Asthma-COPD Overlap
“I developed pain in the back of my ribs and went to see my primary care physician,” the La Quinta resident says. “He ordered a CT scan that showed chronic obstructive pulmonary disease (COPD).”
COPD, which includes chronic bronchitis and emphysema, is a long-term lung disease that makes it difficult to breathe. The airways in the lungs become narrowed due to swelling and thickening, and the airways and tiny air sacs lose their ability to stretch and shrink back.
The leading cause of COPD is smoking; however, one in four diagnosed with the condition never smoked. Other risk factors include a history of childhood respiratory infections and smoke exposure from coal or wood-burning stoves or secondhand cigarette smoke.
Lovett was referred to Anil Perumbeti, MD, Board Certified in Pulmonary Disease, Critical Care Medicine and Internal Medicine at the Eisenhower Pulmonary, Critical Care and Sleep Clinic.
“Rib pain and shortness of breath were Mrs. Lovett’s primary symptoms at that time,” Dr. Perumbeti relates. “We started her on two medications: Spiriva and Wixela.” Spiriva® is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs, and Wixela® is a combination of an inhaled steroid, to reduce inflammation, and a bronchodilator.
The treatment helped to control Lovett’s symptoms for a while. But in 2020, during a visit to her home state of Michigan with her husband, she developed breathing problems and was briefly hospitalized. Then, during a second visit to Michigan, she again wound up in the hospital with a COPD flareup, this time for a week.
Once she got back to the desert, she continued to have breathing problems.
“But I kept getting sick and had to take [oral] steroids each time,” she relates. “While they helped, I felt I was having to take them too often. But you’ve got to do what you’ve got to do.”
“The concern with frequent exacerbations (flare-ups) is that patients can develop worsening lung disease and have a poorer quality of life,” Dr. Perumbeti notes. “Then they can start having side effects from repeated doses of oral steroids.” These can include thinning skin and bones, blood clots, high blood pressure and diabetes.
Because it was the height of the Covid-19 pandemic, Dr. Perumbeti was overwhelmed with seeing critically ill patients in the hospital. But Lovett was able to schedule a telehealth visit with him.
“He suggested that maybe it was asthma reacting to these triggers, not just COPD,” she says. “He ordered some tests and they revealed I had what’s called eosinophilic asthma.” This is a type of asthma caused by high levels of white blood cells — called eosinophils. While the purpose of these white blood cells is to help fight infections, sometimes they over-react and cause inflammation.
Lovett’s asthma diagnosis meant she had what’s called asthma-COPD overlap, or ACO. It’s not a separate disease, but it is a way for doctors to recognize the mix of symptoms and formulate a treatment plan tailored to the individual patient. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), 15 to 55 percent of patients (with variation by gender and age) may have ACO.
“Someone whose lungs have been damaged by untreated or poorly controlled asthma and continued exposure to irritants such as smoke or air pollution is at increased risk of developing COPD,” Dr. Perumbeti explains. “And patients with COPD often have undiagnosed overlap with asthma. Both can have similar triggers and symptoms.
“We started Mrs. Lovett on the conventional treatment for ACO with her type of asthma, which was the addition of a third medication called Dupixent®,” he continues. Dupixent is one example of a biologic — a newer type of self-administered injectable medication that’s processed in the body differently than oral medications or steroids.
“We also evaluated her for allergens that could be triggering her asthma,” he continues. It revealed significant allergies to such things as cat dander, grass and dust, enabling Lovett to make lifestyle changes to avoid them. “Lifestyle modifications are essential for good symptom control,” Dr. Perumbeti stresses.
“The biologic medication has been a real gamechanger for me and my quality of life is much improved,” Lovett says. “I haven’t needed oral steroids for nearly two years now. My husband and I even caught Covid and I didn’t get particularly sick — I had a cough and general malaise, but just felt more tired than anything.
“I avoid going out if it’s windy — which happens a lot here in the desert — and I don’t spend extended periods outdoors because there are things in the air that bother me,” she continues. “I do better in the controlled environment of our home where we have air cleaners to keep the dust down.
“I’m not as active as I was when I was working, but I do pretty much what I want to do,” she adds. “I keep up a pretty big house for two, get together with the kids about once a month (she and her husband have three daughters and eight grandchildren) and do all the cooking and cleaning, go out to dinner, and homeschool one of my granddaughters twice a week.”
She also has resumed writing a historical romance novel that she set aside years ago, and she helps her husband with his songwriting, an avocation to which he’s devoting more time now that he, too, has retired from nursing.
“I went through two years of being sick a lot,” Lovett says. “But now I feel like I did before all this started. I truly believe my quality of life wouldn’t be what it is without Dupixent. I’m grateful to Dr. Perumbeti and Eisenhower.
“It’s a whole different ballgame now and I’m very optimistic,” she adds.
What to do if you have asthma or COPD symptoms
“It’s important to monitor your symptoms and keep a log so you can give a thorough description to your primary care doctor who can determine the appropriate testing for either condition — or both,” advises Dr. Perumbeti. “If your symptoms aren’t controlled with initial treatment, a referral to a pulmonary specialist is in order.”
It’s also important to discuss with your provider any changes to the guidelines and recommendations for treating these conditions, he notes, referring to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) and GINA (Global Initiative for Asthma) guidelines.
“These are updated yearly and things definitely do change,” he says. “About four years ago, the guidelines for asthma were updated to include the new injectable biologics which have been a real gamechanger for those who have asthma or asthma-COPD overlap.
“Mrs. Lovett, for example, has had near-perfect control of her asthma and COPD since starting on one of these drugs,” he adds. “And good symptom control significantly reduces the likelihood of COPD progressing.”
Speak to your primary care physician about any concerns you have about breathing issues. To find a primary care physician, call 760.568.1234, or visit EisenhowerHealth.org/PrimaryCare.
