Can biologics help in managing asthma-COPD overlap?

Question

Hello doctor,

My father is 70 years old and has had asthma for several decades. However, he was recently informed that he may also have chronic obstructive pulmonary disease (COPD). His breathing has progressively worsened. He experiences frequent wheezing, persistent coughing, and occasional shortness of breath, even at rest.

He is currently using inhalers and nebulizers, but despite this, he still ends up in the emergency room every few months. During his last hospital visit, the healthcare team mentioned a condition called asthma-COPD overlap (ACO) and suggested adding a biologic treatment.

What exactly does asthma-COPD overlap mean? Is it more serious or dangerous than having just asthma or COPD alone? We are quite worried because he is also losing weight and experiencing disrupted sleep due to nighttime coughing.

What treatment options are available to help stabilize his condition and prevent further worsening? Could biologic therapies be helpful in his case?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I have read your query and can understand your concern.

You are right to be concerned. What your father is facing is known as asthma–chronic obstructive pulmonary disease overlap (ACO), a complex condition that tends to be more severe than asthma or chronic obstructive pulmonary disease (COPD) alone. It means he exhibits features of both chronic asthma (such as inflammation and responsiveness to corticosteroids) and COPD (such as irreversible airway damage due to long-term exposure, not necessarily smoking). Let me explain what this means and what can be done:

1. What is asthma–COPD overlap (ACO)?

ACO is not a separate disease, but rather a term used when a person has features of both asthma and COPD.

It is commonly seen in older adults with a long-standing history of asthma and newer signs of COPD, including chronic cough, sputum production, and airflow limitation.
Patients with ACO often have more frequent exacerbations, more rapid lung function decline, and more persistent symptoms.

2. Why is it more serious?

ACO typically results in both heightened airway inflammation and irreversible structural changes in the lungs.

Patients with ACO are at greater risk of hospitalizations, particularly when they experience frequent exacerbations, as your father has.
Standard inhaler therapies may be insufficient, which is why newer therapies such as biologics are often explored.

3. What are the treatment goals?

To prevent exacerbations and improve lung function.
To enhance daily activity levels and maintain body weight.
To reduce nighttime symptoms and improve the quality of sleep.

iI would recommend the following treatment strategies for ACO:

A. Inhaled therapy:

Triple inhaler therapy is considered the mainstay treatment:

Inhaled Corticosteroid (ICS) + Long-acting beta-2 agonist (LABA) + Long-acting muscarinic antagonist (LAMA)

Examples include:

Fluticasone furoate (Inhaled corticosteroid) + Umeclidinium (LAMA) + Vilanterol (LABA) Budesonide (Inhaled corticosteroid) + Glycopyrrolate (LAMA) + Formoterol fumarate (LABA).

These combinations help manage ACO's inflammatory (asthma) and obstructive (COPD) components.

B. Nebulizers: Nebulized bronchodilators can still be helpful during acute flares. However, triple therapy inhalers are more effective and convenient for long-term management.

C. Biologic therapy:

Considered when:

Blood eosinophil counts are elevated.
There are frequent exacerbations despite optimal inhaler therapy.
Asthma symptoms are still severe even with COPD overlap.

Additional supportive measures can include:

Pulmonary rehabilitation: Structured programs involving exercise and education to improve lung capacity and reduce breathlessness.
Vaccinations: Annual influenza, pneumococcal, and COVID-19 vaccines are essential for preventing respiratory infections.
Nutritional support: Weight loss is a poor prognostic sign in COPD; a referral to a dietitian may help maintain nutritional health.
Management of nighttime symptoms: This may include adjusting the timing of inhalers and assessing for associated issues like gastroesophageal reflux disease or obstructive sleep apnea.

When to be concerned, and act promptly:

Persistent shortness of breath at rest.
Unexplained or unintentional weight loss.
More than two emergency room visits or hospitalizations per year.
Sleep disturbance caused by respiratory symptoms.

These signs suggest that the current treatment regimen may need to be escalated, possibly by initiating biologic therapy or enrolling in pulmonary rehabilitation.

What to do next:

Request a comprehensive re-evaluation by his pulmonologist, including blood eosinophil testing and spirometry.
Ensure that he is on an optimized inhaler regimen, ideally with triple therapy.
Ask about eligibility for biologic treatments based on his clinical profile.
Discuss referral for pulmonary rehabilitation.
Assess for additional needs such as nighttime oxygen or evaluation for sleep-disordered breathing.

I hope this helps.

Thank you.