By Annette M. Boyle

Michael B. Foggs, MD

Michael B. Foggs, MD

CHICAGO – Your patient presents with wheezing, coughing and shortness of breath. Is it asthma, chronic obstructive pulmonary disease (COPD) or both?

The diagnosis and decision about treatment are not so simple, however. In fact, they can be fraught with danger.

“What would count as malpractice in asthma is standard practice in COPD,” said Michael B. Foggs, MD, past-president of the American College of Allergy, Asthma and Immunology (ACAAI) and a member of the Food and Drug Administration’s Pulmonary Allergy Drugs Advisory Committee.

“Chronic persistent asthma should always be treated with inhaled corticosteroids,” Foggs said. “If they have COPD, then they should be on long-acting beta agonists (LABA), but you could skip inhaled corticosteroids (ICS), though that would be considered malpractice for chronic persistent asthma. If a patient has asthma COPD overlap syndrome that’s predominately asthma, then you want to make sure they have inhaled corticosteroids on board to reduce inflammation and LABA for bronchodilation.” Asthmatics should not be put on LABA alone, he said.

That only begins to explain how tricky proper diagnosis can be for primary care providers in the VA, particularly with the large number of patients who have both conditions.

“As many as 50% of older patients with obstructive airways disease have overlapping symptoms of COPD and asthma,” Foggs noted, so physicians must determine which condition is dominant. A thorough history helps, as does spirometry for confirmation.

“I see patients referred for COPD when they only have asthma — and the reverse. For primary care providers, learning to distinguish between them or to diagnose a patient with both requires formal training, focus and time — something often in short supply,” Foggs told U.S. Medicine.

There are a few features in a patient history that can aid diagnosis. Up to 90% of adult patients with asthma have allergies, and most will have had asthma since childhood. Nearly 90% of patients with COPD have a history of smoking.

spirometry photo

Spirometry testing at the Cincinnati VAMC, where physicians have pioneered a new program to offer the testing in community based clinics and then sending the results are electronically to lung experts for review. Photo courtesy of Cincinnati VAMC

That history of smoking makes COPD about four times more prevalent among veterans than in the general population, according to David Au, MD, investigator in the VA’s Northwest Center of Excellence and associate professor of medicine and pharmacy at the University of Washington in Seattle. The VA has 969,000 patients with COPD.

Recognizing that a patient has COPD instead of or in addition to asthma also has significant implications for patient health. About 26 million Americans have asthma, and the same number have COPD. While the numbers diagnosed are the same, the outcomes differ widely. “Nationwide, deaths from asthma are around 3,500, while 134,000 die from COPD each year,” Foggs noted.

Monotherapy or Combination

Current guidelines recommend starting patients with COPD on LABA monotherapy. If they need additional medication, a long-acting anticholinergic medication (LAMA) could be added. If the patient continues to have symptoms with that combination, a physician would add ICS.

As inhaled corticosteroids can also help patients with COPD during exacerbations, it may seem reasonable to always prescribe a LABA and ICS for a patient who has COPD. One of the characteristics of COPD, however, is a high level of mucus production. That, plus the older age at which most people develop COPD, increases the risk of pneumonia with most inhaled corticosteroids.

“Every time you put a patient with COPD on inhaled corticosteroids, you’re looking for pneumonia as a side effect. While not everyone will develop it, pneumonia’s always a risk for these patients. Inhaled corticosteroids don’t increase pneumonia in pure asthmatics,” Foggs said.

As a result of the increased risk of pneumonia, many physicians are reluctant to add inhaled corticosteroids unless absolutely necessary; but, recent research may change their thinking.

Canadian researchers reviewed data from 2003-2011 for 11,872 patients over age 66 with COPD and found that those initially prescribed a combination of LABA and ICS had lower rates of mortality and hospitalization for COPD than those started on LABA alone. 1

The overall improvement was modest, with 37.3% mortality for patients taking only LABAs, compared with 36.4% for those on the combination. Hospitalizations showed a similar difference, 30.1% for monotherapy and 27.8% for the combination.

Patients who had COPD and asthma benefitted the most. The combination therapy reduced the risk of hospitalization or death by 6.5% at five years.

Taking a long-acting anticholinergic reduced the effect of the combination. Those who had never taken an LAMA reduced their risk of death or hospitalization by 8.4% at five years.

The study showed the combination did not compound a patient’s risk of pneumonia or osteoporosis, compared to the side effects of the individual drugs.

“Our finding of an association between LABAs and ICSs and outcomes helps clarify the management of patients with COPD and asthma, as many studies of COPD medications have excluded people with asthma and vice versa,” wrote lead author Andrea Gershon, MD, of the Sunnybrook Health Sciences Centre and Institute for Clinical Evaluative Sciences, Toronto, and colleagues.

“Our findings also offer insight into the optimal treatment of COPD patients without asthma — those who would not be considered especially corticosteroid responsive,” concluded the authors.

Foggs noted that a therapy already exists that combines a LABA and ICS and another that has both LABA and LAMA elements. “In a few years we’ll have drugs with all three components, which will help patients with COPD who need sustainable bronchodilation with two mechanisms and need ICS to suppress inflammation.”

1 Gershon AS, Campitelli MA, Croxford R, Stanbrook MB, To T, Upshur R, Stephenson AL, Stukel TA. Combination long-acting β-agonists and inhaled corticosteroids compared with long-acting β-agonists alone in older adults with chronic obstructive pulmonary disease. JAMA. 2014 Sep 17;312(11):1114-21.