Good definitions, research lacking for COPD-asthma overlap

 

ORLANDO – Experts agreed that asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome, referred to as ACOS, is an area in dire need of more careful study to give clinicians data they can actually use.

The topic is even more pressing given the growing interest and research into biological treatments for asthma and consideration of their possible use in COPD, experts said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization. Their remarks came in what was ostensibly a “debate” on whether ACOS is a distinct entity requiring special treatment but largely turned into a discussion about gaps in knowledge on the topic.

The dilemma, they said, is that the research tends to look almost exclusively at extreme cases, with asthma studies excluding COPD patients and COPD studies excluding asthma patients.

“The problem here is that it has not been defined in a way that everyone agrees on – that does create a problem because, if there’s no consensus on the diagnostic criteria, then it may be difficult to study this overlap,” said Donald Tashkin, MD, director of the pulmonary function laboratories at the University of California, Los Angeles. “Because there is no agreement on how to diagnose ACOS, it hasn’t been studied with respect to its responsiveness to different treatment options.”R. Stokes Peebles Jr., MD, professor of allergy, pulmonary, and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., said that, although the number of published articles on ACOS has skyrocketed over the last several years, review articles have outnumbered original research articles.

 

There is disagreement in published definitions: One set of definitions includes a criterion of fractional exhaled nitric oxide not seen in any other definitions, whereas some other definitions require a history of smoking while others don’t, he said.

“How does one manage a disease without a definition and without clinical studies? It’s impossible for me to know,” Dr. Peebles said.

A commentary piece published in 2016, he noted, called for the term ACOS to be “abandoned” and then replaced when new phenotypes and underlying subtypes are identified and when “a new taxonomy of airway diseases is generated.” Dr. Peebles said he agreed with this suggestion.

Jeffrey Drazen, MD, the Distinguished Parker B. Francis Professor of Medicine at Harvard Medical School, Boston, and the editor of the New England Journal of Medicine, also lamented the polar nature of the research.

 

“We all treat patients in the middle, everybody does, all the time – and we would love more guidance,” he said. “One of the reasons the number of articles has gone up is that there have been lots of case definitions. But we can’t get consensus. So who do we have to bring to the table to get a consensus definition so we can get the funding we need from the drug companies or governmental bodies to do the research that we all want?”

Dr. Tashkin said the way forward could be to draw on the points of consensus that do exist on certain criteria.

Dr. Peebles said an international panel is needed to draw up a consensus guideline, with the panel including both pulmonologists and allergists – “people experienced with clinical trials, who take care of a lot of patients.”

 

ORLANDO – Experts agreed that asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome, referred to as ACOS, is an area in dire need of more careful study to give clinicians data they can actually use.

The topic is even more pressing given the growing interest and research into biological treatments for asthma and consideration of their possible use in COPD, experts said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization. Their remarks came in what was ostensibly a “debate” on whether ACOS is a distinct entity requiring special treatment but largely turned into a discussion about gaps in knowledge on the topic.

The dilemma, they said, is that the research tends to look almost exclusively at extreme cases, with asthma studies excluding COPD patients and COPD studies excluding asthma patients.

“The problem here is that it has not been defined in a way that everyone agrees on – that does create a problem because, if there’s no consensus on the diagnostic criteria, then it may be difficult to study this overlap,” said Donald Tashkin, MD, director of the pulmonary function laboratories at the University of California, Los Angeles. “Because there is no agreement on how to diagnose ACOS, it hasn’t been studied with respect to its responsiveness to different treatment options.”R. Stokes Peebles Jr., MD, professor of allergy, pulmonary, and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., said that, although the number of published articles on ACOS has skyrocketed over the last several years, review articles have outnumbered original research articles.

 

There is disagreement in published definitions: One set of definitions includes a criterion of fractional exhaled nitric oxide not seen in any other definitions, whereas some other definitions require a history of smoking while others don’t, he said.

“How does one manage a disease without a definition and without clinical studies? It’s impossible for me to know,” Dr. Peebles said.

A commentary piece published in 2016, he noted, called for the term ACOS to be “abandoned” and then replaced when new phenotypes and underlying subtypes are identified and when “a new taxonomy of airway diseases is generated.” Dr. Peebles said he agreed with this suggestion.

Jeffrey Drazen, MD, the Distinguished Parker B. Francis Professor of Medicine at Harvard Medical School, Boston, and the editor of the New England Journal of Medicine, also lamented the polar nature of the research.

 

“We all treat patients in the middle, everybody does, all the time – and we would love more guidance,” he said. “One of the reasons the number of articles has gone up is that there have been lots of case definitions. But we can’t get consensus. So who do we have to bring to the table to get a consensus definition so we can get the funding we need from the drug companies or governmental bodies to do the research that we all want?”

Dr. Tashkin said the way forward could be to draw on the points of consensus that do exist on certain criteria.

Dr. Peebles said an international panel is needed to draw up a consensus guideline, with the panel including both pulmonologists and allergists – “people experienced with clinical trials, who take care of a lot of patients.”

 

ORLANDO – Experts agreed that asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome, referred to as ACOS, is an area in dire need of more careful study to give clinicians data they can actually use.

The topic is even more pressing given the growing interest and research into biological treatments for asthma and consideration of their possible use in COPD, experts said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization. Their remarks came in what was ostensibly a “debate” on whether ACOS is a distinct entity requiring special treatment but largely turned into a discussion about gaps in knowledge on the topic.

The dilemma, they said, is that the research tends to look almost exclusively at extreme cases, with asthma studies excluding COPD patients and COPD studies excluding asthma patients.

“The problem here is that it has not been defined in a way that everyone agrees on – that does create a problem because, if there’s no consensus on the diagnostic criteria, then it may be difficult to study this overlap,” said Donald Tashkin, MD, director of the pulmonary function laboratories at the University of California, Los Angeles. “Because there is no agreement on how to diagnose ACOS, it hasn’t been studied with respect to its responsiveness to different treatment options.”R. Stokes Peebles Jr., MD, professor of allergy, pulmonary, and critical care medicine at Vanderbilt University Medical Center, Nashville, Tenn., said that, although the number of published articles on ACOS has skyrocketed over the last several years, review articles have outnumbered original research articles.

 

There is disagreement in published definitions: One set of definitions includes a criterion of fractional exhaled nitric oxide not seen in any other definitions, whereas some other definitions require a history of smoking while others don’t, he said.

“How does one manage a disease without a definition and without clinical studies? It’s impossible for me to know,” Dr. Peebles said.

A commentary piece published in 2016, he noted, called for the term ACOS to be “abandoned” and then replaced when new phenotypes and underlying subtypes are identified and when “a new taxonomy of airway diseases is generated.” Dr. Peebles said he agreed with this suggestion.

Jeffrey Drazen, MD, the Distinguished Parker B. Francis Professor of Medicine at Harvard Medical School, Boston, and the editor of the New England Journal of Medicine, also lamented the polar nature of the research.

 

“We all treat patients in the middle, everybody does, all the time – and we would love more guidance,” he said. “One of the reasons the number of articles has gone up is that there have been lots of case definitions. But we can’t get consensus. So who do we have to bring to the table to get a consensus definition so we can get the funding we need from the drug companies or governmental bodies to do the research that we all want?”

Dr. Tashkin said the way forward could be to draw on the points of consensus that do exist on certain criteria.

Dr. Peebles said an international panel is needed to draw up a consensus guideline, with the panel including both pulmonologists and allergists – “people experienced with clinical trials, who take care of a lot of patients.”