Asthma COPD overlap: Impact of associated comorbidities

De novo discovery of traits co-occurring with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of chronic lung conditions. Genome-wide association studies have identified single-nucleotide polymorphisms (SNPs) associated with COPD and the co-occurring conditions, suggesting common biological mechanisms underlying COPD and these co-occurring conditions. To identify them, we have integrated information across different biological levels (i.e., genetic variants, lung-specific 3D genome structure, gene expression and protein-protein interactions) to build lung-specific gene regulatory and protein-protein interaction networks. We have queried these networks using disease-associated SNPs for COPD, unipolar depression and coronary artery disease. COPD-associated SNPs can control genes involved in the regulation of lung or pulmonary function, asthma, brain region volumes, cortical surface area, depressed affect, neuroticism, Parkinson's disease, white matter microstructure and smoking behaviour. We describe the regulatory connections, genes and biochemical pathways that underlay these co-occurring trait-SNP-gene associations. Collectively, our findings provide new avenues for the investigation of the underlying biology and diverse clinical presentations of COPD. In so doing, we identify a collection of genetic variants and genes that may aid COPD patient stratification and treatment.

Fluticasone Furoate/Vilanterol Use Trends and Characteristics in Patients With Obstructive Airway Disease: A Real-World Study of 10,374 Patients From India

Introduction Obstructive Airway Diseases (OADs) are the leading cause of death among chronic respiratory diseases worldwide, and novel therapies are direly needed. Fluticasone furoate/vilanterol (FF/Vi) (100/25 µg) is the first once-daily ICS/uLABA marketed in India for COPD since 2021. Considering its limited real-world experience in OAD patients in Indian clinical settings, a large drug utilization study (DUS) was planned. Methodology We conducted a cross-sectional, observational DUS at 1900 outpatient clinics in India from October 2021 to March 2022. Prescription data and medical history of patients who were prescribed the FF/Vi combination were collected. Results It was observed that FF/Vi was prescribed in an almost equal number of patients with COPD (44.2%) and asthma (42.9%). The majority of the patients (74%) were switched from previous ICS/LABA to this ICS/uLABA, while 26% of patients were treatment naïve. The average CAT score was 19.5±7.8 (43.2% GOLD Group C and 32.2% GOLD Group B) in COPD patients, while the average ACQ-5 score was 2.6±1.3 (33.1% GINA Step 3, 29.5% GINA Step 2) in asthmatic patients. Most of the patients (63.9%) had raised biomarkers (Blood eosinophil count >300 cells/μl). Prior history of exacerbation was present in 65% of patients with annual exacerbation rates of 1.2 in COPD, 1.1 in asthma, and 1.2 in asthma-COPD overlap syndrome (ACOS). Leukotriene inhibitors (42%) and LAMAs (30.8%) were common add-on medications. Conclusion We observed a trend towards a shift to once-daily ICS/uLABA (FF/Vi) by physicians, especially in symptomatic and exacerbating OAD patients with underlying comorbidities.

Obstructive sleep apnea reduces functional capacity and impairs cardiac autonomic modulation during submaximal exercise in patients with chronic obstructive pulmonary disease: A follow-up study

BACKGROUND

Functional capacity and heart rate variability (HRV) are important prognostic markers in chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSA). However, the impact of the overlap of these diseases and the one-year clinical follow-up has not yet been evaluated.

OBJECTIVES

To assess whether the presence of OSA can impair functional performance and cardiac autonomic control during exercise in patients with COPD; and to verify whether the overlap of these diseases could lead to worse clinical outcomes during the one-year follow-up.

METHODS

Thirty-four patients underwent pulmonary function tests, echocardiography and polysomnography for diagnostic confirmation, disease staging, exclusion of any cardiac changes, and allocation between groups. The patients underwent the six-minute walk test (6MWT) to assess functional capacity and HRV during exercise. Subsequently, patients were followed up for 12 months to record outcomes such as exacerbation, hospitalization, and deaths. At the end of this period, the patients were revaluated to verify the hypotheses of the study.

RESULTS

The OSA-COPD group showed greater functional impairment when compared to the COPD group (p=0.003) and showed worse cardiac autonomic responses during the 6MWT with greater parasympathetic activation (p=0.03) and less complexity of the autonomic nervous system, in addition to being more likely to exacerbate (p=0.03) during one year of follow-up.

CONCLUSION

OSA-COPD produces deleterious effects on functional performance and a greater autonomic imbalance that impairs clinical outcomes.

Multi-ancestry meta-analysis of asthma identifies novel associations and highlights the value of increased power and diversity

Asthma is a complex disease that varies widely in prevalence across populations. The extent to which genetic variation contributes to these disparities is unclear, as the genetics underlying asthma have been investigated primarily in populations of European descent. As part of the Global Biobank Meta-analysis Initiative, we conducted a large-scale genome-wide association study of asthma (153,763 cases and 1,647,022 controls) via meta-analysis across 22 biobanks spanning multiple ancestries. We discovered 179 asthma-associated loci, 49 of which were not previously reported. Despite the wide range in asthma prevalence among biobanks, we found largely consistent genetic effects across biobanks and ancestries. The meta-analysis also improved polygenic risk prediction in non-European populations compared with previous studies. Additionally, we found considerable genetic overlap between age-of-onset subtypes and between asthma and comorbid diseases. Our work underscores the multi-factorial nature of asthma development and offers insight into its shared genetic architecture.

Pharmacologic Management Strategies of Asthma-Chronic Obstructive Pulmonary Disease Overlap

The best therapeutic approach to patients with asthma-chronic obstructive pulmonary disease overlap (ACO) is unknown. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents, because patients with ACO have been excluded from most clinical studies in asthma and COPD. Because of the underlying asthma initial therapy, early use of inhaled corticosteroids along with a long-acting bronchodilator is recommended. If maintenance inhaler therapy is not effective, advanced therapies based on phenotyping and identification of treatable traits may be considered.

Sleep-Related Breathing Complaints in Chronic Obstructive Pulmonary Disease

This review presents the normal physiologic changes in ventilation during sleep and how they can be detrimental to chronic obstructive pulmonary disease (COPD). Sleep-related breathing disorders (SRBDs) in COPD lead to higher morbidity and mortality if left unrecognized and untreated. The diagnosis of SRBDs requires a high index of suspicion, as symptoms may overlap with other sleep disorders. Mortality risk is improved when patients with COPD with OSA (overlap syndrome) are treated with positive airway pressure and when long-term nocturnal noninvasive ventilation is started on chronic stable hypercapnic COPD. Treatment of isolated nocturnal oxygen desaturation has not been associated with improved survival.

Biomarkers for Comorbidities Modulate the Activity of T-Cells in COPD

In smoking-induced chronic obstructive pulmonary disease (COPD), various comorbidities are linked to systemic inflammation and infection-induced exacerbations. The underlying mechanisms are unclear but might provide therapeutic targets. T-cell activity is central in systemic inflammation and for infection-defense mechanisms and might be influenced by comorbidities. Hypothesis: Circulating biomarkers of comorbidities modulate the activity of T-cells of the T-helper type 1 (Th1) and/or T-cytotoxic type 1 (Tc1). T-cells in peripheral blood mononuclear cells (PBMCs) from non-smokers (NS), current smokers without COPD (S), and COPD subjects (total n = 34) were ex vivo activated towards Th1/Tc1 and were then stimulated with biomarkers for metabolic and/or cardiovascular comorbidities (Brain Natriuretic Peptide, BNP; chemokine (C-C motif) ligand 18, CCL18; C-X3-C motif chemokine ligand 1, CX3CL1; interleukin-18, IL-18) or for asthma- and/or cancer-related comorbidities (CCL22; epidermal growth factor, EGF; IL-17; periostin) each at 10 or 50 ng/mL. The Th1/Tc1 activation markers interferon-γ (IFNγ), tumor necrosis factor-α (TNFα), and granulocyte-macrophage colony-stimulating factor (GM-CSF) were analyzed in culture supernatants by Enzyme-Linked Immunosorbent Assay (ELISA). Ex-vivo activation induced IFNγ and TNFα without differences between the groups but GM-CSF more in S vs. NS. At 10 ng/mL, the different biomarkers increased or reduced the T-cell activation markers without a clear trend for one direction in the different categories of comorbidities or for the different T-cell activation markers. At 50 ng/mL, there was a clear shift towards suppressive effects, particularly for the asthma— and cancer-related biomarkers and in cells of S and COPD. Comorbidities might suppress T-cell immunity in COPD. This could explain the association of comorbidities with frequent exacerbations.

Association between Obstructive Lung Disease and Cardiovascular Disease: Results from the Vermont Diabetes Information System

The association between obstructive lung disease and cardiovascular disease (CVD) has been suggested previously, but few studies have looked at this association in a diabetic cohort, a population highly susceptible to both comorbidities. A total of 1003 subjects in community practice settings were interviewed at home at the time of enrolment into the Vermont Diabetes Information System, a clinical decision support program. Patients self-reported their personal and clinical characteristics, including any obstructive lung disease. Laboratory data were obtained directly from the clinical laboratory. We performed a cross-sectional analysis of the interviewed subjects to assess a possible association between obstructive lung disease and CVD. In a multivariate logistic regression model, obstructive lung disease was significantly associated with CVD, even after correcting for potential confounders, including gender, obesity, low income, cigarette smoking, alcohol problems, and high comorbidity (odds ratio = 1.96; 95% confidence interval 1.37–2.81; p < 0.01). All components of CVD, including coronary artery disease (CAD), congestive heart failure (CHF), peripheral vascular disease (PVD), and cerebrovascular accidents (CVA), were also significantly associated with obstructive lung disease. These data suggest an association between obstructive lung disease and CVD in patients with diabetes. Future studies are needed to identify the mechanism supporting this association

Real-world effectiveness of mepolizumab in patients with severe asthma and associated comorbidities

BACKGROUND

Patients with severe asthma frequently have associated comorbidities, which can compound existing symptoms, complicating asthma management.

OBJECTIVE

To describe the real-world effectiveness of mepolizumab in patients with severe asthma stratified by common overlapping comorbidities.

METHODS

This was a retrospective analysis of patients with asthma from the MarketScan Commercial and Medicare Supplemental Database initiating mepolizumab treatment (index date). Eligible patients had more than or equal to 1 claim (excluding claims for diagnostic tests) with a diagnosis code for more than or equal to 1 of 7 comorbidities (atopic disease, nasal polyps, chronic sinusitis, obesity, respiratory infections, chronic obstructive pulmonary disease, and depression/anxiety) during the 12-month preindex baseline period; these were used to stratify patients into 7 nonmutually exclusive subgroups. Outcomes included asthma exacerbations and exacerbation-related health care resource utilization during the 12-month baseline and follow-up periods. Each patient acted as their own control.

RESULTS

Of the 639 patients included, the most common comorbidities were atopic diseases (73.2%), respiratory infections (55.6%), and chronic sinusitis (45.1%). Across all 7 comorbidity subgroups, there were significant (P < .05) reductions of 38% to 55% and 57% to 83% in exacerbations and exacerbations requiring hospitalization, respectively, during the follow-up vs baseline period, except for exacerbations requiring hospitalization in the nasal polyp subgroup, owing to the small subgroup sample size. During the follow-up vs baseline periods, mean number of oral corticosteroids claims was significantly (P < .001) reduced by 29% to 38%; 39% to 47% of patients achieved greater than or equal to 50% oral corticosteroids dose reduction. Significant reductions in exacerbation-related health care resource utilization were also observed.

CONCLUSION

Mepolizumab treatment provided real-world clinical benefits in patients.

Prevalence, socio-demographic and environmental determinants of asthma in 4621 Ghanaian adults: Evidence from Wave 2 of the World Health Organization's study on global AGEing and adult health

Background

A previous multi-site study involving lower- and middle-income countries demonstrated that asthma in older adults is associated with long-term exposure to particulate matter, male gender and smoking. However, variations may occur within individual countries, which are relevant to inform health promoting policies as populations live longer. The present study estimates asthma prevalence and examines the sociodemographic characteristics and environmental determinants associated with asthma in older adults in Ghana.

Methods

This study utilised data from the nationally representative World Health Organization Study on global AGEing and adult health (SAGE) Ghana Wave 2. A final sample of 4621 individuals residing in 3970 households was used in analytical modelling. Factors associated with asthma were investigated using single level and multilevel binary logistic regression models.

Results

Asthma was reported by 102 (2.2%) respondents. Factors associated with asthma in the univariate model were: those aged 60–69 (OR = 5.22, 95% CI: 1.24, 21.95) and 70 or more (OR = 5.56, 95% CI: 1.33, 23.26) years, Ga-Adangbe dialect group (OR = 1.65, 95% CI: 1.01, 2.71), no religion (OR = 3.59, 95% CI: 1.77, 7.28), having moderate (OR = 1.76, 95% CI: 1.13, 2.75) and bad/very bad (OR = 2.75, 95% CI: 1.58, 4.80) health state, and severe/extreme difficulty with self-care (OR = 3.49, 95% CI: 1.23, 9.88) and non-flush toilet facility (OR = 0.62, 95% CI: 0.39, 0.99). Factors independently associated with asthma in the adjusted models were: those aged 60–69 (OR = 4.49, 95% CI: 1.03, 19.55) years, father with primary education or less (OR = 0.40, 95% CI: 0.17, 0.94), no religion (OR = 2.52, 95% CI: 1.18, 5.41), and households with non-flush toilet facility (OR = 0.58, 95% CI: 0.35, 0.96). Significant residual household-level variation in asthma was observed. Over 40% of variance in asthma episodes could be attributable to residual household-level variations.

Conclusion

Individual as well as household factors were seen to influence the prevalence of asthma in this national survey. Clinical management of these patients in health facilities should consider household factors in addition to individual level factors.

COPD Comorbidities Predict High Mortality - Asthma-COPD-Overlap Has Better Prognosis

The purpose of this study was to investigate the characteristics and survival of patients with COPD and asthma-COPD overlap (ACO) and how these patient groups differ from each other. We examined the impact of different comorbidities, multimorbidity, lung function and other factors have on survival in COPD and ACO patients. We also examined the causes of death to determine how many patients die of other than respiratory diseases. This retrospective study includes 214 patients with an exacerbation of COPD requiring hospitalisation during the year of 2005. The patients were followed up until the end of year 2015. The survival of ACO patients was significantly higher than COPD patients (4.7 vs. 1.7 years, p = 0.001). Poor lung function predicted worse survival in both patient groups, but the prognosis was still better in ACO patients with both FEV1 over and under 50% of predicted (median survival 8.4 years vs. 5.8 years, p < 0.001) compared to COPD (4.9 and 3.1 years, respectively). In this study setting, the negative effect of having three or more comorbidities on survival was significant in both groups. We didn't see major differences in the profiles of comorbidity patterns, in the underlying cause of deaths or in the pulmonary functions between ACO and COPD groups at the beginning of follow-up. Patients with a BMI over 25 seemed to have a trend for better survival (p = 0.055), but no differences were found between ACO and COPD groups.

DYNAMICS OF FUNCTIONAL CONDITION AND QUALITY OF LIFE IN PATIENTS WITH ASTHMA-COPD OVERLAP AND CONCOMITANT ARTERIAL HYPERTENSION AGAINST THE BACKGROUND OF COMPLEX THERAPY

Patients with ACO have significant poorer health-related quality of life and more severe functional limitations compared to asthma and COPD alone. Most commonly, chronic respiratory disease is associated with cardiovascular disease, such as arterial hypertension. However, the impact of concomitant cardiac diseases on the quality of life and functional status of patients with ACO remains poorly understood. The aim of the work was to study dynamics of functional condition and quality of life in with ACO and concomitant AH against the background of complex therapy. Materials and methods. We selected for participating in the study 100 patients with ACO and concomitant AH. Examination of the patients included: clinical methods, spirometry, and questinaries – mMRS, CAT, SGRQ, performing 6MWT. Results. After 16 weeks of treatment there were no changes in lung functional status in patients on standard treatment, at the same time, in group of patients who had an active rehabilitation program, there was a significant improvement in the bronchial response to the action of bronchodilators, although other indicators of the functional status of the lungs didn't show significant changes. Patients who additionally used an active rehabilitation program had a significant improvement in clinical symptoms, shortness of breath, and quality of life according to CAT, mMRC, and SGRQ scores, respectively. There was also a significant increase in distance during the 6MWT in this group of patients. Conclusions. Conducting an active rehabilitation program (physical rehabilitation in combination with an educational program and self-management) in group of patients with ACO and concomitant AH, who are on standard medical treatment, significantly improves the bronchial response to the action of bronchodilators, decreases clinical manifestations, shortness of breath and improve quality of life and exercise tolerance, according to CAT, mMRC, SGRQ and 6MWT questionnaires, respectively.

The many faces of asthma-chronic obstructive pulmonary disease overlap

PURPOSE OF REVIEW

Asthma and chronic obstructive pulmonary disease (COPD) are common diseases that often overlap. The term asthma-COPD overlap (ACO) has been used to define this entity but there remain several speculations on its exact definition, impact, pathophysiology, clinical features, and management. We reviewed recent publications on ACO to obtain more insight of current knowledge and outline future needs.

RECENT FINDINGS

Criteria for ACO vary from one publication to another and the many variable features of these patients underline the need to reconsider the evaluation and approach of patients with overlapping features based on clinical traits and underlying biological mechanisms. Epidemiological studies reveal that ACO patients have generally an increased burden of illness and healthcare use in addition to poorer quality of life (QoL) compared with asthma and higher or equal to COPD. However, their long-term outcome seems better than patients with COPD alone. Various methods have been proposed to evaluate these patients but their usefulness compared to 'classical' investigation of obstructive lung diseases remains speculative and needs further evaluation. Furthermore, there are no formal studies that examined and compared the different treatment strategies of well-characterized patients with ACO as such patients are usually excluded from clinical trials.

SUMMARY

ACO is a common condition with variable features and a high burden of disease. There is no consensus on its definition, diagnostic, and clinical features and more research should be done on its optimal management and long-term outcomes.

Management of asthma COPD overlap

OBJECTIVE

To review the latest literature on management approaches to patients with asthma chronic obstructive pulmonary disease (COPD) overlap (ACO).

DATA SOURCES

Studies and reports were identified from the databases of PubMed/Medline and ClinicalTrials.gov from the US National Institutes of Health and the Cochrane Register of Controlled Trials.

STUDY SELECTIONS

Studies on the management of asthma, COPD, and ACO were included in this review.

RESULTS

Patients with asthma COPD overlap tend to have greater morbidity than those with asthma or COPD alone, but the information on the best therapeutic approach to this group of patients is still limited. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents, because most clinical studies in asthma and COPD have excluded patients with ACO. Because of the potential risk described in patients with asthma with the use of long-acting 2 agonist monotherapy, initial therapy for patients with ACO is recommended to include a long-acting bronchodilator in conjunction with inhaled corticosteroids. Long-acting muscarinic antagonists are effective in both asthma and COPD and should be considered in ACO as an add-on treatment. If inhaler therapy is not effective, advanced therapies based on phenotyping and identification of treatable traits may be considered.

CONCLUSION

Few studies have evaluated prospectively therapies in the ACO population, and future studies need to determine best strategies for the treatment of these patients, focusing on targeting its different phenotypes and its treatable traits.

Rinsing of oropharynx and storage place of respiratory medicine inhaler: A cross-sectional audit

BACKGROUND

In patients with bronchial asthma and those with chronic obstructive pulmonary disease (COPD), inhalation therapy and rinsing of the mouth and the oropharynx by gargling ("RMOG") after inhalation are recommended. We performed a cross-sectional audit aimed at investigating (a) the proportion of patients performing "RMOG" after inhalation and (b) storage place of patients' inhaler.

METHODS

Patients with bronchial asthma and those with COPD were asked by medical aids at outpatient visits whether they did "RMOG every time," "RMOG sometimes," or "no RMOG" after inhalation, and where they stored their inhaler.

RESULTS

During a six month study period up to September 2017, 330 consecutive patients with asthma and those with COPD were included in the study. Two hundred and thirty-two (70.3%) of the 330 patients answered "RMOG every time" and 98 (29.7%) of them did "RMOG sometimes" and did "no RMOG." There was a difference in the proportion of patients performing RMOG after inhalation with patient age. With regard to the storage location of inhaler, we found the proportion of patients performing RMOG was higher in those who stored inhalers in a room with running water than in those who stored inhalers at other places. This difference was found in patients with both bronchial asthma and those with COPD.

CONCLUSIONS

Further implementation of "patient education" on performing RMOG after inhalation for patients receiving inhaled medication is still necessary. Our results suggest that it is better to store inhalers in places where there is easy access to tap water used for RMOG.

Differences in the risk of mood disorders in patients with asthma-COPD overlap and in patients with COPD alone: a nationwide population-based retrospective cohort study in Korea

BACKGROUND

Although feelings of anxiety and depression are common in patients with chronic obstructive pulmonary disease (COPD), little is known about the estimates of their incidence in patients with asthma-COPD overlap (ACO), which has been described and acknowledged as a distinct clinical entity. We aimed to estimate the risk of depression and anxiety among patients with ACO and compare it with the risk among those with COPD alone in the general population.

METHODS

We conducted a nationwide population-based retrospective cohort study using the Korean National Sample Cohort database between 1 January, 2002, and 31 December, 2013. Patients who were diagnosed with COPD (International Classification of Diseases, 10th revision [ICD-10] codes J42-J44) at least twice and prescribed COPD medications at least once between 2003 and 2011 were classified into two categories: patients who were diagnosed with asthma (ICD-10 codes J45-J46) more than twice and at least once prescribed asthma medications comprised the ACO group, and the remaining COPD patients comprised the COPD alone group. Patients who had been diagnosed with depression or anxiety within a year before the index date were excluded. We defined the outcome as time to first diagnosis with depression and anxiety. Matched Cox regression models were used to compare the risk of depression and anxiety among patients with ACO and patients with COPD alone after propensity score matching with a 1:1 ratio.

RESULTS

After propensity score estimation and matching in a 1:1 ratio, the cohort used in the analysis included 15,644 patients. The risk of depression during the entire study period was higher for patients with ACO than for patients with COPD alone (adjusted hazard ratio, 1.10; 95% confidence interval, 1.03-1.18; P value = 0.0039), with an elevated risk in patients aged 40-64 years (1.21; 1.10-1.34; 0.0001) and in women (1.18; 1.07-1.29; 0.0005). The risk of anxiety was higher for patients with ACO than for patients with COPD alone (1.06; 1.01-1.12; 0.0272), with a higher risk in patients aged 40-64 years (1.08; 1.00-1.17; 0.0392); however, the risk was not significant when stratified by sex.

CONCLUSIONS

This population-based study revealed a higher incidence of depression and anxiety in patients with ACO than in patients with COPD alone.

A Propensity Score-Matched Analysis of Laparoscopic versus Open Surgery in Patients with COPD

Purpose: This study aims to compare outcomes of laparoscopic surgery to the outcomes of open surgery in patients with chronic obstructive pulmonary disease (COPD). Plethora of studies compares laparoscopic and open surgery in the general population; however, there is a paucity of existing literature examining the optimal surgical techniques in the COPD population. Materials and Methods: A propensity score-matched analysis using the 2012-2015 National Inpatient Sample (NIS) was conducted to match COPD patients undergoing the most common laparoscopic procedures to COPD patients undergoing the same procedures through an open approach. A multivariate logistic regression model was used to assess mortality and complications, and a multivariate linear regression model was used to compare the length of stay and total cost between open and laparoscopic surgery groups in COPD patients. Results: In general, open surgeries in COPD patients had worse outcomes than laparoscopic surgeries. Laparoscopic cholecystectomies were 45% less likely, colectomies were 58% less likely, and diagnostic procedures were 44% less likely to result in mortality than their open counterparts. All surgical cohorts except incisional hernia repairs had higher complication rates with an open approach. Aggregate complication rate reduction among procedures ranged between 29% and 65%. Total costs were higher in all open surgical cohorts except for appendectomies ($3,424-8,455). All open surgeries were associated with a longer length of stay, ranging from an extra day to 3 days, depending on surgery type. Conclusions: Laparoscopic surgery should not be considered a contraindication in patients with COPD. Careful consideration of surgical technique can have significant implications on patient outcomes and hospital costs in the COPD population.