Clinical Review

The Asthma-COPD Overlap Syndrome

Fed Pract. 2015 September;32(suppl 10):19S-23S

References

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Quality of Life, Morbidity, and Moratality

In addition to being more prevalent in the elderly, ACOS is associated with more severe symptoms, impairment in quality of life (QOL), more frequent exacerbations, and high health care utilization. The ACOS phenotype is also at risk for accelerated decline in lung function secondary to its association with advancing age, tobacco smoking, presence of bronchial hyper-reactivity, and exacerbations. ¹⁴

Burrows and colleagues described the characteristics and course of asthma in subjects aged > 65 years and concluded that asthma in this group may be associated with severe symptoms, higher death rates, and chronic airway obstruction. ¹⁹ In this study, the subjects with suspected ACOS smoked at least 20 pack-years and had a significantly lower mean FEV1 (48.1% predicted ± 23.7) than any other group. Kauppi and colleagues reported on health-related QOL (HRQOL) and found that when compared to subjects with asthma or COPD only, the overlap group had the poorest HRQOL score. ²⁰ Chung and colleagues reported a similar reduction on self-rated health in the overlap group as well. ²¹ Miravitles and colleagues reported that 17.4% of subjects previously diagnosed with COPD belonged to the COPD-asthma overlap phenotype. ²² The overlap phenotype in this study had more dyspnea, wheezing, exacerbations, worse respiratory-specific QOL, and reduced levels of physical activity. Soriano and colleagues identified higher relative risks for pneumonia and respiratory infections in individuals aged > 65 years with asthma and COPD. ²³ In a study of hospital discharge registry data covering the Finnish population, Andersén and colleagues reported that the average numbers of treatment periods during 2000 to 2009 were 2.1 in asthma, 3.4 in COPD, and 6.0 in ACOS. ²⁴ Panizza and colleagues reported that long-standing asthma was associated with chronic airflow obstruction and increased risk of mortality. ²⁵

Although patients with both asthma and COPD are at risk for exacerbations, those with ACOS are at risk for more frequent and severe exacerbations. ²⁶ In the PLATINO study population, subjects with ACOS had higher risk for exacerbations, hospitalization, and worse general health status when compared with those with COPD. ²⁷ Frequent exacerbations of COPD leads to a greater loss of lung function compared with those who have infrequent exacerbations. ¹⁴ A lower FEV ₁ is associated with increased disease severity in both asthma and COPD, and this is of particular concern to those with ACOS.

Of significance is the association of the ACOS phenotype with tobacco smoking. Although asthma is a risk factor for accelerated lung function decline, smoking status significantly accelerates the decline, and the loss may be even greater in those with asthma who smoke. ^28,29 This can ultimately predispose patients to the ACOS phenotype. Fortunately, quitting smoking can slow the decline in lung function as reported in the Lung Health Study. ³⁰ The annual decline in FEV ₁ in subjects who quit smoking at the beginning of the 11-year study was 30.2 mL /year for men and 21.5 mL /year for women. For those who continued smoking, the decline in FEV ₁ was 66.1 mL /year in men and 54.2 mL /year in women. For those with ACOS, treating tobacco use and dependence should be regarded as a primary and specific intervention.