Initial Treatment for Asthma-COPD Overlap

Rationale for ICS/LABA as First-Line Therapy

The Canadian Thoracic Society recommends ICS/LABA combination therapy as the initial treatment for patients with asthma-COPD overlap, rather than LAMA/LABA dual therapy, due to the presence of concomitant asthma 1
Multiple international consensus documents, including GINA/GOLD, Spanish COPD guidelines, and Czech guidelines, recommend initiating ICS/LABA combination therapy as the foundation for asthma-COPD overlap 2
ICS/LABA combination therapy is the preferred initial treatment when asthma features coexist with COPD, even though LAMA/LABA would typically be preferred for COPD alone 1

Major criteria for diagnosing asthma-COPD overlap include FEV₁ increase ≥15% and ≥400 mL with bronchodilator, sputum eosinophilia ≥3%, or documented history of asthma 2
Minor criteria for diagnosing asthma-COPD overlap include FEV₁ increase ≥12% and ≥200 mL, elevated total IgE, or history of atopy 2
Two major criteria OR one major plus two minor criteria strongly suggest asthma-COPD overlap and mandate ICS-containing therapy 2

The American College of Chest Physicians recommends escalating to triple therapy (ICS/LAMA/LABA) if symptoms persist or exacerbations occur on ICS/LABA alone, with a strength of evidence rated as high 1, 3
The 2023 Canadian Thoracic Society guidelines recommend triple therapy for patients at high exacerbation risk (≥2 moderate or ≥1 severe exacerbation yearly) 1
Triple therapy should preferably be administered as single-inhaler triple therapy (SITT) rather than multiple inhalers, with a moderate level of evidence supporting this approach 1

The American Thoracic Society recommends adding roflumilast if FEV₁ <50% predicted with chronic bronchitis phenotype, particularly with prior hospitalization for exacerbation, with a low level of evidence supporting this approach 3, 4
The European Respiratory Society suggests considering macrolide therapy (e.g., azithromycin) in former smokers with persistent exacerbations, with a moderate level of evidence supporting this approach 3

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) warns against using LAMA/LABA as initial therapy in asthma-COPD overlap, as this can increase the risk of severe exacerbations and asthma-related mortality 1
The American College of Chest Physicians strongly recommends against using ICS monotherapy in COPD management due to lack of benefit and increased adverse events, with a high level of evidence supporting this approach 1, 5

The British Thoracic Society recommends assessing response at 30 minutes post-treatment with peak flow measurement in acute settings, with a moderate level of evidence supporting this approach 6
The American Thoracic Society suggests demonstrating ≥15% improvement from baseline peak flow over at least 5 days before continuing chronic nebulized therapy, with a low level of evidence supporting this approach 6
The European Respiratory Society recommends monitoring for pneumonia risk with ICS use, particularly in COPD patients, with a high level of evidence supporting this approach 1