Asthma as a Risk Factor for COPD: Early Lung Disease, Adult COPD and How to Educate Patients
Not long ago, doctors were taught that asthma and COPD were two distinctly separate diseases. Then they began to notice that some of their patients had a more confusing clinical presentation: COPD patients had asthma-like features and vice versa. These early observations were on to something, but only recently have studies confirmed the presence of asthma-COPD overlap syndrome. It’s imperative for pharmacists to become familiar with the criteria for this new syndrome so they can monitor potentially conflicting medications and provide counseling to improve medication adherence.
Asthma, COPD and How They Overlap
Asthma and chronic obstructive pulmonary disease (COPD) share similar symptoms and comorbidities. With its progressive clinical decline, COPD is more deadly, ranking as the third leading cause of death in the United States, yet both diseases affect millions of Americans—32 million have COPD and 23 million are diagnosed with asthma. However, several defining characteristics set them apart:
Asthma: Diagnosed in childhood – reversible airway obstruction – exacerbated by allergens.
COPD: Onset after the age of 40 – irreversible airway obstruction – exacerbated by respiratory illness – primarily in people with a history of smoking.
In spite of these differences, experts in the pulmonary field have spent years debating whether the two diseases are always so distinct. Now the answer is clear—they’re not. The CHAIN study published in January 2016 verified asthma-COPD overlap syndrome (ACOS). Patients with COPD have ACOS if they meet one major criterion or two minor criteria.1
- Bronchodilator response greater than 400 mL and 15 percent
- Past history of asthma
- Blood eosinophils greater than 5 percent
- Immunoglobulin E greater than 100 IU/mL
- Two separate bronchodilator tests with response greater than 200 mL and 12 percent
In the CHAIN cohort of 831 patients with COPD, 15 percent met the criteria for ACOS, and 98 percent sustained the criteria after one year. And this isn’t the only research supporting a connection between asthma and COPD. It turns out that persistent childhood asthma predicts an increased risk of developing COPD, according to the Childhood Asthma Management Program (CAMP).
For the CAMP study, researchers recruited 684 children between the ages of 5 to 12. The children—diagnosed with persistent asthma—reported to a study center for lung function tests every year until they were 23 years old. At the end of the study, 11 percent were diagnosed with chronic obstructive pulmonary disease (COPD), and 75 percent had an early decline in lung function and/or reduced lung growth, reported the New England Journal of Medicine in May 2016.2 The most important takeaway from the study is the need to target at-risk children and teach them about preventive measures, such as avoiding cigarettes.
Complex Treatment Decisions for ACOS
Pharmacologic treatments for patients with asthma and COPD are well established, but individualized therapy takes on new significance when clinicians must determine the best therapy for patients with ACOS. It only takes a few examples to highlight the complexity of treatment decisions when patients present with an overlap of asthma and COPD:
- Inhaled corticosteroids (ICS) are used for long-term control of asthma, but they’re only recommended for patients with COPD when they reach stage C and must control acute exacerbations, according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines.3
- Overuse of ICS is associated with pneumonia in patients with COPD.
- GOLD recommends long-acting beta-agonists (LABA) as an alternative therapy for certain patients with COPD, yet LABA without inhaled corticosteroids may increase mortality in patients with asthma.
- To date, no one knows if LABA monotherapy is safe for patients with ACOS.
The bottom line is this: an estimated 10 to 20 percent of asthma patients have features of COPD, while about 10 to 20 percent of those with COPD have features of asthma.4 While physicians must untangle the clinical symptoms, pharmacists’ expertise can help guide medication choices in this group of patients.
Using Medication Therapy Management to Educate Patients
The first step for pharmacists is understanding the differences between asthma, COPD, and ACOS. You can then use medication therapy management (MTM) as the pathway to educate patients about prevention and to monitor long-term management:
- Create a healthcare team: The emphasis in today’s value-based healthcare system is on using teams to manage outpatient care—an approach that works well with chronic pulmonary diseases. You may need to reach out to physicians to form a collaborative partnership, but as physicians and insurance providers must report quality measures, they’re motivated to build teams and find ways to reimburse pharmacists.
- Assess for ACOS: As a member of the team, you’ll probably have access to lab reports, so don’t hesitate to review for overlapping symptoms. Even without lab tests, ask patients about their symptoms and verify their medical history for hints of possible ACOS.
- Teach proper inhaler use: More than half of patients with COPD use improper inhaler techniques. 5 It’s important to demonstrate each step—emphasizing whether the inhaler should be shaken and whether to breathe in slowly or quickly.
- Set-up automatic refills: It’s essential for patients to get timely refills so they always have a supply of medication.
- Review medications: The heart of MTM is reviewing medications to ensure the best therapy and proper dose, but be sure to take advantage of this time to screen for adherence. Patients who engage in MTM have better adherence—keep track of their improvement because adherence is a triple-weighted item on CMS quality measures and subsequent Star Ratings.6 Also, review for medications that may not be appropriate for overlapping asthma and COPD.
- Vaccinations: Pharmacists should recommend and consider providing influenza and pneumococcal vaccinations to patients with pulmonary disease.
- Smoking cessation: Patients who smoke should stop to improve their prognosis. Don’t forget to talk with parents of asthmatic children—warn them that second-hand smoke will increase the chance of their child’s asthma progressing to COPD. Be prepared to refer them to a local smoking cessation program.
Improve the Prognosis Through Pharmacist Outreach
It sounds simple—exacerbations decrease, hospitalizations go down and longevity improves when patients are on the best regimen and actually stick with the plan. Unfortunately, many patients aren’t compliant and continue to engage in habits that aggravate pulmonary disease. Pharmacists can use MTM to discuss risk factors, promote adherence, and target patients with complex, overlapping diseases. In the end, it all boils down to one simple statement—your role is vital.
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- “Defining the Asthma-COPD Overlap Syndrome in a COPD Cohort,” January 2016, http://www.ncbi.nlm.nih.gov/pubmed/26291753 ↩
- “Patterns of Growth and Decline in Lung Function in Persistent Childhood Asthma,” May 2016, http://www.nejm.org/doi/10.1056/NEJMoa1513737 ↩
- “The GOLD Guidelines and COPD Treatment,” July 2016, http://drugtopics.modernmedicine.com/drug-topics/news/gold-guidelines-and-copd-treatment-0 ↩
- “Asthma vs COPD: What’s the Difference?” February 2016, http://www.medscape.com/viewarticle/858840 ↩
- “A Pharmacist’s Role in the Management of Chronic Obstructive Pulmonary Disease,” July 2016, https://www.uspharmacist.com/article/a-pharmacists-role-in-the-management-of-chronic-obstructive-pulmonary-disease ↩
- “MTM Essentials for COPD Management, Part 2,” July 2015, http://drugtopics.modernmedicine.com/sites/default/files/images/DrugTopics/UCONN/drtp0715_CE.pdf ↩