Practical approach to ACOS

Yasutaka Nakano, M.D., Ph.D.

Faculty/Presenter Disclosure

Faculty: Yasutaka Nakano

Relationships with commercial interests:

– Speakers Bureau/Honoraria: NBI

– Consulting Fees: Olympus

64-year-old Korean male (1)

3-year history of exertional shortness of

breath (mMRC 3)

current smoker with a 60 pack-year history

medical history of asthma since childhood

cough, sputum, and dyspnea

intermittent episodes of shortness of breath

with wheezing at night

Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,

Respirol Case Rep. 2015 Oct 8;3(4):119-21.

64-year-old Korean male (2)

mild fattening of the diaphragms

Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,

Respirol Case Rep. 2015 Oct 8;3(4):119-21.

64-year-old Korean male (3)

blood eosinophil count: 429/μL (6.6%)

total IgE level: 1089 U/mL

positive skin prick tests:

– Dermatophagoides pteronyssinus

– Cockroach

– Lepidoglyphus destructor

Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,

Respirol Case Rep. 2015 Oct 8;3(4):119-21.

64-year-old Korean male (4)

Lee H, Tho NV, Nakano Y, Lee B-J, Park HY,

Respirol Case Rep. 2015 Oct 8;3(4):119-21.

64-year-old Korean male (5)

Does this patient have

Asthma?

COPD?

Asthma COPD overlap syndrome

Patient with asthma

– who smokes

– may also have COPD

Patient with COPD

– may also have asthma

Asthma COPD

sm

oke

r

asth

ma

Asthma

sm

oke

r

COPDasth

ma

Asthma COPD Overlap Syndrome

sm

oker

AC

OS

When should we consider ACOS in asthma?

Persistent airflow limitation

(FEV1/FVC < 0.7)

Smoking history

When should we consider ACOS in COPD?

Diagnosis of asthma before 40 years of age

BDR of 400 mL or more

History of allergic rhinitis or atopy

Elevated serum IgE

Elevated peripheral eosinophil count

(e.g., >400/μL)

DD Sin. Tuberc Respir Dis 2017; 80: 11-20

GINA/GOLD definition of ACOS

Asthma COPD

Age of onset □Before age 20 years □After age 40 years

Pattern of symptoms □Variation over minutes,

hours or days

□Worse during the night

or early morning

□Triggered by exercise,

emotions including

laughter, dust or exposure

to allergens

□Persistent despite

treatment

□Good and bad days but

always daily symptoms

and exertional dyspnea

□Chronic cough &

sputum preceded onset of

dyspnea, unrelated to

triggers

Lung function □Record of variable

airflow limitation

(spirometry or peakflow)

□Record of persistent

airflow limitation

(FEV1/FVC<0.7 post BD)

Lung function between

symptoms

□Normal □Abnormal

GINA/GOLD definition of ACOS (cont.)

Asthma COPD

Past history or family

history

□Previous doctor

diagnosed asthma

□Family history of

asthma and other allergic

conditions (allergic rhinitis

or eczema)

□Previous doctor

diagnosed COPD, chronic

bronchitis or emphysema

□Heavy exposure to risk

factor: tobacco smoke,

biomass fuels

Time course □No worsening of

symptoms over time.

□Variation of symptoms

either seasonally, or from

year to year

□Symptoms slowly

worsening over time

(progressive course over

years)

□Rapid acting

bronchodilator treatment

provides only limited relief

Chest X-ray □Normal □Severe hyperinflation

GINA/GOLD: Asthma COPD and ACOS, 2015.

SEPAR definition of ACOS (1)

Of patients with persistent airflow limitation

(FEV1/FVC < 0.7)

One major criterion or two minor criteria

Major criteria

– Previous history of asthma

– Bronchodilator response to salbutamol > 15%

and 400mL

Soler-Cataluna JJ, et al. Arch Bronconeumol 2012;48:331-7

SEPAR: Spanish Society of Pulmonology and Thoracic Surgery)

SEPAR definition of ACOS (2)

Of patients with persistent airflow limitation

(FEV1/FVC < 0.7)

One major criterion or two minor criteria

Minor criteria

– IgE > 100 IU or history of atopy

– Bronchodilator response to salbutamol of >

12% and 200 mL at least two separate

occasions or blood eosinophilia > 5%

Soler-Cataluna JJ, et al. Arch Bronconeumol 2012;48:331-7

Diagnosis of ACOS in patients with asthma

Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.

Diagnosis of ACOS in patients with asthma

Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.

Diagnosis of ACOS in patients with asthma

Tho, Park, Nakano. Respirology 2016 Apr;21(3):410-8.

Definition of ACOS from ATS Roundtable Discussions

Three major + One minor criteria

Major criteria1. Persistent airflow limitation (post-bronchodilator

FEV1/FVC <0.70 or LLN) in individuals 40 years of

age or older; LLN is preferred

2. At least 10 pack-years of tobacco smoking

OR

Equivalent indoor or outdoor air pollution exposure (e.g.

biomass)

3. Documented history of asthma before 40 years of age

OR

BDR of >400 mL in FEV1Sin, Nakano, Park et al. ERJ 2016;48:664-73

Definition of ACOS from ATS Roundtable Discussions

Three major + One minor criteria

Minor criteria

1. Documented history of atopy or allergic rhinitis

2. BDR of FEV1 ≥200 mL and 12% from baseline

values on 2 or more visits

3. Peripheral blood eosinophil count of ≥300

cells/μL

Sin, Nakano, Park et al. ERJ 2016;48:664-73

Japanese ACOS perspective

Major criteria

– Persistent airflow limitation

– At least 10 pack-years of tobacco smoking

– History of asthma

Minor criteria

– History of atopy or allergic rhinitis

– FeNO > 40 ppb

– BDR of FEV1 ≥200 mL and 12% from baseline values

on 2 or more visits

– Peripheral blood eosinophil count of ≥300

cells/μL

Key exclusion criteria of COPD trials

Sin, Nakano, Park et al. ERJ 2016;48:664-73

Key exclusion criteria of asthma trials

Sin, Nakano, Park et al. ERJ 2016;48:664-73

Treatment of ACOS

Smoking cessation

Rehabilitaion

Vactination

Long acting bronchodilator (LAMA, LABA)

Inhaled corticosteroids (ICS)

What we need

Diagnostic criteria

Thank you

감사합니다