pulmonologists think about the asthma-COPD overlap syndrome (ACOS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Miravitlles" 1 => "B. Alcázar" 2 => "F.J. Álvarez" 3 => "T. Bazús" 4 => "M. Calle" 5 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 46 | 14 | 60 |
| 2024 September | 46 | 14 | 60 |
| 2024 August | 49 | 28 | 77 |
| 2024 July | 55 | 18 | 73 |
| 2024 June | 68 | 37 | 105 |
| 2024 May | 82 | 30 | 112 |
| 2024 April | 45 | 28 | 73 |
| 2024 March | 47 | 22 | 69 |
| 2024 February | 39 | 15 | 54 |
| 2023 March | 7 | 3 | 10 |
| 2023 February | 29 | 17 | 46 |
| 2023 January | 23 | 41 | 64 |
| 2022 December | 28 | 35 | 63 |
| 2022 November | 48 | 23 | 71 |
| 2022 October | 32 | 24 | 56 |
| 2022 September | 20 | 23 | 43 |
| 2022 August | 31 | 42 | 73 |
| 2022 July | 27 | 42 | 69 |
| 2022 June | 27 | 33 | 60 |
| 2022 May | 45 | 32 | 77 |
| 2022 April | 28 | 31 | 59 |
| 2022 March | 32 | 30 | 62 |
| 2022 February | 36 | 32 | 68 |
| 2022 January | 36 | 41 | 77 |
| 2021 December | 31 | 45 | 76 |
| 2021 November | 40 | 48 | 88 |
| 2021 October | 82 | 48 | 130 |
| 2021 September | 40 | 54 | 94 |
| 2021 August | 22 | 29 | 51 |
| 2021 July | 28 | 27 | 55 |
| 2021 June | 41 | 28 | 69 |
| 2021 May | 29 | 36 | 65 |
| 2021 April | 72 | 76 | 148 |
| 2021 March | 65 | 27 | 92 |
| 2021 February | 50 | 27 | 77 |
| 2021 January | 34 | 20 | 54 |
| 2020 December | 38 | 27 | 65 |
| 2020 November | 28 | 17 | 45 |
| 2020 October | 22 | 22 | 44 |
| 2020 September | 64 | 15 | 79 |
| 2020 August | 85 | 10 | 95 |
| 2020 July | 97 | 23 | 120 |
| 2020 June | 22 | 10 | 32 |
| 2020 May | 36 | 13 | 49 |
| 2020 April | 30 | 23 | 53 |
| 2020 March | 24 | 16 | 40 |
| 2020 February | 23 | 19 | 42 |
| 2020 January | 20 | 29 | 49 |
| 2019 December | 24 | 13 | 37 |
| 2019 November | 31 | 19 | 50 |
| 2019 October | 14 | 6 | 20 |
| 2019 September | 16 | 11 | 27 |
| 2019 August | 27 | 19 | 46 |
| 2019 July | 30 | 18 | 48 |
| 2019 June | 20 | 12 | 32 |
| 2019 May | 44 | 17 | 61 |
| 2019 April | 33 | 37 | 70 |
| 2019 March | 30 | 20 | 50 |
| 2019 February | 24 | 21 | 45 |
| 2019 January | 26 | 13 | 39 |
| 2018 December | 29 | 12 | 41 |
| 2018 November | 46 | 13 | 59 |
| 2018 October | 76 | 22 | 98 |
| 2018 September | 42 | 10 | 52 |
| 2018 May | 31 | 2 | 33 |
| 2018 April | 45 | 8 | 53 |
| 2018 March | 71 | 7 | 78 |
| 2018 February | 41 | 8 | 49 |
| 2018 January | 130 | 11 | 141 |
| 2017 December | 114 | 14 | 128 |
| 2017 November | 28 | 3 | 31 |
| 2017 October | 26 | 12 | 38 |
| 2017 September | 32 | 16 | 48 |
| 2017 August | 26 | 11 | 37 |
| 2017 July | 21 | 16 | 37 |
| 2017 June | 37 | 21 | 58 |
| 2017 May | 41 | 15 | 56 |
| 2017 April | 37 | 15 | 52 |
| 2017 March | 15 | 19 | 34 |
| 2017 February | 23 | 11 | 34 |
| 2017 January | 25 | 11 | 36 |
| 2016 December | 25 | 10 | 35 |
| 2016 November | 36 | 17 | 53 |
| 2016 October | 37 | 26 | 63 |
| 2016 September | 40 | 17 | 57 |
| 2016 August | 54 | 13 | 67 |
| 2016 July | 38 | 15 | 53 |
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