Current Approaches for Phenotyping as a Target for Precision Medicine in COPD Management

Figures & data

Figure 1. Distribution of the CAT score among the different modified GOLD 2011 classification. Reproduced from Lopez-Campos et al. (17). © 2015 Lopez-Campos et al. This figure is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non- Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Noncommercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php.

Figure 2. Exemplification of different COPD cases with a similar functional impairment but different radiological expression. (A) Patient with predominantly airway disease; (B) patient with centrilobular emphysema; and (C) patient with panlobular empysema. Open arrows indicate the most typical and suggestive lesion of the three different diseases. By courtesy of Claudio Tantucci, 2015. Respiratory Medicine Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.

Figure 3. Relationship between the severity of airflow limitation and breathlessness as assessed by the mMRC questionnaire (panel A), exercise capacity as assessed by the 6 MWD (panel B), reported exacerbations in the year before inclusion in the study (panel C), and health status as assessed by SGRQ-C (panel D). Reproduced from Agustí et al. (23). © 2010 Agusti et al.; licensee BioMed Central Ltd. This is an Open Access figure distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Table 1. Strengths and weaknesses of the use of independent variables for the stratification of patients with COPD, both as a general concept and in the GOLD proposal.

	General concept	Current GOLD proposal
Strengths	• It makes clinical sense• With a reduced number of variables, relevant clinical information is obtained	• The selected variables are clinically relevant• The variables are easy to obtain• Provides information on the short- and long-term impact
Weaknesses	• A small number of variables do not capture the full complexity of the disease• Different types of patients do not have a single treatment• The selection is based on information from cohorts: ecological fallacy	• Cut-off points are arbitrary• More than one variable per axis• Different concepts of risk throughout the document• Frequent exacerbator concept is under debate• Discussion about its prognostic impact• Separation of lung function for treatment selection

Figure 4. Multidimensional indexes available.

Figure 5. Different definitions of asthma-COPD overlap syndrome according to different guidelines. GesEPOC, Spanish COPD Guidelines; CPPS, Czech Pneumological and Pathophysiological Society; FMS, Finnish Medical Society Duodecim; GOLD/GINA, Global Initiative for Chronic Obstructive Lung Disease/Global Initiative for Asthma; GEMA4.0, Spanish Guideline for Asthma Management 4.0. Adapted from (81).

Figure 6. GesEPOC 2017 stratification proposal. LAMA: long-acting muscarinic antagonist. LABA: long-acting β₂ agonist; ICS: inhaled corticosteroids. Reproduced with permission from Miravitlles et al.; GesEPOC. Arch Bronconeumol 2017 (76). Copyright material is from the Spanish Society of Pulmonology and Surgery Thoracic (SEPAR).

Table 2. Strengths and weaknesses of the use of clinical phenotypes for the stratification of patients with COPD, both as a general concept and in the GesEPOC proposal.

	General concept	Current GesEPOC proposal
Strengths	• They easily recognize types of patients• They have a specific therapeutic response	• Includes the most common phenotypes• They are easy to identify• They have some associated treatment strategy
Weaknesses	• They are not mutually exclusive, nor collectively exhaustive• The phenotype must be the natural expression of the disease, with treatment is complex• Not all the characteristics that define them are stable over time• The selection is based on information from cohorts: ecological fallacy	• Variable phenotype concept is controversial• Frequent exacerbator concept is under debate• Definition of ACO, a proposal• Does not include relevant phenotypes, e.g., bronchiectasis• There are patients who are left out with no phenotype

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