A new alphabet for COPD care: where “E” stands for España

From the author:

In their correspondence, R.P. Young and R.J. Hopkins helpfully identify the Spanish guidelines [1] for chronic obstructive pulmonary disease (COPD) which, along with a later publication [2], have helped specify key subgroups of COPD (marked by high eosinophil count, personal history of asthma or atopy, or positive IgE or skin tests) who potentially have an asthma–COPD overlap syndrome (ACOS) component benefiting from inhaled corticosteroid (ICS)/long-acting β-agonist (LABA) combinations. Not so helpful in profiling ACOS patients are forced expiratory volume in 1 s reversibility criteria, since up to 50% of all COPD patients may reverse over 12% and 200 mL after bronchodilator use [3–5].

There is a need to better define and prospectively study ACOS. For now, post hoc analyses of completed COPD studies have begun to confirm that ICS therapies can benefit COPD subgroups with high eosinophil counts and exacerbation risks [6]. Other subgroups with strong potential to benefit from ICS include COPD patients with a history of atopic disease, onset before age 40, and patients with positive IgE or skin test history.

Guidelines need to be transparent and provide clear therapeutic direction in the fashion of a road traffic signal: green, yellow, or red. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) A, B, C and D classes do not clearly identify “ICS-needy” patients. Instead, all categories of GOLD patients utilise ICS/LABA combinations and this can be like looking at a traffic light through fog. While Young and Hopkins appropriately identify several ACOS risk factors, and stress escalation of therapies when needed, they still leave a muddle where GOLD A, B, C and D groups all contain “ICS-needy” patients.

The proposed “E” group (including three subgroups with frequent exacerbations, high eosinophil counts, or IgE–asthma components) would help to clear the fog and direct clinicians to utilise ICS/LABA and ICS/LABA + long-acting muscarinic antagonist (LAMA) combinations for this new “E” group where patients are most likely to benefit. Remaining GOLD A, B, C and D patients may thrive with LAMA/LABA bronchodilator combinations. In the future, more specific pathophysiologic ACOS biomarkers (such as IL4, IL5, IL13, IL33, TSLP, periostin and others) may help to better identify ACOS and direct therapies to specific phenotypic subgroups in the totality of patients with COPD.

Disclosures