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pulm.aco.v1

Asthma–COPD Overlap (ACO) — GINA/GOLD 2026 ICS-foundation

pulmonologychronicadult
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Detailed

Confirm PERSISTENT airflow limitation (post-BD FEV1/FVC <0.70) PLUS features of BOTH asthma and COPD — ACO is a clinical description, not a single disease (GINA 2026 / GOLD 2026 joint ACO chapter)

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Advance rule
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Advance when

Fixed obstruction confirmed AND mixed asthma+COPD features documented

Patient inputs (15)

Age of asthma onset (<40 supports asthma component) + biologic eligibility; GINA/GOLD 2026 syndromic criteria

Prior physician diagnosis of asthma (esp. <40 yr) is the single most reliable ACO criterion (Barrecheguren PMID 25405671; Caillaud PMID 27501862)

Personal/family atopy, allergic rhinitis, IgE sensitisation — minor ACO criterion (Cataldo PMID 28243078; OR hay-fever 5.50 PMID 27501862)

Noxious-exposure burden (≥10 pack-years) establishes the COPD component; smoking blunts ICS response (GOLD 2026; Cataldo PMID 28243078)

Variable symptoms (diurnal/nocturnal, episodic) favour an asthma component vs the slowly-progressive COPD pattern (GINA 2026 Box 1-2)

ACO carries a higher exacerbation burden than COPD alone (IRR 1.65, Jo/Rhee PMID 31953230); drives escalation

Symptom burden tracking (mMRC/CAT) — drives review cadence and escalation (GOLD 2026 Assessment; CHAIN PMID 27684372)

Detect SABA-only or LABA-LAMA-WITHOUT-ICS — both AVOIDED when an asthma component is present (the key ACO safety teaching point; GINA/GOLD 2026)

Acute exacerbation severity + LTOT eligibility in the COPD component (GOLD 2026)

Post-BD FEV1/FVC <0.70 (fixed, COPD) WITH bronchodilator reversibility ≥12% AND ≥200 mL (asthma) — the defining objective ACO dyad (Cataldo PMID 28243078; GINA/GOLD 2026)

Eosinophilic-COPD treatable trait: ≥300 cells/µL predicts ICS-response in ACO (Jo/Rhee IRR 0.52 PMID 31953230) + biologic eligibility (BOREAS PMID 37272521); the eosinophil pivot is FOR ICS here, not against it

DLCO preserved/normal favours asthma component; markedly reduced + restriction favours ILD mimic (differential discriminator)

FeNO marks T2 inflammation; supports asthma component + predicts ICS/dupilumab response (GINA 2026 Box 3-4; Cataldo minor criterion PMID 28243078)

IgE sensitisation supports the atopic asthma component; omalizumab eligibility in severe-T2 ACO (Sposato PMID 30043557)

Exclude bronchiectasis/ILD/cancer mimics; HRCT signet-ring vs UIP vs emphysema discriminates (research bundle §3)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalsevereaco_severe_exacerbation
    Acute severe ACO exacerbation — behaves like the WORSE of asthma and COPD (higher exacerbation burden than COPD alone, IRR 1.65, Jo/Rhee PMID 31953230): severe airflow obstruction + hypoxia, OR life-threatening asthma-like features (silent chest, exhaustion), OR type-II respiratory failure (COPD component)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaco_frequent_exacerbator
    ≥2 moderate exacerbations OR ≥1 hospitalisation in 12 months despite triple ICS/LABA/LAMA with verified technique — refractory ACO (GINA 2026 Step 5; ATS/ERS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateics_containing_foundation_mandatory
    ACO confirmed (fixed post-BD FEV1/FVC <0.70 + asthma component) — an ICS-CONTAINING regimen is the FLOOR. SABA-only and LABA-LAMA-WITHOUT-ICS are CONTRAINDICATED while an asthma component is present (the defining ACO teaching point — the INVERSE of eos-gated COPD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeosinophil_feno_ics_biologic_decision
    Blood eosinophils + FeNO drive the ICS/biologic decision chain — but in the INVERSE direction to COPD: eos ≥300 (or sputum eos ≥2.5%) → STRONG ICS-responder (reinforces the ICS floor) AND biologic-eligible if refractory; sputum eos ≥2.5% test characteristic 82.4% sens / 84.8% spec for ICS-responsive overlap (Kitaguchi PMID 22589579; Jo/Rhee PMID 31953230)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatediscriminate_asthma_vs_copd_vs_aco
    §5.5.2 discrimination-as-data — the CORE of this engine. Is it pure ASTHMA, pure COPD, or ACO? Syndromic-feature score with test characteristics: post-BD FEV1/FVC <0.70 fixed (present in COPD AND ACO; ABSENT in pure asthma) + bronchodilator reversibility ≥12% AND ≥200 mL or FEV1 variability ≥400 mL (present in asthma AND ACO; minimal in pure COPD) + asthma diagnosis <40 yr (strong asthma/ACO criterion) + atopy/IgE + eos/FeNO↑ + ≥10 pk-yr smoking (COPD/ACO). ACO = fixed obstruction AND large reversibility/variability AND asthma-history/eosinophilia/atopy (Cataldo Belgian consensus PMID 28243078; Barrecheguren PMID 25405671)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

ACO ICS-containing foundation — ICS/LABA → triple ICS/LABA/LAMA (GINA/GOLD 2026 joint)
axis: aco_ics_foundation_stepwisestep 1 - Tier 1 — ICS/LABA foundation (NEVER SABA-only, NEVER LABA-LAMA-without-ICS)
Selected step "Tier 1 — ICS/LABA foundation (NEVER SABA-only, NEVER LABA-LAMA-without-ICS)" — ACO confirmed (fixed post-BD FEV1/FVC <0.70 + asthma component) — an ICS-containing regimen is the FLOOR regardless of eosinophil count when an asthma component is present (GINA/GOLD 2026; Jo/Rhee ICS IRR 0.55-0.69 PMID 31953230)
  • budesonide-formoterol
    first line
    ICS_LABA
    160/4.5 µg 2 puffs BID (or per asthma-component severity) • inhaled • BID (MART possible for the asthma component)
    triggers: aco_confirmed, asthma_component_present
    ICS-containing foundation per GINA/GOLD 2026 joint ACO description — ICS treats the eosinophilic/asthma component; budesonide-formoterol also supports a MART reliever strategy. RxCUI 19831 = budesonide IN (combination — NEEDS_RXNAV_VALIDATION for SCD/SBD; not hand-authored)
    rxcui 1246304
  • fluticasone furoate-vilanterol
    first line
    ICS_LABA
    100/25 µg or 200/25 µg Ellipta 1 inhalation daily • inhaled • once daily
    triggers: aco_confirmed, once_daily_preference
    Alternative once-daily ICS/LABA foundation (GINA/GOLD 2026). RxCUI 41126 = combination base-ingredient code — NEEDS_RXNAV_VALIDATION for SCD/SBD
    rxcui 1424889

outpatient playbook — drug actions (4)

  1. 1. ICS/LABA foundation
    Budesonide-formoterol 160/4.5 µg 2 puffs BID OR fluticasone furoate-vilanterol 100-200/25 µg daily • inhaled • BID / once daily
    trigger: ACO confirmed (asthma component present)
    ICS-containing FLOOR per GINA/GOLD 2026 — never SABA-only/LABA-LAMA-without-ICS
  2. 2. Triple ICS/LABA/LAMA
    Fluticasone furoate-umeclidinium-vilanterol 100-200/62.5/25 µg Ellipta daily OR budesonide-glycopyrrolate-formoterol 160/9/4.8 µg MDI 2 puffs BID • inhaled • once daily / BID
    trigger: Persistent symptoms or ≥1 exacerbation on ICS/LABA
    Add LAMA — ICS retained as the foundation (GINA/GOLD 2026)
  3. 3. Severe-T2 biologic
    Dupilumab 200-300 mg SC q2w; omalizumab per IgE/weight q2-4w; mepolizumab 100 mg SC q4w; tezepelumab 210 mg SC q4w • SC • q2-4 weeks
    trigger: Persistent exacerbations on triple + T2 trait (eos/FeNO/IgE)
    QUEST/BOREAS/Sposato/NAVIGATOR — phenotype-gated biologic
  4. 4. Smoking-cessation pharmacotherapy
    Varenicline 0.5 mg → 1 mg BID; bupropion SR 150 mg BID; NRT patch + lozenge • PO/transdermal • per agent
    trigger: Active smoker
    Highest-impact intervention — smoking blunts ICS response (GOLD 2026 Follow-up & Prevention)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Persistent airflow limitation WITH features of both asthma and COPD (variable + persistent obstruction, smoking + atopy) — GINA 2026 / GOLD 2026 joint ACO description; Post-BD FEV1/FVC <0.70 (fixed, COPD-like) AND large bronchodilator reversibility (≥12% AND ≥200 mL, or FEV1 variability ≥400 mL — asthma-like) (Cataldo PMID 28243078); Established COPD with a documented physician diagnosis of asthma before age 40 (Caillaud/Roche INITIATIVES BPCO PMID 27501862).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Asthma–COPD Overlap (ACO) — GINA/GOLD 2026 ICS-foundation** (pulm.aco.v1).
Phenotype framing: §5.5.2 discrimination-as-data — the CORE of this engine: ASTHMA (early onset, fully reversible, non-smoker, no fixed obstruction) vs COPD (≥10 pk-yr, fixed obstruction, eos-gated ICS, minimal reversibility) vs ACO (BOTH — fixed post-BD FEV1/FVC <0.70 AND large BDR/variability AND eosinophilia/atopy/asthma-history). Syndromic-feature score: major = high BDR (>200 mL & ≥12%) + asthma dx <40; minor = atopy/IgE, eos/FeNO↑, symptom variability (Cataldo PMID 28243078). Sputum eos ≥2.5% predicts ICS response (82.4% sens / 84.8% spec, Kitaguchi PMID 22589579)
Scope: Confirm PERSISTENT airflow limitation (post-BD FEV1/FVC <0.70) PLUS features of BOTH asthma and COPD — ACO is a clinical description, not a single disease (GINA 2026 / GOLD 2026 joint ACO chapter)

No severity triggers fired against current inputs.

Plan

Regimen axis: **ACO ICS-containing foundation — ICS/LABA → triple ICS/LABA/LAMA (GINA/GOLD 2026 joint)** — step "Tier 1 — ICS/LABA foundation (NEVER SABA-only, NEVER LABA-LAMA-without-ICS)".
1. budesonide-formoterol 160/4.5 µg 2 puffs BID (or per asthma-component severity) inhaled BID (MART possible for the asthma component) (ICS_LABA, first line) — ICS-containing foundation per GINA/GOLD 2026 joint ACO description — ICS treats the eosinophilic/asthma component; budesonide-formoterol also supports a MART reliever strategy. RxCUI 19831 = budesonide IN (combination — NEEDS_RXNAV_VALIDATION for SCD/SBD; not hand-authored)
2. fluticasone furoate-vilanterol 100/25 µg or 200/25 µg Ellipta 1 inhalation daily inhaled once daily (ICS_LABA, first line) — Alternative once-daily ICS/LABA foundation (GINA/GOLD 2026). RxCUI 41126 = combination base-ingredient code — NEEDS_RXNAV_VALIDATION for SCD/SBD

Setting playbook (outpatient) — Confirm ACO (discriminate from pure asthma / pure COPD), establish and maintain an ICS-CONTAINING regimen as the foundation, reduce the (higher-than-COPD) exacerbation burden, and refer severe-T2 refractory disease for biologic assessment (GINA/GOLD 2026)
3. ICS/LABA foundation Budesonide-formoterol 160/4.5 µg 2 puffs BID OR fluticasone furoate-vilanterol 100-200/25 µg daily inhaled BID / once daily — ACO confirmed (asthma component present) (ICS-containing FLOOR per GINA/GOLD 2026 — never SABA-only/LABA-LAMA-without-ICS)
4. Triple ICS/LABA/LAMA Fluticasone furoate-umeclidinium-vilanterol 100-200/62.5/25 µg Ellipta daily OR budesonide-glycopyrrolate-formoterol 160/9/4.8 µg MDI 2 puffs BID inhaled once daily / BID — Persistent symptoms or ≥1 exacerbation on ICS/LABA (Add LAMA — ICS retained as the foundation (GINA/GOLD 2026))
5. Severe-T2 biologic Dupilumab 200-300 mg SC q2w; omalizumab per IgE/weight q2-4w; mepolizumab 100 mg SC q4w; tezepelumab 210 mg SC q4w SC q2-4 weeks — Persistent exacerbations on triple + T2 trait (eos/FeNO/IgE) (QUEST/BOREAS/Sposato/NAVIGATOR — phenotype-gated biologic)
6. Smoking-cessation pharmacotherapy Varenicline 0.5 mg → 1 mg BID; bupropion SR 150 mg BID; NRT patch + lozenge PO/transdermal per agent — Active smoker (Highest-impact intervention — smoking blunts ICS response (GOLD 2026 Follow-up & Prevention))

Non-pharmacologic actions:
- Pulmonary rehabilitation referral — especially after any exacerbation; within 3 weeks
- Allergen / trigger avoidance counselling (asthma component)
- Annual influenza, PCV20 (or PCV15+PPSV23), RSV (≥60), COVID, Tdap
- Lung cancer screening — annual LDCT if 50-80 yr, ≥20 pack-years, current or quit ≤15 yr (USPSTF 2021)
- Written ACO action plan (green/yellow/red) incorporating both components
- Weight management / OSA + GERD optimisation (obesity over-represented in ACO — PMID 27501862)

AVOID / contraindication checks:
- ACO_never_SABA_only_maintenance_ICS_containing_regimen_mandatory (GINA 2026 §5 ACO; GOLD 2026 joint description)
- ACO_avoid_LABA_LAMA_without_ICS_when_asthma_component_present (GINA/GOLD 2026 — the defining ACO contraindication; inverse of COPD eos gated ICS)
- ACO_do_not_apply_COPD_ICS_withdrawal_WISDOM_logic_while_asthma_component_persists (WISDOM PMID 25196117 logic is COPD only — does NOT transfer to the asthma component of ACO)
- ICS_pneumonia_risk_acknowledged_but_outweighed_by_asthma_component_benefit_in_ACO (FLAME pneumonia 4.8% vs 3.2% P=0.02 PMID 27181606 — risk noted; ICS still foundational in ACO unlike eos low pure COPD)
- Beta_blocker_avoid_nonselective_cardioselective_OK_if_strong_CV_indication (GINA 2026 §3; GOLD 2026 Multimorbidity)
- Pregnancy_continue_ICS_containing_regimen_uncontrolled_disease_worse_than_drug_avoid_roflumilast (GINA 2026 §3 pregnancy; GOLD 2026)
- Smoking_cessation_highest_impact_intervention_smoking_blunts_ICS_response (GOLD 2026 Follow up & Prevention; Cataldo PMID 28243078)
- Biologic_eligibility_gate_by_T2_phenotype_eos_FeNO_IgE_before_initiation (ATS/ERS 2024; GINA 2026 Step 5; Sposato PMID 30043557)

Monitoring

Regimen monitoring:
- annual spirometry track fixed obstruction and reversibility (GINA/GOLD 2026)
- blood eos and FeNO to track T2 trait and biologic candidacy (eos >=300 = strong ICS-responder, Jo/Rhee IRR 0.52 PMID 31953230)
- mMRC or CAT q visit symptom burden (GOLD 2026 Assessment; CHAIN PMID 27684372)
- ACT q visit for the asthma component (<20 = uncontrolled step-up trigger; GINA 2026 Box 2-2)
- exacerbation diary ACO burden exceeds COPD alone (IRR 1.65, Jo/Rhee PMID 31953230)
- inhaler technique and adherence q visit BEFORE any step up (GINA 2026 §3)
- biologic response at 4 months >=50pct exac reduction = responder (ATS/ERS 2024)
- lung function decline may be slower than pure COPD when treated (-13.9 vs -29.3 mL/yr, Park/Sin KOLD PMID 29499758 — appropriate ICS-containing therapy matters)
- NEVER withdraw ICS while asthma component persists (inverse of COPD ICS-deprescribing — GINA/GOLD 2026)

Setting (outpatient) monitoring:
- Spirometry annually (track fixed obstruction + reversibility)
- Blood eos + FeNO to track the T2 trait and biologic candidacy
- mMRC + CAT + ACT each visit
- Inhaler technique + adherence each visit BEFORE step-up
- Exacerbation diary (burden exceeds COPD alone)

Follow-up plan: Written action plan, vaccinations (influenza, pneumococcal PCV20 or PCV15+PPSV23, RSV, COVID, Tdap), smoking-cessation reinforcement, pulmonary rehab within 3 weeks of any exacerbation, allergen/trigger control, 1-week post-exacerbation follow-up, advance-care planning in advanced disease (GINA/GOLD 2026)
- Close-out criterion: Prevention bundle + rehab referral + follow-up complete

Monitoring phase: Annual spirometry, exacerbation diary, inhaler technique audit (BEFORE any step-up), mMRC/CAT each visit, blood eos + FeNO to track the T2 trait and biologic candidacy, biologic response at 4 months; never withdraw ICS while the asthma component persists (the inverse of COPD ICS-deprescribing) (GINA/GOLD 2026; ATS/ERS 2024)

Disposition

Current setting: outpatient — Confirm ACO (discriminate from pure asthma / pure COPD), establish and maintain an ICS-CONTAINING regimen as the foundation, reduce the (higher-than-COPD) exacerbation burden, and refer severe-T2 refractory disease for biologic assessment (GINA/GOLD 2026)

Disposition criteria:
- Continue ICS-containing regimen if controlled; step up if exacerbation pattern worsens
- Reclassify to pulm.asthma.core.v1 or pulm.copd.core.v1 if discrimination shows a single dominant disease (do NOT keep on the ACO pathway if criteria are not met)
- Refer for biologic assessment if severe-T2 refractory on triple

Escalation triggers (move to higher acuity):
- Acute severe exacerbation with O2 requirement / life-threatening features → ED (treat as worse-of-both physiology)
- Persistent uncontrolled on triple with ≥2 exacerbations/yr → severe-asthma/ACO specialty clinic for biologic assessment (ATS/ERS 2024)
- Diagnostic uncertainty (is it pure asthma, pure COPD, bronchiectasis, IPF?) → re-route via the discrimination workup

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Acute severe ACO exacerbation — behaves like the WORSE of asthma and COPD (higher exacerbation burden than COPD alone, IRR 1.65, Jo/Rhee PMID 31953230): severe airflow obstruction + hypoxia, OR life-threatening asthma-like features (silent chest, exhaustion), OR type-II respiratory failure (COPD component)
- [MODERATE] ≥2 moderate exacerbations OR ≥1 hospitalisation in 12 months despite triple ICS/LABA/LAMA with verified technique — refractory ACO (GINA 2026 Step 5; ATS/ERS 2024)
- [MODERATE] ACO confirmed (fixed post-BD FEV1/FVC <0.70 + asthma component) — an ICS-CONTAINING regimen is the FLOOR. SABA-only and LABA-LAMA-WITHOUT-ICS are CONTRAINDICATED while an asthma component is present (the defining ACO teaching point — the INVERSE of eos-gated COPD)

Citations

- GINA 2026 Strategy Report (released May 2026) + GOLD 2026 Report — JOINT asthma–COPD overlap (ACO) description (ACO is a clinical description, not a single disease; ICS-containing therapy foundational) [PMID:33209021](https://pubmed.ncbi.nlm.nih.gov/33209021/)
- Cited evidence (PMID 27501862) [PMID:27501862](https://pubmed.ncbi.nlm.nih.gov/27501862/)
- Cited evidence (PMID 27684372) [PMID:27684372](https://pubmed.ncbi.nlm.nih.gov/27684372/)
- Cited evidence (PMID 31953230) [PMID:31953230](https://pubmed.ncbi.nlm.nih.gov/31953230/)
- Cited evidence (PMID 22589579) [PMID:22589579](https://pubmed.ncbi.nlm.nih.gov/22589579/)

Last reconciled with current guidelines: 2026-05-25.
References
  • GINA 2026 Strategy Report (released May 2026) + GOLD 2026 Report — JOINT asthma–COPD overlap (ACO) description (ACO is a clinical description, not a single disease; ICS-containing therapy foundational) — PMID:33209021
  • Cited evidence (PMID 27501862) — PMID:27501862
  • Cited evidence (PMID 27684372) — PMID:27684372
  • Cited evidence (PMID 31953230) — PMID:31953230
  • Cited evidence (PMID 22589579) — PMID:22589579