1. A Belgian survey on the diagnosis of asthma-COPD overlap syndrome.
Publications
A Belgian survey on the diagnosis of asthma-COPD overlap syndrome.
Cataldo et al., International Journal of COPD.
NS ID XL-0090-RD08/2017-VA
Prices and SmPC available upon request via your medical representative

2. Context
Methods
Results
Conclusion
Discussion
Symbicort

3. ACO, little is known about this prevalent disease1
CONTEXT
ACO, little is known about this prevalent disease1
Patients with chronic airway disease may present features of both asthma and COPD, commonly referred to as asthma-COPD overlap (ACO)2,3.
The reported frequency of ACO varies widely, ranging between 15% - 55% in studies using the clinical definition of ACO2.
As COPD patients might mostly benefit from bronchodilator therapies, there is a challenge for the clinician to recognize an asthma component that will require ICS prescription2,4.
Recommendations on the diagnosis of ACO are diffuse and inconsistent1,2.
Cataldo et al., Int J of COPD. 2017: 12;
GINA, 2017
Soler-Cataluna et al., Arch Bronconeumol. 2012; 48(9):
GOLD, 2017

4. Prevalence of ACO varies widely1
CONTEXT
Prevalence of ACO varies widely1
Prevalence of ACO diagnosed according to different criteria (within COPD population)
Patients, %
Yong Suk et al., Ann Allergy Asthma Immunol. 2017; 118:

5. COPD patients with asthma features require ICS treatment1
CONTEXT
COPD patients with asthma features require ICS treatment1
Pharmacologic treatment algorithms by GOLD Grade (Highlighted boxes and arrows indicate preferred treatment pathways)
LABA + ICS
In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts may also be considered as a parameter to support the use of ICS, although this is still under debate.
GOLD, 2017

6. Recommendations on the diagnosis of ACO are diffuse and inconsistent1
CONTEXT
Recommendations on the diagnosis of ACO are diffuse and inconsistent1
GINA, 2017

7. CONTEXT
Study Objective1
A diagnosis of asthma or COPD is often proposed after a first visit, while ACO is rarely diagnosed at this time because longitudinal follow-up is needed.
Therefore, criteria were assessed that could be considered for diagnosing ACO either in an asthma patient or in a COPD patient.
This survey aimed:
to identify consensus on criteria for diagnosing ACO and
to map criteria for initiating ICS therapy in COPD patients.
1. Cataldo et al., Int J of COPD. 2017: 12;

8. Context
Methods
Results
Conclusion
Discussion
Symbicort

9. A Belgian survey on the diagnosis of Asthma COPD Overlap1
METHODS
A Belgian survey on the diagnosis of Asthma COPD Overlap1
There is an urgent need for a better definition of ACO patients:
to offer appropriate clinical care
to facilitate their inclusion in clinical trials
Online survey developed by a Belgian expert panel:
Didier Cataldo Vincent Ninane
Jean-Louis Corhay Rudi Peché
Eric Derom Charles Pilette
Renaud Louis Walter Vincken
Eric Marchand Wim Janssens
Alain Michils
Sponsor: AstraZeneca
Support: XPE Pharma
1. Cataldo et al., Int J of COPD. 2017: 12;

10. Design of the survey1 Online survey
METHODS
Design of the survey1
Online survey
Belgian pulmonologists from the three Belgian regions involved in care of asthma and COPD patients
Selected participants were contacted by or phone via XPE Pharma
Experts from the panel were excluded
Questionnaires in French and Dutch
4 questions to be answered on a webpage
<< Back >> button deactivated
Correction of entries after completion of each page was not possible
1. Cataldo et al., Int J of COPD. 2017: 12;

11. METHODS
4 questions1
QUESTION 1 (open): What are the most important criteria that make you think of ACO in a patient? List at least three criteria and rank them from most to least important.
QUESTION 2 (closed): What features are decisive to qualify a COPD patient as ACO patient? – predefined criteria provided (score 3 most important)
QUESTION 3 (closed): What features are decisive to qualify an asthma patient as ACO patient? – predefined criteria provided (score 3 most important)
QUESTION 4 (open): What are the most important criteria for you to prescribe ICS to a COPD patient? List at least three criteria and rank them from most to least important.
NB: order of questions 2 and 3 varied
1. Cataldo et al., Int J of COPD. 2017: 12;

12. Participant flow chart1
METHODS
Participant flow chart1
1. Cataldo et al., Int J of COPD. 2017: 12;

13. Characteristics of the participants (N=87)1
METHODS
Characteristics of the participants (N=87)1
1. Cataldo et al., Int J of COPD. 2017: 12;

14. Context
Methods
Results
Conclusion
Discussion
Symbicort

15. RESULTS
Important criteria for the diagnosis of ACO
‘Reversibility in lung function and/or airway obstruction’ is the most important criterion for ACO1
Major criteria for diagnosing ACO
Notes: The bubble size and presented number and percentage (in gray) indicate the number and percentage of pulmonologists who considered the criterion relevant for the diagnosis of ACO. Overlap with the main reported criterion shows the number of each combination (indicated in blue) of both answers provided by pulmonologists. Overlap between the other criteria is not shown.
Abbreviations: ACO, asthma–COPD overlap; FeNO, fractional exhaled nitric oxide.
1. Cataldo et al., Int J of COPD. 2017: 12;

16. RESULTS
Criteria to qualify a COPD patient as ACO patient
‘Degree of variability of airway obstruction’ and ‘degree of response to bronchodilators’ were considered most relevant criteria1
Features to diagnose a COPD patient as ACO patient
Notes: Gray bars show the percentage of pulmonologists who considered the criterion as “relevant” (Likert score 5–7). The two criteria considered relevant by most pulmonologists were retained as major criteria. Other criteria surpassing the 70% cutoff mark for relevancy (vertical dashed line) were considered as minor criteria. Black bullet shows mean Likert score (with SD).
Abbreviations: ACO, asthma–COPD overlap; IgE, immunoglobulin E; FeNO, fractional exhaled nitric oxide; CT, computed tomography; N, number of pulmonologists; SD, standard deviation.
1. Cataldo et al., Int J of COPD. 2017: 12;

17. RESULTS
Criteria to qualify an asthma patient as ACO patient
‘Persistence over time of an obstructive disorder’ and ‘smoker (former or active smoker)’ were considered most relevant criteria1
Features to diagnose an asthma patient as ACO patient
Notes: Gray bars show the percentage of pulmonologists who considered the criterion as “relevant” (Likert score 5–7). The two criteria considered relevant by most pulmonologists were retained as major criteria. Other criteria surpassing the 70% cutoff mark for relevancy (vertical dashed line) were considered as minor criteria. Black bullet shows mean Likert score (with SD).
Abbreviations: ACO, asthma–COPD overlap; IgE, immunoglobulin E; FeNO, fractional exhaled nitric oxide; CT, computed tomography; N, number of pulmonologists; SD, standard deviation.
1. Cataldo et al., Int J of COPD. 2017: 12;

18. RESULTS
Guidance for ACO diagnosis proposed by the expert panel
Presence of 2 major criteria and at least one minor criterion are required for the diagnosis of ACO1
Criteria for ACO diagnosis: guidance from the Belgian survey
Note: A diagnosis of ACO is accepted in both COPD and asthma patients when the two major criteria and at least one minor criterion are met.
Abbreviations: ACO, asthma–COPD overlap; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; PFTs, pulmonary function tests; IgE, immunoglobulin E; FeNO, fractional exhaled nitric oxide; CT, computed tomography.
1. Cataldo et al., Int J of COPD. 2017: 12;

19. RESULTS
Criteria to prescribe ICS to a COPD patient
‘Exacerbations’ was the most mentioned criterion to prescribe ICS to a COPD patient1
Major criteria for prescribing ICS to COPD patients
Note: Figure shows the percentage of pulmonologists who considered the criterion important for prescribing ICS to COPD patients.
Abbreviations: ICS, inhaled corticosteroids; FeNO, fractional exhaled nitric oxide; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ACO, asthma–COPD overlap; N, number of pulmonologists.
1. Cataldo et al., Int J of COPD. 2017: 12;

20. Context
Methods
Results
Conclusion
Discussion
Symbicort

21. Relevance of this publication1
CONCLUSION
Relevance of this publication1
The strengths and novelty of the Belgian expert recommendations are that they provide, for the first time, specific criteria for previously diagnosed asthma or COPD patients in whom the suspicion of ACO is raised during follow-up.
Criteria used to classify COPD patients as ACO were largely similar to those used to prescribe ICS in COPD patients.
1. Cataldo et al., Int J of COPD. 2017: 12;

22. Context
Methods
Results
Conclusion
Discussion
Symbicort

23. Importance of clearly defined criteria for diagnosis of ACO1
DISCUSSION
Importance of clearly defined criteria for diagnosis of ACO1
ACO patients have generally more severe disease and worse prognosis2,3,4,5.
ACO patients display a systemic inflammation6.
ACO patients have a higher societal burden impacting daily activities7.
Cataldo et al., Int J of COPD. 2017: 12;
Andersen et al., Clin Respir J. 2013; 7(4):
Brzostek et al., Postepy Dermatol Alergol. 2014; 31(6):
Gerhardsson de Verdier et al., Value Health. 2015; 18(6):
Hardin et al., Respir Res. 2011; 12: 127
Harada et al., Int J Chron Obstruct Pulmon Dis. 2015; 10:
Ding et al., Expert Rev Respir Med. 2016; 10(3):
ACO diagnosed according to criteria used in the different publications; BE criteria were not yet available.

24. ACO patients have more severe and more frequent exacerbations1
DISCUSSION
ACO patients have more severe and more frequent exacerbations1
% of frequent and severe exacerbations among subjects with COPD compared to subjects with COPD and asthma
Patients, %
1. Hardin et al., Respir Res. 2011; 12: 127

25. ACO patients have lower QoL and more exacerbations1
DISCUSSION
ACO patients have lower QoL and more exacerbations1
Clinical features of subjects with COPD and asthma compared to those with COPD alone
1. Hardin et al., Eur Respir J. 2014; 44:

26. ACO patients have a higher hospital burden1
DISCUSSION
ACO patients have a higher hospital burden1
Mean number of treatment periods per patient
34-44 years years years years years >85 years
Asthma
COPD
ACO
1. Andersen et al., Clin Respir J. 2013; 7(4):

27. ACO patients have a poorer prognosis1
DISCUSSION
ACO patients have a poorer prognosis1
1. Lange et al., Lancet Respi Med. 2016; 4:

28. ACO patients have a poorer prognosis1
DISCUSSION
ACO patients have a poorer prognosis1
1. Lange et al., Lancet Respi Med. 2016; 4:

29. ACO patients have a higher disease cost than asthma patients1
DISCUSSION
ACO patients have a higher disease cost than asthma patients1
Average all-cause and asthma-related costs during the 12-month preindex and postindex periods for the matched population.
1. Gerhardsson de Verdier et al., Value Health. 2015; 18(6):

30. Context
Methods
Results
Conclusion
Discussion
Symbicort

31. Symbicort in Asthma: Superior efficacy at lower mean ICS dose1*
Symbicort is indicated as treatment for asthma and COPD, not for ACO.
Kuna et al., Int J Clin Pract. 2007; 61(5):
* Vs sal/flu + SABA

32. Symbicort in COPD: Exacerbation reduction & rapid symptom relief1,2
SmPC Symbicort Turbohaler (160/4,5) & (320/9), latest edition
SmPC Symbicort aerosol (160/4,5), latest edition
Szafranski et al., Eur Respir J. 2003; 21: 74-81

33. Symbicort in COPD: Exacerbation reduction & rapid symptom relief1,2
SmPC Symbicort Turbohaler (160/4,5) & (320/9), latest edition
SmPC Symbicort aerosol (160/4,5), latest edition
Partridge et al., Ther Adv Respir Dis. 2009; 180:
Data of File: Symbicort (bud/for) CDLM individual activity variable, April 2017, REF 5449
*** p=NS, **** p <0.02

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NS ID XL-0090-RD08/2017-VA