Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines: 2017 Update


Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines: 2017 Update
 
Chronic obstructive pulmonary disease (COPD) is a leading cause of chronic morbidity and mortality worldwide and is projected to become the third leading cause of death by 2020. The burden of COPD is predicted to increase due to additional exposure to environmental risk factors for development of the disease and greater risk of the disease as the population ages.1,2
 
In 2017, an updated and revised version of the standard-setting Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines was released. As part of the revision, the definition of COPD was updated to include the importance of environmental disturbances and host factors that contribute to disease pathophysiology.1 COPD is a treatable disease characterized by persistent respiratory symptoms that typically include breathlessness (dyspnea), chronic cough and/or sputum production, and airflow limitation due to airway and alveolar abnormalities attributed to toxic environmental gases/particles.1 Patients with COPD are also subject to periods of symptom worsening, or exacerbations, which negatively impact health status, increase hospitalization rates/readmissions, and contribute to disease progression. Healthcare providers evaluate for exacerbations during formal patient assessments.1
 
Host factors, such as genetic abnormalities (eg, alpha-1 antitrypsin deficiency), developmental delays in lung development, age, and gender are identified as risk factors for COPD.1 Environmental exposures to fumes, gases, air pollutants, and occupational dusts contribute to impaired lung function.1 The most prevalent environmental risk factor for COPD is cigarette smoking, which is associated with a higher mortality rate, a higher burden of respiratory symptoms and lung function abnormalities, and greater decreases in lung function.1 The updated 2017 GOLD guidelines introduce a 5-step program for long-term smoking cessation; a long-term quit success rate of up to 25% can be achieved with time and appropriate resources for smoking cessation in patients with COPD.2
 
For the diagnosis of COPD in patients with risk factors, chronic cough and/or sputum production, and dyspnea, a spirometric assessment is conducted to confirm the presence of persistent airflow limitation. Patients with the severity of airflow limitation post bronchodilator of less than 0.70 forced expiratory volume in 1 second (FEV1)/forced vital capacity are considered to have a spirometrically confirmed diagnosis.2
 
The 2011 GOLD guidelines introduced the ABCD tool, which expanded on the previous GOLD 1 to 4 symptom scoring scale, which was based exclusively on airflow limitation (FEV1 value). Although evaluating airflow limitation (from mild to very severe [GOLD 1 to 4]) is important for diagnosis, airflow limitation is an unreliable marker of the severity of breathlessness, exercise limitation, and health status impairment. The ABCD tool performed no better than spirometric-graded symptom severity (GOLD 1 to 4) for predicting mortality and outcomes, especially among patients meeting group D criteria (lung function was not separated from exacerbation history).2 The 2017 GOLD guidelines introduce an updated ABCD assessment tool for COPD disease severity that requires the formal assessment of disease-specific symptoms and an evaluation of patient history of exposure to disease risk factors to determine disease severity independent from spirometric results (Table 12).2
 
The modified British Medical Research Council questionnaire (mMRC) can be used to evaluate breathlessness, which has been shown to correlate with other measures of health status in terms of predicting future mortality. However, as COPD poses symptomatic burdens beyond breathlessness, the GOLD guidelines recommend the use of the COPD Assessment Test (CAT), which measures disease-specific health status. The CAT is a simple questionnaire designed for routine daily clinical practice that enables assessment of symptoms and the risk of adverse health events beyond breathlessness alone. Scores ≥10 are uncommon in healthy persons and should be the threshold for considering regular treatment for symptoms assessed by the CAT test.1,2
 
In terms of patient evaluation under the revised GOLD guidelines, a patient with COPD would undergo spirometry to determine the severity of airflow limitation (GOLD 1 to 4), then assessment of dyspnea using mMRC or CAT for symptoms; exacerbation history would also be recorded (classified in group A to D). Let us consider the case of a hypothetical patient whose test results show a spirometry score of less than 30% (severity of airflow limitation), which corresponds with a GOLD grade 4. The same hypothetical patient has a CAT score of 18 (symptom burden) and had no exacerbation events within the past year. This patient would have been classified as GOLD group D (without exacerbation inclusion); however, based on the updates, he would now be classified as GOLD grade 4, group B (Figure1).1
 
In the past, the GOLD guidelines included recommendations for initial therapy; however, patients with COPD on treatment with persistent symptoms or resolution of symptoms often need adjustments, such as escalation and de-escalation of therapy.1 The updated GOLD guidelines for 2017 offer recommendations for pharmacologic therapeutic options to guide clinicians in providing personalized treatment based on a patient’s symptoms and comorbidities; these recommendations are stratified by GOLD ABCD scale classifications (Table 21).1 The GOLD guidelines emphasize the need for clinicians to focus on the short- and long-term impacts of COPD, with the goals of relieving and reducing symptom burden, improving quality of life, and reducing the risk of adverse events (AEs).1
 
All patients with a less severe symptomatic burden and lower risk of COPD exacerbations (GOLD group A) should receive treatment with a bronchodilator (either short-acting or long-acting). If symptoms persist or worsen, the recommendation is for patients to try another bronchodilator class. Initial therapy with a long-acting beta2 antagonist (LABA) or a long-acting muscarinic antagonist (LAMA) is recommended for patients with greater symptom burden and low risk of exacerbations (GOLD group B). If a patient has persistent breathlessness on LABA or LAMA monotherapy, escalation of treatment to combination therapy is recommended. Treatment with dual bronchodilation with different classes of agents (LAMA/LABA) can increase efficacy because of the decreased risk of AEs compared with increasing the dose of bronchodilator monotherapy. Inhaler devices offering LABA and LAMA combination therapy as well as twice-daily regimens have shown improvement of symptoms and health status in patients with COPD. However, if the addition of a second bronchodilator does not improve symptom burden, de-escalation to a different single bronchodilator is recommended.1
 
For patients with a high risk of exacerbations and lower symptomatic burden (GOLD group C) LAMA monotherapy is recommended as initial therapy; LAMA was superior to LABA in exacerbation prevention in head-to-head trials, the results of which supported this recommendation. Patients with persistent exacerbations are recommended to receive LABA/LAMA bronchodilator combination therapy. The GOLD guidelines cite evidence that in patients with a history of exacerbations, a combination of long-acting bronchodilators is more effective than monotherapy; the LABA/LAMA combination was more effective at decreasing the number of exacerbations compared with the combination of an inhaled corticosteroid (ICS) and a LABA.2 An ICS is not recommended as monotherapy. The ICS/LABA combination is more effective than monotherapy with either drug in terms of improving health status and lung function, as well as reducing exacerbations in patients with moderate to very severe COPD (GOLD grade 3 and 4) and exacerbations. However, guidelines recommend LABA/LAMA as preferred therapy, given the increased risk for developing pneumonia with ICS.1
 
Initial combination therapy with 2 agents from different classes (LAMA/LABA) is recommended for patients who experience a high burden of COPD symptoms and a high risk of exacerbations (GOLD group D). If a monotherapy is chosen for this group, however, a LAMA is preferred for exacerbation prevention based on a comparison with a LABA. Although the LABA/LAMA combination was superior to LABA/ICS in preventing exacerbations, the GOLD guidelines recommend individualization of treatment based on patient characteristics. Patients with a history of asthma may benefit from LABA/ICS as a first choice. Because ICS plus a LABA is more effective than either component alone in improving lung function and health status and reducing exacerbations, the combination may be considered for this patient group. For patients with persistent moderate to very severe COPD symptoms or further exacerbations on LABA/LAMA dual bronchodilator therapy, escalation to triple therapy is recommended by adding an ICS. Based on the 2017 GOLD guidelines, an oral phosphodiesterase type 4 inhibitor (ie, roflumilast) may be considered as an add-on therapy for patients with COPD and chronic bronchitis with severe airflow restriction and COPD exacerbations despite triple combination therapy (LAMA/LABA/ICS).1
 
The updated guidelines focus on individualized treatment options and emphasize patient adherence to therapy, self-management, and palliative care. They recommend routine identification and treatment of comorbidities (eg, cardiovascular disease, metabolic syndrome, osteoporosis, lung cancer, skeletal muscle dysfunction) as these influence mortality, hospitalizations, symptom severity, and outcomes for patients with COPD. The importance of proper assessment of inhaler technique also is emphasized; assessment of technique is recommended before concluding that a given bronchodilator therapy is insufficient and dose escalation is required. Additional pharmacologic treatment interventions for patients with COPD exacerbations are provided in the update, with the goal of reducing hospital readmissions due to exacerbations. In addition, pulmonary rehabilitation is recommended for the medical management of patients with severe symptoms and frequent COPD exacerbations. The guidelines also recommend exercise, smoking cessation, and the influenza vaccine for all patients with COPD, as well as the pneumococcal vaccine for all patients 65 years and older.1
 
The 2017 GOLD guidelines include updates to the ABCD symptom assessment tool and revised guidance regarding the use of spirometry to evaluate the severity of airflow limitation. They focus on disease assessment and the use of pharmacologic treatments and nonpharmacologic interventions (eg, smoking cessation) to relieve symptomatic burden and improve patient health status.

References 
1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2017 Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD website. http://goldcopd.org/download/326/. Published January 2017. Accessed April 26, 2017.
 
2. Global Initiative for Chronic Obstructive Lung Disease. 2017 Pocket guide to COPD diagnosis, management, and prevention; a guide for health care professionals. GOLD website. http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf. Published January 2017. Accessed April 26, 2017.
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