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Letter to the Editor
Rhinitis: A Clinical Marker of COPD-Asthma Overlap Phenotype?
Reflexiones sobre la rinitis como un marcador clínico de fenotipo EPOC-asma
Juan Marco Figueira Gonçalves
Servicio de Neumología, Hospital Universitario Nuestra Senora de la Candelaria, Santa Cruz de Tenerife, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">According to the EPI-SCAN study&#44; up to 17&#37; of patients diagnosed with COPD may be classified as having COPD-asthma overlap syndrome&#44; and&#44; as such&#44; be candidates for the early introduction of inhaled corticosteroids&#46; For the diagnosis of asthma-COPD overlap syndrome&#44; GesEPOC proposes the following major criteria&#58; bronchodilator test &#62;15&#37; and 400<span class="elsevierStyleHsp" style=""></span>ml&#44; eosinophilia in sputum&#44; and a diagnosis of asthma before the age of 40 years&#59; and minor criteria&#58; elevated total IgE&#44; atopy and bronchodilator test &#62;12&#37; and 200<span class="elsevierStyleHsp" style=""></span>ml on 2 or more occasions&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Surprisingly&#44; rhinitis&#44; observed in up to 75&#37; of patients with allergic asthma and up to 80&#37; of non-allergic asthmatics&#44; was excluded from the diagnostic criteria&#44; in favor of atopy and elevated total IgE levels&#44; with the aim of identifying an eosinophilic inflammatory substrate&#46; However&#44; diseases such as asthma or rhinitis may occur with eosinophilic infiltration&#44; but with no evidence of sensitization or elevated IgE levels&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">While the concept of a single pathway in asthma is well established&#44; very little scientific evidence on the coexistence of rhinitis and COPD is available as yet&#46; Several studies have reported that up to 88&#37; of COPD patients report upper respiratory tract symptoms&#44; primarily rhinorrhea&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> Jamieson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> identified what they defined as an allergic phenotype in COPD patients who showed positive sensitization to pneumoallergens and&#47;or allergic upper respiratory tract symptoms&#44; demonstrating that these are more symptomatic subjects with a higher risk of exacerbations&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In accordance with the single pathway concept&#44; the type of inflammatory substrate in the upper airways should give an idea of the type of inflammation occurring in the bronchi&#46; Hurst et al&#46; detected elevated IL-8 levels in the nasal lavage of patients with COPD&#44; suggesting a neutrophilic response&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> These findings coincide with those of Vachier et al&#46;&#44; who&#44; after analyzing nasal mucosa biopsies of active smokers with COPD&#44; found elevated levels of neutrophils and CD8&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> In contrast&#44; Hens et al&#46; reported high levels of eotaxin in the nasal lavage of COPD patients with no increase in IL8 concentrations compared to asthma subjects&#44; suggesting an eosinophilic response&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Moreover&#44; Neves MC et al&#46; confirmed that rhinitis symptoms in COPD patients are associated with nasal eosinophilia with an OR of 4&#46;1 &#40;1&#46;59&#8211;11&#46;39&#41;&#44; and that these patients are more likely to show a positive bronchodilator test&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These contradictory findings might support the concept of COPD phenotypes&#46; Until it is confirmed in clinical trials&#44; the high prevalence of rhinitis in asthma patients makes it reasonable to propose this symptom as a clinical marker for the COPD-asthma overlap syndrome&#46;</p></span>"
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