Abstract
Introduction (with objective): Asthma and Chronic Obstructive Pulmonary Disease (COPD) are highly prevalent chronic respiratory diseases in Brazil, associated with significant morbidity and mortality and economic impact on the Unified Health System (SUS). Clinical Protocols and Therapeutic Guidelines (PCDT) are central instruments for standardizing diagnosis, treatment, and access to health technologies. However, an asymmetrical development is observed between the PCDT for Asthma and the PCDT for COPD, despite the two conditions sharing clinical, functional, and pathophysiological aspects, especially in patients with overlapping characteristics, present in 15 to 32% of cases. This asymmetry can generate inequities in care, variations in clinical practice, and limitations in access to appropriate therapies. Objective: To evaluate the divergences between the PCDT for Asthma and COPD in the SUS, focusing on therapeutic recommendations for severe patients and those with asthma-COPD overlap, exploring their potential clinical, care, and economic consequences. Material and Method: Descriptive and comparative analysis of the current Asthma and COPD Clinical Protocols and Therapeutic Guidelines (PCDTs) in the Brazilian Unified Health System (SUS), complemented by a narrative review of the scientific literature and national [1, 2] and international (GOLD and GINA) [3,4] technical documents. The diagnostic approach, severity stratification, therapeutic recommendations, incorporation of technologies, and treatment individualization strategies were evaluated, in addition to the practical applicability of the protocols and their impact on equity of care. Results: The Asthma PCDT recognizes the heterogeneity of the disease, proposes inflammatory control strategies, and presents a structured therapeutic escalation, including therapies directed at severe asthma. However, in steps 4 and 5, the protocol evolves directly from dual therapy with inhaled corticosteroids associated with long-acting beta-agonists (ICS/LABA) to biological therapies, without considering triple therapy with the addition of a long-acting muscarinic antagonist (LAMA). Although this strategy is recommended by GINA and cited in the Asthma Clinical Protocol and Therapeutic Guidelines (PCDT) for patients with overlapping conditions, LAMA is not formally incorporated, nor is there clarity regarding access via the COPD Clinical Protocol and Therapeutic Guidelines (PCDT). The COPD Clinical Protocol and Therapeutic Guidelines (PCDT) is aligned with GOLD, focusing on bronchodilation and prevention of exacerbations, including triple therapy (ICS/LABA/LAMA). However, in the presence of concomitant asthma, the guidance is to follow the Asthma Clinical Protocol and Therapeutic Guidelines, which hinders access to triple therapy in patients with overlapping conditions, potentially resulting in undertreatment, early use of biological therapies, and unequal access within the Brazilian Unified Health System (SUS). Conclusions: The discrepancy between the Asthma and COPD Clinical Protocol and Therapeutic Guidelines highlights the need for greater harmonization between protocols, considering the complexity and overlap of chronic respiratory diseases. Updating and integrating the guidelines, with a more personalized and evidence-based approach, represents a strategic opportunity to improve clinical outcomes, promote equity in access to treatment, and optimize the use of resources in the Brazilian Unified Health System (SUS), making it a relevant debate for improving public policies in respiratory health.
