Mike Hess, MPH, RRT, RPFTWestern Michigan University Homer Stryker M.D. School of MedicineAsthma Educator Sharing Day 2019

Disclosures

I have accepted speaking/consulting fees from:

• Boehringer-Ingelheim • Theravance Biopharma• Mylan • Olympus

Once upon a time, I helped run GOLD’s social media.

Objectives

• Review relationships between poorly-treated asthma in younger populations and the development of COPD during aging

• Discuss controversies regarding partially-reversible airway obstruction

• Identify care delivery and research goals to minimize progressive loss of lung function and optimize outcomes.

The “Dutch

Hypothesis”Revisited

Patient Criteria

• Age• Gender• Symptoms• Airway Obstruction• Reversibility• Degree of Allergy• Presence of

“Complicating Factors”• Smoking History

Thorax 2009

“There is a need to re-evaluate the concept of asthma and chronic obstructive pulmonary disease (COPD) as separate conditions, and to consider situations when they may coexist, or when one condition may evolve into the other.”

GOLD/GINA

• Combination may be a different disease (ACOS)

• Stepwise diagnosis:• Recognition of airways disease• Syndromic classification• Confirmation via PFT/spirometry

• Referral due to outcomes

Everything Old is New Again?

1961• One disease (CNSLD)

• Different manifestations

• Complex process requiring additional research

2015• One disease (ACOS)

• Different manifestations

• Complex process requiring additional research

PRECISION PRACTICALITY

What Do We Know?Asthma / COPD Overlap

Asthma / COPD Overlap

• Asthma is heterogenous

• COPD is heterogenous

•Overlap is heterogenous

%Chronic respiratory condition patients

demonstrating evidence of overlap

Relative risk of exacerbation/hospitalization in PLATINO study population compared to COPD

More likely to report

• Activity limitation d/t health

• Health status “fair” or “poor”

PLATINO study population compared to COPD

Relative risk of developing COPD withchildhood severe asthma

Tai A, Tran H, Roberts M, et alThe association between childhood asthma and adult chronic obstructive pulmonary disease

Thorax 2014;69:805-810.

Airway Remodeling 1

Olin, J.T., & Wechsler, M.E. (2014). Asthma: pathogenesis and novel drugs for treatment. BMJ, 349, g5517 .

Airway Remodeling 2

https://www.sciencedirect.com/book/9780123868824/handbook-of-pharmacogenomics-and-stratified-medicine

Histoverlap

Ichinose, Masakazu. (2009). Differences of Inflammatory Mechanisms in Asthma and COPD. Allergology international : official journal of the Japanese Society of Allergology. 58. 307-13. 10.2332/allergolint.09-RAI-0106.

What Do We DO?Asthma / COPD Overlap

GOLD/GINA Stepwise Approach 1

# 1 Does Your Patient Have Obstructive Airways Disease?

Don’t Forget the Diagnosis!

• Spirometry

• History / Risk Factors / Screening

• Examination

• Labs / Rads / Other Testing

GOLD/GINA Stepwise Approach 2

# 1 Does Your Patient Have Obstructive Airways Disease?#2 WHAT Obstructive Airways Disease Do They Have?

The Breakdown

ASTHMA• (Relatively) Young• Normal Spirometry• Significant BD Response• Volatile Symptoms

• Atopy/Allergies (high)• Normal CXR/imaging

COPD• (Relatively) Old• Impaired Spirometry• Questionble BD Response• Variable Symptoms w/Baseline• Not so much allergies• Bad things on CXR/imaging

Add-Ons

ASTHMA

• Normal-Increased DLCO

• Elevated Eosinophils

• High FeNO

COPD

• Often Impaired DLCO

• OCCASIONALLY Elevated Eosinophils, esp. during flare

• Normal to Low FeNO

GOLD/GINA Stepwise Approach

# 1 Does Your Patient Have Obstructive Airways Disease?#2 WHAT Obstructive Airways Disease Do They Have?#3 What are YOU going to do about it?

Initial Therapy

• Asthma: GINA / EPR-3• (ICS, no LABA monotherapy)

• COPD: GOLD Box• (LAMA and/or LABA, no ICS monotherapy)

• Overlap: • ICS and LAMA/LABA

INHALER TECHINQUE!!!!

Same As It Ever Way

• Modifiable Risk Factors (smoking)

• Diet / Exercise

• Comorbid Conditions

• Vaccines

#FluShotFriday

Same As It Ever Was

• Modifiable Risk Factors (smoking)

• Diet / Exercise

• Comorbid Conditions

• Vaccines

• Self-Efficacy

Don’t Forget the Socials!

• Environmental Health Concerns

• Access to Meds / Therapies

• Health Literacy

• Family / Caregiver / Network Support

GINA’s Advice

“In a majority of patients, the initial management of asthma & COPD can be satisfactorily carried

out at a primary care level”

Call for Backup

• Refractory Symptoms / Exacerbations

• Unusual Symptoms

• Significant Comorbids

• Diagnostic Uncertainty

The Continuing Mission

• REVIEW • Symptom Burden (CAT and/or ACT)• Exacerbations Since Last Encounter

• ASSESS• Regimen Adherence• Alternate Therapies

• ADJUST• Medication, Device, Other Therapy

Other Therapies to Consider

• Monoclonal Antibodies• Little to no evidence in COPD, helpful with asthma

• Phosphodiesterase-4 Inhibitors• Little to no evidence in asthma, helpful with COPD

• Macrolides• Potentially helpful for both!

Where Do We Go?Asthma / COPD Overlap

Much Work To Be Done

• Better Understanding of ALL Phenotypes

• Inclusion of Overlap Cohorts in Clinical Trials/Studies

• More personalized therapy plans

The Big Three

• Increased Inflammation

• Increased Bronchodilator Response

• Increased Response to Corticosteroids

By Any Other Name?

• Asthma/COPD Overlap

• Obstructive Asthma

• Chronic Obstruction with Reactive Airways

• Reactive COPD

• Type “X” Lung Disease?

Mike Hess, MPH, RRT, RPFTWestern Michigan UniversityHomer Stryker M.D. School of Medicinemichael.hess@med.wmich.edu

Slide Number 1DisclosuresObjectivesSlide Number 4Slide Number 5Slide Number 6The �“Dutch Hypothesis”�RevisitedPatient CriteriaSlide Number 9Slide Number 10Thorax 2009GOLD/GINAEverything Old is New Again?Slide Number 14What Do We Know?Asthma / COPD OverlapSlide Number 17Slide Number 18Slide Number 19Slide Number 20Airway Remodeling 1Airway Remodeling 2HistoverlapWhat Do We DO?GOLD/GINA Stepwise Approach 1Slide Number 26Don’t Forget the Diagnosis!GOLD/GINA Stepwise Approach 2Slide Number 29The BreakdownAdd-OnsGOLD/GINA Stepwise ApproachInitial TherapyINHALER TECHINQUE!!!!Same As It Ever Way#FluShotFridaySame As It Ever WasDon’t Forget the Socials!GINA’s AdviceCall for BackupThe Continuing MissionOther Therapies to ConsiderWhere Do We Go?Slide Number 44Much Work To Be DoneThe Big ThreeBy Any Other Name?Slide Number 48Mike Hess, MPH, RRT, RPFT